Chris Blagbrough Driven to Suicide by The Mental Health System in Huddersfield, West Yorkshire, England

Christopher Blagbrough committed suicide by hanging.  He was only 22 years old.  Of course it should never have happened; but it was not just another tragic loss to add to the already terrible statistical record of the Calderdale and Huddersfield region of Yorkshire, as one of the highest area in the country for male suicides.  Firstly because it should never have been even remotely possible for him to have had the opportunity to take his own life in the way he did, but also because he was literally driven to it by the actions of a number of mental health professionals within the Calderdale and Huddersfield NHS,  and left totally unprotected by the Trust management and mental health system, in spite of the Herculean efforts of his parents Peter and Jeanette Blagbrough over a period of 2 and a half years.

At the time of his suicide, Chris had been held under the Mental Health Act on the low-secure forensic / rehabilitation Castle hill Unit, St. Luke's Hospital, Huddersfield for almost 3 years.  Christopher hung himself from a window fitment.  Unfortunately it was not the first time he had attempted this.  Following a previous attempt, alterations had been made to the window fitment - but when Chris moved into another room, where this ligature point was still in place and available.  Some six or seven months earlier two Ward managers and a patient had done a suicide risk assessment of the Ward, including identifying ligature points, and 3 months later an External Review Team (brought into inspect the Ward as a result of a large number of complaints about it) also identified and made strong recommendations regarding ligature points.  Why was no action taken?

Chris was found dead at 6.00am but his parents were not informed until about 5 hours later.  Why such a delay?  according to the Coroner he was reported to have been on Level 3 Observations, i.e. within visual sight at all times plus 5 minute checks.  Staff claim he was checked a 5.55am  and was sleeping, but at 6.00am was not only hanging, but was said to be "limp and cold" (in a central heated building?).  A fellow patient claims he heard a member of staff shout "My God,- he's icy cold."  He also claims that he himself was also on an observation level that night, had been unable to sleep, and has never been checked.  Another patient claims night time observations are often not done.  Patients are now being treated by a Doctor and Ward Management not to speak to either Chris's parents or the parents of another patient. Why?

Perhaps the Inquest will answer some of these questions - but will it also tell his parents why their son was held for almost 3 tears in a secure mental hospital as a result of only a single minor incident for which he was found guilty for in a court of law, on the grounds that he knew what he was doing, and therefore was not suffering from any identifiable mental illness.  In 1999, before he went to court, Dr. Bhatercharjee (RMO) told Chris's parents he was only keeping Chris in hospital to see if a mental illness would develop.  At a Mental Health Tribunal in February 2001 he agreed with the second opinion Forensic Psychiatrist that Chris was not mentally ill.  So why was he in a Mental Hospital ? Or why their own and Chris's complaints raised at every level about the way he was treated whilst in the hospital were completely ignored ? Or why he was eventually convinced he would never, ever, be able to escape from this situation, and was driven to take the only escape rout to him ?

This is Chris's Story.  The only child of loving parents, he grew up in a happy family environment, was sensitive and caring, got on well with most people and had a good circle of friends.  He became a school prefect and was reported to be mature responsible and hardworking.  The day after leaving school he began work at one of the area's most prestigious engineering firms, and began an engineering courses at the Technical College.  Perhaps he was too responsible and hardworking, as in the 3 years that followed, besides studying hard ( he was nominated for a City & Guilds Silver Award ), he was often working 50-60 hours a week to help the firm fulfill contracts.  When his father suffered a near fatal brain hemorrhage, which left him disabled and partially sighted, though still only 18 1/2 he willingly took on the additional responsibility of sorting out and winding up his father's garage business.  Little wonder he began to suffer from stress, insomnia and a severe vitamin B12 deficiency.

Before his mother, an RGN Nurse, was able to check her concerns about this, Chris suffered a brief psychotic incident, during which he unexpectedly stabbed his father with a kitchen knife as he lay in bed, causing 2 minor cuts to his shoulder, requiring just 3 stitches each.  Seeing Chris was unwell, his father called an ambulance, but the Police came, and Chris was arrested.  Chris was interviewed by the Police, a solicitor only coming in half way through the interview.  Everyone later agreed that the interview was inadmissible, but in court, a year later, the judge allowed it to be used against him.  His father was also pressed to make a statement to the Police.  He made it clear he would not press any charges, but eventually made a statement when he was assured it would never be used against Chris but would help to get the medical care he needed more quickly.  This statement was later used to take Chris to court, in spite of all Peter's protests and refusal to press charges.

Examined by Police Surgeon Dr. David Lord, Chris was proclaimed physically and mentally fit, but he was then sent to Doncaster Young Offenders Institute Medical Wing, and examined by forensic psychiatrist Dr. Rooney Young, Wakefield Regional Secure Unit.  He claimed it was obvious that he had recently suffered a psychotic incident.  Neuroleptic medication was prescribed, Largactyl (Chlorpromazine), which resulted Chris becoming paralyzed and wheel chair bound. unable to talk, blink or swallow and left without food.  His mother's intervention prevented further doses, which she feared would have killed him.

He was then transferred to Northowram Hospital under Dr. Britto for 3 weeks, where his health improved, there were no adverse incidents reported, and Chris was helped by trips out to play badminton, swim and visit local shops.

Then the Castle Hill Secure Unit became involved and seemed to take control of Chris. He was transferred there and his GP was called in to agree a Section Order, but was not allowed to examine him, only being allowed to look at him through a window.  Being told if he did not agree to Section Chris would be sent to prison, he felt it was in Chris's best interests to agree.  He was held for a year on a MHA Section 3, this being renewed after 6 months without a Manager's Hearing (a Board of Managers didn't even exist at that time) and without the Medical Health Act requirement of an automatic Mental Health Tribunal (MHT) referral taking place.  (This was not a one-off oversight, since at least one other patient is known to have been denied this right a few months later).  Unfortunately the Blagbrough's were inexperienced in Mental Health legislation at that time.  They asked for information on Chris's legal rights but were never given any.  His parents were never asked for their consent for him to be sectioned, nor consulted or advised by an Approved Social Worked.

All their efforts were directed towards supporting Chris, as he tried to adjust to the problems and pressures of life on the Castle Hill Unit (CHU), trying to prevent him from being took to court, and especially to finding what had caused his one psychotic attack.

An automatic Vitamin B12 Deficiency Test identified a profound deficiency (15Ng/L- acceptable levels being between 170/ 900 Ng/L) leading to an emergency injections which continued for the rest of his life.  Chris's solicitor requested that he be allowed to see a specialist at the local BUPA hospital to investigate the B12 deficiency further, and this was agreed.  An appointment was made, but Chris was not allowed to attend.  His parents were later told that Chris has been examined by Dr. Bhatercharjee 2 1/2 hours prior to the appointment and it has been decided he was not fit to attend.  However BUPA stated the appointment had been cancelled by the CHU 6 days previously.  A second appointment was made, with the same outcome.

Investigations by his parents led them to contact Professor Hutto, University of North Carolina USA, who has researched B12 deficiency related psychosis.  He stated he had never known a B12 level as low a Christopher's and in his opinion it could well have caused the psychotic incident.

Another specialist in this field, expressed a willingness to assess Chris, but due to pressure of work, requested that Chris either be taken to him, or that copies of his medical notes be sent to him before he committed himself to traveling to Huddersfield.  Chris's RMO, Dr. Bhattercharjee, newly appointed to his first consultancy, made it quite clear that he resented these opinions being sought by the parents, refused to consider the possibility of a B12 deficiency psychosis cause, claiming he had no experience of it, refused to allow this specialist to see either Chris or his medical records.  This vitally important issue was never investigated.  Dr. Chesterman Forensic Psychiatrist, giving an Independent Assessment for Chris's MHT in 2001 started, "the reason could be found, should be found, and on his unit would be found. "  Why not on the CHU ? Formal complaints to the Trust on these issues were never answered. 

Dr. Bhatercharjee, resenting the fact that Mrs. Blagbrough was qualified to raise informed medical concerns.  He displayed open hostility on this and all other issues subsequently raised by the family relating to Chris's care, and the hostility increased as time progressed.

In spite of all the parents efforts, complaints, protests and refusals to press charges (or possibly because of them?) Dr. Bhattercharjee became more insistent that Chris should be taken to court, even telephoning the Crown Prosecution Service (CPS) and Defense Barristers saying he wanted a conviction so he could "dispose" of him. Thus, having spent more than a year in a mental hospital, Chris appeared in court. Given the option of either admitting unlawful wounding of pleading not guilty to attempted murder, the family felt blackmailed into making a plea of guilty to unlawful wounding, because they dare not risk a chance of attempted murder.  As a result Chris was put on a MHA treatment and restraining Section 37/41, order for life.  This is the same section as the Yorkshire Ripper, a fact which had the most devastating psychological impact on Chris.  After the hearing he said, "My life is now over." And it was.

The downhill spiral had really begun as soon as Chris was transferred to the CHU.  At first he did receive some sympathetic support from his primary nurse, who felt Chris should not be on that unit.  All his recommendations on Chris's behalf for therapeutic interventions were turned down.  Within 6 months this nurse committed suicide and this had a devastating impact on Chris.

Given the drug Venlafaxine he suffered vomiting attacks.  His mother informed the staff this was a British National Formulary (BNF) recorded side effect of the drug, but they refused to accept this saying the vomiting was self induced.  His father brought this to the attention of the Ward Manager, pointing out that the drug was not helping Chris and should not be increased,  with the results that the following day the drug dose was doubled to 300mg.  This caused palpitations and severe heart pains (also BNF listed side effects), necessitating him being rushed on to a heart monitor and 10 minute checks for the following 3 days, as well as the immediate sudden withdrawal of the drug, which itself causes serious side effects.  Though feeling very ill he was not even allowed short rest periods on his bed.  later the unpleasant side effects of Modecate left him feeling very unwell for days following injections, including regular severe mouth ulcers causing difficulty with eating and speaking, plus rashes to his body.

Chris often said he wished he had been sent to prison instead of the CHU, stating his "sentence" would probably have been shorter, he'd have known when he would be free and the conditions could hardly been worse.  He felt the CHU is run on a penal ethos of intimidation, blame and punishment, with no effort to provide care or support.  Even worse was the overwhelming power and control enjoyed by the RMO whereby every action or problem was justified by his "clinical opinion" and blamed on Chris because of his "illness".  Chris was made to feel he had lost all control over his own life.  Dr. Bhattercharjee and Staff continually told Chris that he was, "A criminal and a danger to society" causing him considerable psychological distress.  Dr. Bhattercharjee also told him he would never be allowed to live at home with his parents again, and that this was a Home Office ruling.  When his father telephoned the Home office to question this he was told they did not have the jurisdiction to make suck an order.

Chris had been brought up to walk away from trouble and he tried to get on well with the majority of staff and patients alike, but being so young and slightly built he became the victim of bullying by some patients immediately he went onto the unit.  All his belongings were either stolen or taken from him and if he objected he was beaten up.  His parents gave him a case to lock his things in, but this was cut open and the contents stolen.  This on a locked unit where all knives and sharp objects are prohibited.  Complaints to staff and management were ignored, so after Chris was seriously attacked by 3 patients, his father reported it to the Police. They took no action.

Chris eventually learned the only way he could survive was by sticking up for himself, but the only achieved him a label of "violent", which was used as an excuse for even more repressive treatment  and the loss of parole.

During a visit by his Grandmother a member of staff struck Chris.  He retaliated, and was then seriously assaulted by the staff member.  Distressed, she wrote a letter of complaint, which was purposely misinterpreted.  Police officers were brought onto the unit and gave Chris a "formal caution", without a legal representative or advocate present, for hitting the staff member but they did not interview his grandmother to find out what she had witnessed.  Chris was later severely assaulted by 2 staff members, causing facial injuries.  His father took photographs, made an official complaint to the Chief Executive and also the Police, without any action being taken by either.  Yet the Police were quick to attend the Unit to give Chris a second "formal caution" following an incident with another patient.

The unit is designated a short-term rehabilitation unit, but if offers little rehabilitation and the majority of patients have been there many years.  With a ward full of young men, locked out of their rooms all day and confined in a small unhealthy, restricted environment, with nothing to occupy them except TV and one pool table, its hardly surprising that boredom, tension and friction will occur.  Chris said a regular topic of discussion was "ways of committing suicide" ! Even on summer days the only access to fresh air for most patients is a very limited amount of time in the small fenced compound and is virtually non-existent in winter as is any form of exercise.  Chris was sometimes offered a few hours a week Occupational Therapy, but often found it offered little to motivate or stimulate him.  Staff escorted ground patrol was granted at times, but seldom took place due to insufficient staffing levels, and any problems on the ward always resulted in it being withdrawn as a punishment.  Occasional escorted off-unit trips were allowed, but though no adverse incidents ever occurred, these were few and intermittent due to staff shortages, and any beneficial effects were short-lived due to the length of the time between them.  He was never allowed any social visits with his parents, and a negotiated and long planned and looked forward to visit to his Aunt was cancelled due to the lack of an escort.

There is one part-time middle aged female psychologist attached to the CHU.  Chris began sessions, but found it difficult to relate to her.  The sessions were discontinued after he became distressed and embarrassed by her constant questions on sexual issued.  No other psychological support of any kind was available.

Some staff bullied and belittled patients, and would threaten and intimidate them if they dared to complain.  Chris was asked to write out a complaint for a fellow patient who was less literate, who then signed it himself and addressed it to the Ward Manager.  A staff Nurse read and destroyed this, then threatened the patients and Chris, accusing him of fraud and deception.  Both Chris and his father made official complaints about this to the Trust's Chief Executive, but were ignored.

It is little wonder that as time passed Chris became institutionalized, experiencing guilt, confusion and depression and his suicide attempts began.  Twice when he was secluded, staff stripped him naked and put him in a room with only a mattress.  Female staff members, doing visual checks, laughed at him.  Embarrassed, Chris tried to cover his nakedness with the mattress, which was then removed from the room.  When his parents questioned this incident they were told his clothes and the mattress were removed for his own safety in case he tried to hand himself.  With a mattress, in a secure room with no ligature points and under statutory observation levels ? Official complaints were never answered and the Ward Manager, later tried to claim they hadn't happened.

For a Tribunal Appeal against his Section in February 2001 Dr. Chesterman, Fulham, Islington and Hammersmith NHS Trust, was consulted and gave the opinion that Chris was not suffering from a mental illness and should be discharged.  Cross examined by Dr. Bhattercharjee agreed this.  However, the non-medical Chairperson of the Tribunal Panel, a Carol Clark (who just happened to be a Non-Executive Director of the Calderdale and Huddersfield NHS Trust and also the Convenor dealing with the Blagbrough's requests for an Independent Review of their complaints), gave her opinion that he was suffering from schizophrenia.  The Appeal was unsuccessful.

In desperation, after years of having their concerns ignored by the Trust, the family appealed to the Complaints Convenor, the Ombudsman, The Mental Health Act Commission and even the General Medical Council, but were told they must follow the Official Complaints Procedure.  Letters from both themselves and their Solicitor were ignored and they were told by Dr. Bhattercharjee to "Complain as much as you like, we will only send you round in vicious circles and you'll never get anywhere."  The only people who listen were Professor Rowden and Alice Mahon MP.

Eventually in May 2001 The Trust Complaints Department informed the family an "Independent" Psychiatric Report had been produced, but they were never allowed to see it.

In total desperation, Chris absconded with his father to Spain.  They stayed away 4 weeks' proving Chris was well and able to cope away from the unit, and with the aim of getting Chris's father prosecuted in an attempt to get the background of the case investigated.  It did not work.  The  CPS chose not to prosecute.  Chris was banned from seeing his father ever again.  This upset him so much he was often in tears about it during the remaining 8 months of his life.

Eventually, due to the sheer weight of complaints from other families as well as the Blagbrough's the Trust was forced to commission an External Review.  Though this did not have the power to investigate any specific complaint, the recommendations from their report prove that in those areas which were examined, the complaints were justified.  No remedial action was taken, and specific recommendations which made for Chris and one other patient were never implemented.  During the Team's involvement it was agreed Chris needed to move on, and arrangements were made for him to attend college to complete his City and Guilds Engineering course.  Dr. Bhattercharjee cancelled this as soon as they had gone, on the pretext that Chris had tried to see his father who had been seen in the hospital grounds by a member of Ward Staff.  He had in fact been asked to attend a meeting at the hospital and had not attempted to see Chris who did not leave the ward.

Chris's solicitor arranged a further and also informed Dr. Bhattercharjee he was breaking human rights legislation by refusing to allow Chris to see his father.  Dr. Bhattercharjee tried to intimidate Chris, saying his solicitor was wrong and that Chris should not be having a tribunal.  He threatened him with never being allowed to go to college or to leave the Unit.  Chris resisted 2 days before his death he instructed his solicitor to go ahead with both actions.  The Tribunal Reports written by Dr. Bhattercharjee and Nursing Staff contained so many vicious lies, the obvious aim was to enforce that threat.  It worked.  Within hours of being given copies of these reports Chris hung himself.  He never went to college to finish his course, nor his father again, nor went back to live with his parents.  But he did find a way to leave the Unit and Dr. Bhattercharjee had "disposed" of him.

One week prior to his death Chris told his mother, "My story is so tragic it is almost laughable."  You've read this story , are you laughing?