kI feel completely brain fried 20mg was too much for me and someone should have protected me from myself’. ‘By the way this is the only time in my life I ever strongly felt that suicide was the only option’.
George was referring to his enforced anti psychotic olanzapine.
He had continually asked the dosage be reduced, as had his parents.
The day before his death, George tried to negotiate a reduction in return for the Prozac his consultant added .
And despite this psychiatrist, rarely, making notes of his consultations, preferring ‘an oral hand over’, he did took the time to record;
’I tried to persuade him to persuade him that olanzapine was the answer to his problems not the cause’
George thought he was suffering from various diseases since he was 13, and his parents sought help from various professionals, but had got no where, and were never offered therapy.
Eventually, after a 10 month wait CAMH’s diagnosed him with ‘delusional’ depression.
This is an extremely rare condition, unknown in hormonal teenagers, the delusions appear based on George’s hypochondria, and, usefully, justified treatment with anti psychotic medication.
Within seven weeks George was dead.
Neither the Coroner, nor the Serious Case Review, considered the accuracy of the diagnosis, the role olanzapine and Prozac , and their combination, and George’s enforced hospitalisation, played in his death, even after reading George’s suicide note.
How could they, when such ‘treatment’ is the only treatment available. And promoted by an all party mental health task force.
Therefore, an open verdict, reflecting the very real likelihood, that medication caused George’s death could not considered, nor a jury verdict risked.
Instead, a narrative verdict was given, blaming the Priory for allowing George home.
Yet, hours before writing his note, George’s mother had picked him up from the Priory Hospital, and was shocked at his wide, staring, expression less eyes, and noticed he could not sit still.
Just after 6am, the next morning, a train driver reported that George, had ‘walked calmly and deliberately’ in front of his high speed train. He was just 15.
George was described by his parents as a popular, active, funny, talented boy;
“We remember George’s incredible life, his amazing achievements, his jovial personality, his very quick wittedness, his integrity, his beautiful smile, his contentedness, but above all we remember his absolute love of his life and his imperative place in our family.
“Living with George brought entertainment to us on a big scale, he was either singing, practicing lines, playing music or playing an instrument. He performed in talent shows, singing competitions, Oliver, and played the role of Bugsy in Bugsy Malone at the town hall, as well as singing in the local church choir and fundraising for the drama club that he belonged. He loved joining clubs and loved his sailing, badminton and karate lessons
“George had aspirations, he wanted to work at the Globe Theatre, either in performing arts or some other job, but it was one of his ambitions. He loved music and wanted to join a rock band. He loved cycling and coming home to tell us that he had found a new path or cycle route. He loved reading about World War One and Two and adventure fiction. He enjoyed school and was on track to achieve high GCSE grades and during May last year and while in hospital, he took biology GCSE and earlier this year we received his certificate and he achieved an A grade.
But all this zest and enthusiasm would have been removed by the dopomine block of his anti psychotic, and George knew it was killing him, but no one listened.
Medication and unhappy encagement was the only ‘help’, he was given by CAMHS, and his family noticed a ‘massive change’ in him.
And he had complained about the terrible way the medication made him feel, and was given melts, when he spat his tablets out.
It was then, that the state decided, he needed hospitalisation, for ‘assessment and treatment’
His parents removed him from the first hospital, as the room was ‘not fit for a dog’, his bed had no sheets, the curtains were too short, he was living out of a suitcase, he looked dishevelled and unclean, and another patient had threatened to kill him.
Despite being paid £800 per day it did not even provide basic accommodation.
George returned home for a short period, but was then sectioned under the MHA to the Priory, for ‘treatment and assessment’,and any objections were made impossible.
But here, he did not even receive an accurate suicide risk assessment, let alone an assessment of his condition, the Coroner noting
‘The information used in the assessment was incomplete inaccurate and did not reflect the actual situation’.
And, the only ‘treatment’ he received was medication, which clearly was having a devastating effect on him.
The Priory were being paid £890 a day, including the days of home leave.
Even basic communication was not provided either with his parents, who complained of this from the start.
George was given home leave, but did not want to return, and on his return, was so unhappy he attempted to kill himself with a shower curtain, but his parents were not immediately informed.
When his father visited, George had looked ‘hideous,’ and he thought he was getting worse.
Dr Hoyos, his consultant psychiatrist, who had to be seconded from CAMHS by the Priory, explained, George did not want to be in the hospital, and had disengaged from staff, and refused to go to lessons.
George knew he was trapped now by section and medication, and felt so desperate, he drew pictures of his own suicide with the words ‘game over young lad’.
But this was treated, as part of his disorder, and ignored .
The main points of the Serious Case Review were as follows;
Despite a nurse recording that George was very suicidal on 24 June 2013, a decision was made to allow George on home leave on 27 June 2013, without an up to date risk assessment, and hours after he had been prescribed an anti-depressant, Fluoxetine, which has a known side effect of potentially increasing suicide.
Inadequate records were taken by the consultant psychiatrist following consultations with George
A risk assessment had been incorrectly written changing George’s suicide risk from YES to NO the day before George died
The management plan did not have any note of current or past risk of self-harm or suicide the day after George had made a suicide attempt
A staff meeting had concluded that George posed “no current risk of suicide” two days before he died, contradicting a report given a few days before which noted that George had woken up in a low mood and had felt suicidal.
A referral to the General Medical Council (GMC) was made regarding this consultant’s record-keeping.
However, this was not pursued by the GMC.
See the Coroner’s Report to NHS England and their response.
But George’s death did not affect the NHS use, and funding of the Priory Group, which increased, as public NHS beds are being phased out.
This is the ‘help’ available to the 1 in 4 teenagers purported to have ‘mental health’ issues.
At best George’s death, ensures their treatment makes them unable to end their tortured existence, which will continue, as long as the real reason for their problems, and the affect of medication continues to be ignored.