Comments/Information on Cygnet’s actual services


So what do we know about the actual provision and quality of Cygnet’s increasingly MHA/MCA enforced services ?

The public service users nor their family know little about Cygnet’s service and even less about the outcomes for service users.

Despite the huge amount, on average of over £6,000 a week spent, Cygnet’s Empire expanding to incorporate all public beds and our government’s 9 billion mental services spend.

A locked ward patient is worth £12,500 per week here is a blog post on February 2017 of a mother whose daughter is against both their wishes on such a ward in a Cygnet Hospital.

One wonders how the services are commissioned, for what and how such a spend could possibly be justified.

All that can be gleaned about these extraordinarily expensive services is from the internet.

As to be expected Cygnet’s own glossy, PR savvy site, proclaims their excellence .

NHS Choices reveals that Cygnet has not filed a Quality Account Report

Quality Accounts are self created annual reports to the public from NHS Healthcare providers giving information about the quality of their organisation’s services.

NHS Choices Site contains only one review from a member of the public headed;

horrendous hellhole

Staff turnover high no basic education provision no meaningful psychological input. I could go on forever about this place words cannot describe just how shocking it is I would advise every man & their dog to avoid this place like the plague.

Visited in February 2016.
Posted on 02 October 2016

Employee Reviews of Cygnet shown on Glassdoor are mainly French care workers, written on a French website.

We can only assume, Cygnet, has been recruiting cheaper more itinerant French workers.

In an industry dependent on  written and oral handovers and multi medications, where accurate and precise communications are essential.

Posted February 2016
Job satisfaction and training available. Regular ward meetings. There are some very good staff that make the team run well.

Lots of bank and agency staff working here, which can make the shift difficult. Lack of Consistency between shifts can make work hard.

March 2016
it was Alpha when I worked there and at that time no pros

endless night shifts 12 hour each lasting for one month or more, managers used bully tactics and favouritism

Conseils à la direction
manage don’t bully

Sept 2016
The service users.
Sometimes there are usable toilets

The management are promoted internally and you wonder whether they have any experience at all.

Many staff are unqualified

No one cares about the people we work with.

Many staff have no place working anywhere, let alone with vile enable people.

This is just a way to siphon off public money.

Advice to Management
Your golden goose will end one day

We also have Will Perk’s Mum’s comment to the press about her 15 year old autistic son’s treatment in Cygnet Woking.

‘In Woking there’s a lack of communication, they get his meds wrong.

I had to report them because someone threatened him and said, ‘If you don’t stop it I’m going to punch your effing face in.’

“Another member of staff was restraining him and pulled his hand right back and hurt him. Both of which I complained about and both of which have been sorted. Both members of staff admitted it. It went through all the right procedures for safeguarding and the hospital was just saying, ‘It’s not unusual I’m afraid for this industry’

And when autistic Mathew Garnet was pushed by an inpatient in Cygnet’s Woking hospital, whilst playing on his Nintendo, his swollen fractured wrist was ignored on the excuse that ‘he did not express pain’, and he was not taken to A and E for 24 hours.

And his mother described his treatment, as the equivalent of being left on an A&E trolley for 6 months .

Is it any wonder, that the USA now own nearly all NHS mental service provision with such public sums paid for such public services.

And in 2017 for private mental health providers ‘things can only get better’.

A Christmas Tale of Autistic lives. And Cygnet’s £12,500 a week NHS bonanza.

matthew%20olay%20op%2016-03-02%20rh_0302t054627-mov-00_00_00_00-still001“The most vulnerable people in our society are being abused by the system. They’re children.”

“It doesn’t seem real. Like it shouldn’t be possible.”

Isabelle Garnet, Mathew’s mother.

The fates of Mathew Garnet at 15 and Will Perks at 14, are typical of many autistic teenagers.

‘Experts’ tell us, that autistics develop ‘mental’ disorders, ADHD, Anxiety, Depression, as Mathew and Will had done, but these are  diagnosed from reactions to society, care and education.

The most worrying and increasing label is psychosis.

Why and how this is diagnosed is unclear, experts merely stating,

‘the link between autism and mental health is complex’.

Such labels, particularly psychosis, justify powerful medication, despite parents remarking, it ’often made matters worse’, and huge pay outs for ‘education’, ‘assessment and treatment’ and ‘care’.

But despite the money spent, if parents can’t cope, with predictability violent reactions to incidents/ inadequate/ change of education the only thing they can do is call the police.

As no agency -social services, GP, education provider- is prepared to get involved in an emergency .

Emergency help, and if necessary sedation, should be provided by GPs or other specialist services, but instead, our most vulnerable, are disproportionately ‘pathwayed’ into private hospitals for years, their lives destroyed.

As, Mathew’s and Will’s were, when they were processed illegally under MHA section- as this is not treatment nor determinable- into psychiatric wards.

Wards where many fit, like Stephanie Brincliffe and those in St Andrews, die young of ‘natural causes’, 99% of deaths may not even be being investigated.

Our NHS spends, unjustifiable/ extortionate sums of up to £12,500 a week, to lock up autistics in secure units like Cygnet Woking, where Mathew and Will were taken.

Regardless of the abuse and outcomes .

Mathew was happy at home.

He liked the Teletubbies, Alvin & the Chipmunks, and going to his local swings.

He adored swimming. “He swims in his own idiosyncratic style,” his mother laughed.

But his specialist weekly boarding school had, “raised concerns that Matthew may be having, possibly, psychotic episodes’

Despite their £4000 a week fee, his mother remarked,“ we were seeing a gradual regression. What self-help skills he had – the hand-washing, the hair-washing, wiping his own bottom – those skills had gone right down.”

This mirrors exactly, my own daughter’s experience in her NAS placement also at 15, even down to the psychotic episodes.

Matthew was anxious, as he was going to be moved to St Andrews in Northampton, over a 100 miles away, as my daughter was to be, if her CAMHS ‘assessment and treatment’, did not cure her aggressive behaviour, which it could not, as it was caused by a faecal impaction and abuse in her NAS school.

Mathew’s father described, how Mathew then “ decided in his head it was Isabelle’s fault, and went straight for her, with his fists. Red mist doesn’t describe it. I was terrified. I told Isabelle to get out of the house, and I basically lay on top of him, trying to restrain him for the next 30 minutes, while he punched and head butted me.”

His mother Isabelle rang the police.

And Mathew was sectioned to Cygnet Woking, where, as his mother remarked his £12,500 ‘assessment and treatment’ was “the equivalent of being left on an A&E trolley for six months”.

Mathew was desperately unhappy, and pulled his hair out, and his head was shaved.

He kept asking his Mum why he was in prison and begging to go home.

When he was attacked by another inpatient, whilst playing on his Nintendo, his wrist was swollen and fractured, but on the excuse that ‘he had not expressed pain’, he was not taken to A and E for 24 hours.

After six-months of endless pleading to NHS England, the local authority and official bodies had achieved nothing, his parents launched a public campaign .

And were interviewed on national TV, as part of the government’s campaign to close public mental inpatient NHS services.

Despite the fact that Mathew was holed up in a private inpatient bed.

And despite, the by now, £ 339,000 paid to Cygnet for effectively nothing, the media and
our PM, insist that lack of proper care is due to a shortage of money.

‘stuck in a system short of funds and beds, especially for adolescents’.

Will Perks was also pathwayed to Woking Cygnet .

His story is an even more shocking account of the abuse of the autistic for profit.

Will was transferred from his specialist school to a mainstream one, were he was bullied, and became depressed. Eventually refusing to go to school.

And then another boy punched him in the face at a local skate park on taking offence at something he’d said. Will was sociable but could appear childish.

Desperate, Will swallowed some pills in an incident at home, his family panicked, it was not an overdose.

But the only help Will received, was for the NHS to use the incident, as the excuse to section Will for his own safety.

As there were no beds near his family’s home in Bristol, he was sent to a ward in Cygnet Bury for three months.

In December last year, Will now 15, was transferred to an inpatient wing in Bristol, but escaped, just before Christmas, hoping to find his way back home to see his mum.

Police found him, and when they tried to detain him, he became distressed, and kicked an officer, as arrested and placed in a police cell for 28 hours.

And was sectioned on Christmas Eve to the same Cygnet ward as Mathew in Woking.

Where his mother said

’ there’s a lack of communication, they get his meds wrong. I had to report them because someone threatened him and said, ‘If you don’t stop it I’m going to punch your effing face in.’

“Another member of staff was restraining him and pulled his hand right back and hurt him. Both of which I complained about and both of which have been sorted. Both members of staff admitted it. It went through all the right procedures for safeguarding and the hospital was just saying, ‘It’s not unusual I’m afraid for this industry.’

“The staff at the hospital say they don’t want Will there – he’s on a ward with people with very serious mental health problems, including serious self-harmers, and he’s witnessing all that. He shouldn’t be there.”

All Will and Mathew want and wanted, was to be at home with the people they loved, and some control over their lives.

But this will never happen, as they are cash cows.

Mathew is now in St Andrews and Will’s pathway is likely to be there, or similar.

But we will never know , as their stories, were only made known, because of a political turf war between public and private providers, and the fact they were under 18, so could not be silenced under the MCA  .

As they will soon be 18,  it is likely, their parents may already be gagged under interim  orders.

So no information can be forthcoming for the rest of their lives.



Anorexic Jodie’s Cygnet ‘help’No psychologist, communication, assessment, protection, just death, cost £21,000.


Jodie was a former air cadet, 12 GCSE straight A student, with exceptional talents in Maths and Art and ” would always put other people first and was a lovely, thoughtful, caring, creative, adventurous and highly intelligent’

She had battled anorexia and depression since she was 15

“She was very ill but she wanted to get well and move forward, but never got the right help.”

Despite her family fighting’’ tooth and nail all the way through Jodie’s mental health care to try and get her the best support.”

Jodie’s ‘help’ was, the only ‘pathway’ available to an ever increasing number of teenagers with mental health problems.

GP to CAMHS to inpatient, first an eating disorder clinic, where she did start eating and her mood improved, but then suddenly, she again became suicidal and set fire to her bed.

But ,” was horrified by what she had done and the harm she could have caused to others – but by this point she was crying out for a lot of help. She had been managing her eating much better and had put on some weight and she was healthier but you had to be careful what you said to her she would say ‘I’m too fat now’.

Her parents wanted her to go somewhere that did not just specialise in eating disorders, who could ‘help her and control what she was doing’.

They ‘left it to the professionals to find somewhere for Jodie with the support that she needed that was keeping her safe’.

But in the trade, Jodie had now become ’treatment resistant’, and the only ‘help’’ left, in her ever more expensive, mental descent, was a Cygnet/Alpha hospital, for ‘ treatment resistant patients’ at £950 a night.

Her father recounts;

It was a shock to all of us to see what kind of place it was, with 20 foot fences around it. But we thought if this is what’s needed, then this is what’s needed. Three weeks she was in there, she was up and down. Some days she was fine other says she would say, ‘I don’t know why I’m here but I do’.

We were expecting her to go and someone to be there to say ‘these are the problems and this is the sort of thing we can look to do’ – some sort of table or structure. But there was no clinical psychologist.

We didn’t feel reassured and wondered how things were going to improve.

On the Monday leading up to her death, I spoke to a doctor and he said we were looking to implement a programme and someone would speak to her.

But to my knowledge those never happened and Jodie did what she did. We’re not medical experts but we always felt something was missing for her treatment

What did become apparent, was, that she was telling us nobody was talking to her.

Given that she had a significant history, I was worried about the observations. She needed it immediately. If that meant she needed to be watched 24 hours a day, then she needed to be watched, this is a person’s life’.

Just three weeks into her stay at Bury Cygnet hospital, after telling her mum, she felt ‘very distressed’, Jodie was found unconscious in her ensuite bathroom, a ligature around her neck and died the following day. She was just 19.

Not surprisingly, her father ‘ thought the hospital staff would have recognised, that what they had was someone who was up and down.’

But the evidence of a Cygnet nurse at the inquest, illustrates the hospital’s perfunctory,bureaucratic self preservatory ‘care’;

“We were aware that she had tried to commit suicide in the past with overdoses but we were not aware that as a young teenager she had tried to ligature before. This was never told to me by Jodie and was not in any documents.”.

The incompetent , chaotic lack of, even basic attention, to this highly vulnerable girl, was only revealed because she had a family able to fight, a lawyer, and a jury.

And, as our government is intent on harvesting cash cows and appealing for more public money, her story was published.

The rare presence of a jury’s deliberations resulted in a verdict of death by misadventure.

The major revelation was a ‘complete lack of sharing’ of vital information between NHS and the private healthcare providers, and, between the childrens’  and adult mental health services.

In addition, the jury found ‘that had Jodie been under the care of more experienced staff, the outcome may have been different.”

They listed the failings including:

-a ‘distinct’ lack of communication with the family, and between healthcare professionals themselves.

-lapses in the recording of information about Jodie’s history

-‘ineffective’ and ‘incomplete’ risk assessments

-insufficient completion of an appropriate care plan

Jodie was not being helped, how could she be , without even basic information, assessment or plan, and no clinical psychologist.

So why did the NHS send someone so desperate, to such a place, and pay nearly a £1000 a night ?

Such failings appear common to deaths in Cygnet hospitals and the Priory.

This appears their modi, and  providers responses to deaths are standard;

“Nothing is more important to us than the wellbeing of the people we support, and our thoughts and sympathies are with Miss Turton’s family at this very difficult time. We have adopted a range of measures to ensure we learn from this very sad event, and will continue to work closely with our healthcare partners to implement them.”

What these measures are, and how/if they were implemented is unknown.

And will remain so, whilst the services remain unaccountable, monopolised, and promoted by our government .

24 year old dies in Cygnet after 11 forced Olanzapine injections in 10 days




Jonathan Malia a father, keen rugby player, and fitness fanatic studying to be a sports therapist.

Was described as “a fun-loving, manageable, intelligent young man,”

He had been diagnosed with bipolar but had been fine for years.

But when he started to feel depressed and couldn’t cope, he sought help, assuming he would be a voluntary patient, instead he was sectioned .

Two weeks, and 3 hospitals later, he died from a “massive pulmonary embolism”.

His girlfriend had rang the hospital on his second day of detention-, he was not allowed to make phone calls or see anyone- and staff told her he was “being aggressive”.

Wouldn’t you be, if you’d asked for help, but found yourself drugged and locked up, incognito, in your second hospital .

Jonathan was then transited 97 miles to the Chamberlain Ward in Cygnet Hospital, a unit that specialised in ‘treating’ patients with “an acute episode of mental illness that requires assessment and stabilisation”.

This appears a fairly common start to inpatient ‘help’ .

‘Stabilisation’ is achieved by the use of high doses of anti psychotics and/or other drugs. .

During the following 10 days, his girlfriend rang the hospital daily, only to be told Jonathan wasn’t in a fit enough state to get to the phone.

She rang on the 11th day and was told, he’d collapsed and been rushed to the nearby Lister Hospital were he was pronounced dead.

A massive thrombosis had triggered a pulmonary embolism.

When Johnathan had been admitted to Lister Hospital, he had had bruises on his head, arms and legs..

Four days of his fluid intake charts were missing.

Vital samples taken from at his post mortem and actioned by the coroner for analysis, were not, instead they were left to deteriorate in a fridge for three weeks and discarded.

There was no paramedic report available at the inquest.

The coroner ignored evidence that his death might have been caused or contributed to, by 11 restraints and injections of Olanzapine, which drug per se, has been linked to causing deep vein thrombosis.

And the Coroner ruled Johnathan died of natural causes.

Johnathan’s aunty said.’There has been a massive cover up – we also feel the verdict had been decided before the inquest ever began’.

Errol Robinson, a Birmingham solicitor who is acting for the family commented:

“Several features about the evidence that came out at the inquest give cause for concern.

One relates to the sample that was taken for analysis by the pathologist which was instructed by the coroner but not actioned. This deteriorated and was discarded, which is wholly unsatisfactory.

Also, the coroner did not accept the need to make any recommendation in relation to the development of deep vein thrombosis in patients taking such therapeutic drugs’

Johnathan’s aunty said;
“Our evidence as a family was disregarded by the coroner who I felt was very disrespectful to us. At one point he told me that my statement was irrelevant.”

“So many questions have gone unanswered – why was Jonathan given 11 injections of the drug. Why did he have bruises on his head, legs and arms when he was admitted to Lister Hospital? Why were there fluid charts missing ? Why were samples from his body left to deteriorate before anyone had analysed them? The questions go on and on.”

Despite a campaign, petition, and letters to the GMC and MOJ and relevant authorities, his family are still waiting for answers they will never get.

It is unknown how many deaths are even investigated internally in mental health care.

We know from the LLB Campaign, SLOVEN only investigated 1%of their LD deaths, and this was not an outlier for public mental hospitals.

We have no statistics for private hospitals and/or residential care providers.

There is no check, or, accountability for the use, or dosage of drugs in private mental health care.

NICE Guidelines can, and are, being ignored, and prescribing psychiatrists are employed by private  for profit mental care providers, and subject to stringent Codes of Conduct and appraisals.

Patients nor family have any control over the medication used.

Coroners inquests are the only possible independent investigation, and these are decreasing ,with no legal aid available to families.

That is if they have not been gagged and cut out by the MCA ,

Narrative verdicts are increasing .

MENCAP reported 3 years ago, that 3 learning disabled die needlessly in state care every day.

We can add to these, those like Johnathan, who simply ask for help.

Government statistics show that mental health service users account for 60% of those who die in the care of the state

And nothing is being done, except to plough millions of public money, now nearly a quarter of the NHS budget, into private monopoly, commissioned by state mental health provision, and a  cross party Mental Health Taskforce, that promotes the use of ‘antipsychotic drugs and mood enhancers’.

Here  are the latest statistics from CQC  on those detained under MHA, it is increasing as huge profits can be made, inpatient ‘treatment’ is around £890 per night.






Payers of $8.4 million for false claims Universal Health Services take over Cygnet Health Care for £205 Million.


Cygnet Health Care is one of the three controlling providers of mental health services in England.

In 2014 Cygnet was bought by USA’s Universal Health Services (UHS) for £205 million..

Simons Stevens was chief executive of the group’s global division and advised Blair on NHS public investment is now chief executive of NHS


Cygnet Health Care then increased UHS’s UK mental health footprint by a £95 million acquisition of Alpha Hospitals .

In September 2012, UHS, and its subsidiaries, Keystone Education and Youth Services LLC and Keystone Marion LLC,Keystone Marion Youth Center, agreed to pay over $6.9 million, to settle allegations that they had submitted false and fraudulent claims to Medicaid.

Between October 2004 and March 2010, these subsidiaries, had provided substandard psychiatric counselling and treatment to adolescents in breach of Medicaid requirements.

And, the United States alleged, that UHS had falsely represented Keystone Marion Youth Centre, as a residential treatment facility, providing inpatient psychiatric services to Medicaid enrolled children, when in fact, it was a juvenile detention facility.

It further alleged, that neither a medical director, nor, licensed psychiatrist provided the required direction for psychiatric services or for the development of initial or continuing treatment plans.

The settlement also settled allegations, that the service providers filed false records or statements to Medicaid, when they filed treatment plans, that falsely represented the level of services that would be provided to the patients.

See below under Other Medicaid Matters p33.

In July 2002, the New York State Insurance Department fined United Health Care $1.5 million for ‘cheating patients out of money’.

Is this the sort of ethos that should now control a quarter of public, enforced, secret unaccountable services to our most vulnerable and receive a tenth of our NHS budget ?

In 2011 Cygnet was warned by the Care Quality Commission that staffing levels at Cygnet Wing Blackheath were inadequate..

Improvements were still required at the CQC inspection in April 2014.

In 2013 the Care Quality Commission issued a warning to Cygnet Hospital Bierley because the service was failing to ensure that appropriate records were kept.

John Hughes, an American founded Cygnet in 1987 after turning the Priory around.

In 2004 Cygnet was valued at £120m in a deal with Barchester Healthcare, which earned Hughes a £19m cash windfall.

Barchester, is part-owned by John Magnier and JP McManus, the Irish racing tycoons who owned Winterbourne View’s Castlebeck,.

They bought a quarter of Cygnet’s business for £30m, and Hughes, and a fellow director took a £7m stake in Barchester.

Hughes completed a £340m buy-out in 2008, backed by Mr Wilson’s health care group Grove, which had bought a 25pc stake in Cygnet years earlier.

And would have received another windfall.

In 2014 Hughes’ sale to UHS earned him a £30 million windfall.

So tycoons have made millions from mental health services now 87% financed by public NHS money, whilst public trusts are cash strapped and in debt.

And, are set to make far more profit from the governments drive ‘to parity with physical health’, and spend a quarter of the NHS budget on their private services.

Robert Kehoe , psychiatrist, advertises himself, as an ‘expert witness’, is now the medical director of Cygnet, and, has apparently, advertised some of their units as being for ‘resistant service users’.

Dr Kehoe was an NHS Consultant for nine years and Assistant Medical Director at Airedale NHS Trust and produces 80 to 100 psychiatric reports per year for Courts and Tribunals.

He is also responsible office for Cygnet Healthcare with national responsibilities for the regulation and revalidation of medical practitioners.

So, one expert, now controls the appraisals and code of conduct of all psychiatrist services and opinions, in a multimillion pound conglomerate, serving a quarter of all mental health services.

Universal Health Services and Cygnets’ overriding ethos, is to make as much profit as possible for its directors, managers and investors.

Does this not conflict with the professional independence of the psychiatrists, psychologists, practitioners, who work for Cygnet, and are subject to Cygnet’s stringent codes of conduct and continual appraisal systems ?

And how does this promote, the diversity of opinion needed for best practice, particularly, in the uncertain arena of psychiatric medicine ?

Amy’s Story- Nearly a Million spent on education, and torture/ death in the Priory.

Everyone said, ‘In there at least she’s going to get help’ but she didn’t 99641453_amy-el-keria-news-large_transqvzuuqpflyliwib6ntmjwfsvwez_ven7c6bhu2jjnt8get anything at all.”

Amy’s mother on her removal to the Priory Hospital Ticehurst House, in August 2012.

3 months later 14 year old Amy was dead.

Amy was a troubled, confused teenager, but why ?

Her mother described her as having ‘ a warm heart and a great sense of humour.

’ She never liked to see people treated unfairly and would be the first to stand and say ‘that’s not right’’

But the tragic irony was, that Amy herself was treated beyond unfairly, and no one, systemically, could stand up for her.

Amy’s forthrightness and conviction, contributed to her CAMH’s diganoses of oppositional defiant disorder (ODD), defined as a pattern of angry/irritable mood, argumentative/defiant behaviour.

And Conduct disorder(CO) a range of antisocial types of behaviour displayed in childhood or adolescence.

It appears normal teenage behaviour, could per se, constitute a ‘disorder’.

It is unknown, what is within this ‘range’ of ‘antisocial’ behaviours, let alone, what would be a normal reaction to living in an enforced residential ‘special needs’ school .

But High Close School, run by Barnados, had had enough of Amy, despite her £200,000 tax free a year income, and, the only place that remained, on Amy’s sad slippery slope, was a £1000 a day Priory Hospital Room.

But what did Amy’s ‘special ‘ education do for the equivalent of the cost 4 Eton places ?

And why, without learning disability diagnoses, are Amy, and ever more ‘troubled’ teenagers, excluded from ordinary schools and placed in such expensive residential care?.

High Close does not appear to have had any pupils attaining a single GCSE, and a parent comment the only I could find states,

poor School
Mark Rating:
I have a child in this School and have come to the conclusion that the place offers a poor teaching environment and the unit staff lie and cover for each other when things go wrong.

As in my daughter’s National Autistic Residential School, ‘pupils’, only obtain P Scales , as teaching appears not to be towards the National Curriculum.

As Amy appeared intelligent, might not boredom/inappropriate education, have lead to her third label, attention deficit hyperactivity disorder (ADHD), a rare, some say non existent condition, that, has now been extended into a  pharma lucrative epidemic, see
ADHD The Disorder The Drugs The Inside Story. By Alan Schwarz.

Tourette’s, and gender identity dysphoria, distress at the gender assigned at birth, recently made a DSM mental disorder, and now increasingly diagnosed in children, were  added to Amy’s list.

Yet despite all these ‘disorders’, Amy must have managed to be chirpy, as depression was not added.

Despite Amy, being so unhappy in school, she had drawn a picture of herself killing herself and had written underneath: ‘If only this could happen, but I haven’t got the guts.’

Exactly as George Werb had done, when he had been trapped by the Priory and his medication..

Why hadn’t her school tried to help such an unhappy child ?

Amy and her mother, would have been unable to systemically complain .

As a care order, enforcing any chosen state provision would have been obtained.

So what was life like for this unhappy, and officially disordered child in the Priory ?

Did she receive any kindness or understanding, in her troubled isolation, living alone with strangers ?

In less than three months of being there, Amy was subjected to at least six incidents of restraint, sometimes involving forced injections.

The first restraint happened just 48 hours after her admission; the last  the day before her death, when she was held by five staff members, and orally sedated

Her inquest heard of several incidents, when she had been physically restrained by staff, sometimes for 15 minutes at a time.

The Priory had a high reliance on agency staff, including some with no psychiatric experience.

They had insufficient time even to read patients’ paperwork or clinical notes, let alone get to know Amy.

Amy was also being bullied, and the Priory had failed to deal with this, or, even care enough to share details of the many times she had said she wanted to kill herself.

Staff admitted, they were under so much pressure, they had not always been able to give the teenager one-to-one time.

So much so, a Jury ruled staffing levels were inadequate, and a lack of one-to-one time caused, or contributed to Amy’s death in a ‘significant’ way

Even basic training for her Tourettes was not given, a member of senior staff had ‘put on training on Tourette’s, but nobody had attended’.

So Amy was alone, ignored, no doubt on medication, bullied, subject to continual excessive prolonged restraints, and crying out continually for help, in the only way she could, by threatening her own life, and was still ignored.

Her last cry for help killed her.

3 months after entering the Priory Amy yet again, told a member of staff she wanted to kill herself.

Only the evening before she had been restrained by 5 members of staff and sedated.

Staff did not assess the risk of her being able to take her own life in her room; and opportunities were missed to help Amy in her room before her death, she was left alone, and this was held by a jury to have caused, or contributed ‘significantly’ to her death.

On the day she died, her risk rating was downgraded to medium.

And a  delay in checking on her in the evening, contributed significantly to her death, at a time when she should have been under even closer scrutiny.

A care assistant eventually belatedly, checked on her in her room and found Amy unconscious, a football scarf tied around her neck.

The scarf had been seen in her room two weeks earlier, but not removed, as the hospital had no list of banned items.

A panic ensued, and staff delayed calling 999, and didn’t summon a doctor immediately .

They also had not been trained in resuscitation, though one care assistant had requested the training.

Amy was vomiting profusely.

When paramedics eventually arrived, an oxygen mask was two small to fit over her mouth, and the lift too small to take a stretcher, so she had to be placed on a body board.

The Jury found that but for all this, her life might have been saved.

Amy’s unhappy last years, culminated in an excruciating death, after 3 months of bullying , restraint, injections and torture .

And, the Priory will have claimed a £1000 for that day’s ‘care’.

Less than a year later George Webb was sectioned to the Priory, as were many more who are now dead.

Freedom of Information request show the Government has no idea how many young people killed themselves while being ‘treated’

Yet do know, a third suffer from a mental ‘disorder’ and want to help them.

And are willing to pay the Priory over £440million a year, £6800 a week ,to do so..

Yet Amy, was not mentally ill, she was merely deemed to have ‘conduct ‘disorders, that private mental services, a quarter of the NHS budget, could make millions out of.


Add 3 more adults and you have the restraint Amy suffered the night before she died.


How The Priory/CAMHS’s Treatment lead to the death of George Werb.

kgeorge-werbI 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.