Engagement session wobble Care Navigation

Today I thought I was looking forward to today’s service User Carer meeting with the Royal College of Psychiatry we was looking at Care Navigators and what a good one looked like, I was all psyched tell them about Tims Navigator Gary Wright the one who went above and beyond for Tim the one who did everything for him the one who services let do everything for Tim but never checked in on was everything ok, never got back to Gary when he had concerns, Gary helped Tim with many aspects of his life even tried addressing Tims mental health needs. Tim was only meant to have Tim on his books for a few weeks but he knew Tim needed intensive support an was not getting from statutory services. I was all excited to share some of the good out of the sadness I tweeted, fb an linked in an update and a pic of Gary with my mum in his fun run tshirt he did a 10k for Wyfi an ran in memory of Tim. But the closer the train got to kings cross did overwhelm swallow me up, I became over stimulated, hyper sensitive walking down to the Royal college of Psychiatry after getting of the tram felt like walking down a minefield the noises of passing traffic, work on nearby buildings, footsteps pounding down the street felt super sonic my mind went into a haze, mentally shutting off, instincts saying can’t engage today I’d triggered myself consciously I thought talking about wyfi been a good organisation would be ok but subconsciously I was challenging why other organisations that came into contact with Tim didn’t do same, i was winding myself up. When I arrived I saw the slide on what we’d be discussing I sat in my seat eyes fixated on the screen I got this but boom tidal wave hit floor was swallowing me up, hands face burning, dry mouth, knees buckling, heart pounding I had get up, I had flee, I made a coffee got upset wiped myself down berated myself I went back in I tried inputting, sharing ideas but everything felt amplified an that made me feel trapped in , hemmed in, panicked which then makes me reactive I know a good navigator why could I not get my points across with going into overwhelm felt not listened to felt I was fighting for something good I felt challenged but probably wasn’t, Care Navigators though I passionately believe in, I know what I’d want in one, I know the type of relationship we’d have I know how I’d want them engage with me, my family an all areas of my life the physical, mental an social but today just not on ball. One of members of group gave me a cuddle I broke its hard fighting for good, it’s hard engage with services it’s even hard engaging when at an engagement meeting. It’s hard though things regarding Tims inquest been know at a standstill and it weighing heavy in my thoughts an heart and today threw me off my A game I’m hoping sharing the slide someone could answer the questions on to them what they’d want a navigator look like because I’ve completely disengaged as I no longer trust the model or service or that they’d get right hoping people can though get their voices heard an I’ll happily forward your thoughts to team an you help me to try focus an be engaged whilst am a little wobbly today taught me need practice self care when engaging in engagement work and trying fight to make change an fighting for answers for tim my brother an best friend. Today wasn’t a good day but won’t let it sway me I’ll brush myself off and try again another day

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Everyday

Everyday I wake I pretend to be ok, I plod on I have too I’ve no choice I’ve a son who needs me, but everyday I wake with the stark reminder my brother’s gone, I go to phone his phone see how is scroll for his number but when get too am held back from phoning, when I’m on Facebook I go check his see what funny pics hes posted but last years worth of posts on his wall are ones I’ve tagged him in hoping in heaven he somehow see’s. I’m laid here now tears slowly streaming down as I thing about him wishing he was still hear, I wish he could say he was ok wipe my tears tell me to get some sleep, it’s late and ask me why I keep waking up at daft o clock in the morning an just lay staring into space. I wish I could scream at him yell at him call him selfish god knows what but I can’t because what he did the day died was a stupid an desperate attempt at get someone to listen to him, help him. I refuse believe he was giving up on life on Mum, on me , on jay n nat n robynn an our kids because kids especially were his world just as he was our’s. I know his Mental Health drove him crazy it did us too we were at a loss time an time again not only Tim reach out for help we did too, We’ve had no support, nowhere to turn too we’re now banging our heads against why an getting people address an learn from failings in his care just as much as Tim banged his head against brick walls trying to get help, I often wonder why no one supporting Tim picked up on the signs he was not ok did not notice him slowly disappearing from the picture, disconnecting with his volunteering, cutting himself off, I often wonder why placed somewhere he didn’t know felt lost an outsider out of his comfort zone not knowing anyone an stuck not getting help from somewhere supposed be supported, Everyday I taunt myself ideas, thoughts reading through paperwork we get passed trying put the jigsaw together but all I get is more questions never getting close to the bottom off never getting the answers to what went wrong not been able fix lessons be learned from. Everyday know feels like a constant pressure a heavy weight trapped in a cycle a haze a whirlwhind trying to clutch to something that will help get the answers and piece together the solutions but everyday feel dragged further an further apart. Every is now a struggle a constant dark fog of grey mist but can spark to red mist when see something or hear something and become hypersensitised too, Every day draws on longer an longer , lonelier an lonelier it’s isolating , it’s frustrating it’s become the loneliest place ever now has the world an it’s hard to paint false smiles, it’s hard show interest in the mundane on one hand want friends an people to care on other you don’t because they can’t fill same space they’re really not person you want see an you want them be good enough but sadly aren’t they can’t fill the gap, can’t step into shoes, interact same way can’t be just like Tim. When out an about my mind will play tricks I’ll see people who look like him chase voices of people hear who sound like him and when realise not is then a slap to face harsh reality hits not him I should remember but I don’t because try pretend switch off from, yearn escape the realities off but can’t I have persevere, try pretend I’ve cracked self maintain the mental health but only just doing dangling by a thread. I wish could wipe the cobwebs off me away, wish could erase the past put Tim back in we’re should be but can’t I’ve just to try face. Accept an one day grieve I don’t want have battle everyday for answers why failings I want put measures in place to prevent deaths like Tims an I’ve to do so logically piece the jigsaw to be able then mourn in peace in a graceful way not angry with tormented by an we’re feel no pain. I don’t want to talk about or thing about but nature of his death but. sadly because can’t grieve an trapped by fights for answers for am stuck in a tidal wave of thoughts about preventable suicide, patient safety, breakdowns, communication , systemic failings I want to pop the thought bubbles, push them away, take a break from just for one day wish could go back to before Tim changed before he passed so can try get normalcy in my life back regain control am make everything ok again.

I’m not scary, nor psycho, I’m nice when get to know me.

On the 1st of February it’s Time To Talk Day I for last few years not partaken in for various reason’s but this year I have because it’s dawned on me people don’t rarely get to try and know me, talk to me, have painted a not nice picture of me not taken time to get to know me or Try understand me they’ll look down when I pass, try look busy, let’s not ask Katie how she is,

These last 18 months have been the most loneliest an most challenging especially with trying raise a toddler an self maintain having PTSD and I was hit with losing my brother to a preventable suicide an passing of my grandad closest thing had to a Dad.

These last 18 months I’ve struggled felt isolated people’s lives moved on mine didn’t , people didn’t want ask me how I was after my brother’s death because they didn’t know how I’d react I’m pictured as an angry, volatile person because have gone 0-10 on blow my head shouting scale but people don’t realise if I persevere I or my sons at threat I will become heightened an will react an I will use certain instances to react because the things that I don’t want to nor ready face come to terms with an deal with I try ignore but I get overwhelmed by something as simple as someone telling my child off is enough to spark that fuse and I’ll explode and I understand that when I explode it’s not a pretty site, I hate myself after it , I will bully myself turn in on myself I attack an put myself, I’ve also been known in certain situations known to suddenly drop everything and run because I don’t want people see the upset, the pain I don’t want people see me react me be weak, be vulnerable, don’t want feel trapped, panicked and nor do I want explode so see I’m stuck in a catch 22 do I blow up, do I let you see me upset.

I can’t though let you see me upset because you’ve not given me a chance, got to know me, not got to understand me a handful of people do they don’t see me as a scary, psycho mad person they see the scared person the person that’s hurting they see past that side of me they know it’s something that’s part of me can’t change no amount of therapy an anger management an counselling will help I’ve just had to adapt, to accept that’s one of my traits and angry Katie is only a small part of me but it’s the part that stands out.

It saddens me and hurts me that people may feel intimidated or scared of me because I’m not a scary or bad person nor am I violent I just get aggressive but that’s because I trying be assertive an protect myself but it comes out like a loud screaming banshee and I’m not that person all the time just a small percent off but because people don’t get past that point sadly the world does become lonely an isolating I try pretend it doesn’t hurt, try ignore how people are, I find myself now to avoiding people because when you stop to talk I struggle know what say, can’t pretend alls ok when not, selfishly don’t want hear how lives great don’t want pretend neither it is and rather not have people squirm , cut short conversations when do try open up because then I’m protecting me not opening up, exposing myself protecting my heart, ,my well being my self care.

Learning how to feel live with my emotions was a blessing at first but not so much at the moment because how now perceived when hit a stumbling block an working way through, medication, therapy hasn’t been an option for me I don’t yet trust services because how I ended up in past an because failings which led my brother’s death I plod on try attack get through each day one at a time.

If people took time to get to know me, too ask , too be my friend they’d see the nice Katie, friendly one,one whould go try out way make sure is ok but people struggle give me a chance I need people do that because it’s only way I’ll be able let you in because I struggle let people in because I’m that used been hurt, rejected people pick up on perceptions on me that I don’t let my guard down an sadly even though I’m extrovert need you make first move an try.

Theirs been days I’ve felt that lost, that alone questioned my existence have had days wished not woken up because don’t want go through life perceived something not, wanted life go back how was too been good but I can’t change the last 18 months just try get me back in check an I’m doing slowly but sadly I’ll always be held back if people can’t see past a small part of me.. and so for Time To Talk Day I wanted to address people picturing me as a monster, psycho, a person feel intimidated by because deep down that’s not me also I want people too try understand how when your anxious, feel at risk an have ptsd you don’t see logical ways out and when we talk about Mental Health we don’t talk much about anger, and how anger is a part of Mental health an how anger has people perceived an so I thought I’d through my blog challenge an address because here’s safe do I can be vulnerable because I’m hid behind the keyboard however tomorrow u may see me in person an if do just try say hello wish me a good day make me feel visible, accepted a chance belong because I do try my very best and don’t want to be seen anymore as scary, psycho Katie and so I hope on Time To Talk Day people see past someone’s Mental Health an see the person that’s within.

Finding a way saying goodbye losing my brother to a preventable suicide

I lost my brother to a preventable suicide he fell through the cracks systemic failures by the trust an social care team under and the supported housing team were he lived. It’s the worst way to lose someone you can never prepare for, comprehend an understand why. I lost a baby born still born in 2002 I knew she was to be born stillborn due to severe spina bifida an hydrocephalus I knew as she took her last breath I’d hold her in my arms I’d kiss her on the head and I’d say goodbye, I lost my Grandad back in February 2017 I called in on the Morning of the Day he died to the hospital the Doctor told me that day when my Nanna came in they’d be stopping his medicine, taking his oxygen away he was getting put on an end of life Pathway, I went up to my mums saw my nanna an held her told her prepare for worst, I went to lighthouse academy my friends held me up, prayed with me I was preparing say goodbye. That night I went back to the hospital treatment had been stopped, as many family members as could were contacted, notified mad dashes to the hospital, he was surrounded by family held he was not in pain nor alone I got to say goodbye even though I wasn’t ready. Nothing can prepare you when you lose a loved one to Suicide because you can’t see it coming, you don’t expect if you knew or had a chance you’ld do everything in your power to stop from happening. This week I read in our legal teams argument for Article 2 systemic failings led to the events of my brother’s preventable suicide , I read that my brother had already passed when the paramedics got too him and probably had been a no of hours it breaks my heart to know he was lost, alone an in his final hours an until found had died that way. I wasn’t their to hold him, my mum didn’t get hold him even though an adult was her baby she did didn’t get that chance like I did with my baby somehow prepare an be their and like with grandad we knew we all surrounded wrapped round him he’ll have felt an known was loved I hate the feeling that losing my brother to a preventable suicide has done I hate knowing he may have felt unloved, unworthy, uncared for because he was. Losing a loved one to suicide is not only their lives lost but also part of you, your family dies too it feels strange, unnatural, not right, it’s broken, fractured, damaged your heart, the heart of your family dies too you get swamped into a dark hole, dark skies descend over all you know, life, joy gets zapped from you. I hate that I didn’t know, didn’t get chance stop, didnt get hold my hand out pull him back, I hate that I didn’t get say goodbye I hate that I don’t get angry at him, I hate that I can’t ask him why, I hate that I can’t bring myself to hate those who failed him, I hate I don’t have an axe to grind I hate that I want to give them a chance to learn lessons from his death I hate it’s been me, my family who held out that olive branch and I hate that they’re reluctant too take I hate that I can’t hate them want give them a chance I don’t understand why because they robbed me of my brother, my best friend , I want scream, yell call them murderers because of their systemic failings but I can’t because I know he deserves more, I know I’ve to give those a chance who failed him, I’ve to fight the legal system for article 2 to make his life matter, his memory, his life be remembered, he be remembered as someone who deserved help, be supported, cared for, a life worth saving and him not be just another life sadly lost to suicide, him not be a statitistic because he was worth more than that. Losing a loved one sadly to a preventable suicide flips your world upside down an know all can do is try make sense off and fit the jigsaw puzzle pieces together that led to that day to understand why and then with that completed puzzle find a way grieve, mourn say goodbye an try prevent someone else from sadly taking their live, give those that failed ideas to come up with pathways, measures to build safety nets to try ensure dosent happen again, I don’t have anyone can go to that can talk to about so I share my feelings here in my blog I know people struggle to talk to you about, ask how help, I know because I struggle with too. I hope that people reading who are in same place my brother was would contact me so I can help you so you don’t do what my brother did as you are worth more than that, for those that have lost a loved one to suicide to feel free contact me you are not alone it may feel it but I know the pain you feeling I feel it too, to Services, councils, NHS trusts social care providers that want make a difference to people affected by addiction, mental health and homelessness and put mental health on their patient safety strategies or looking at suicide prevention of people society turns their back on we’re culture around people with combined needs or are seen as unsafeable or attitudes around personality disorders needs challenging or your pathways not inclusive your not getting everyone on one or you need improve your community contact me if you genuinely want learn knock on my door because like I said lives like my brother’s matter let’s work together an make a difference I can’t bring him back but his memory, story can help save life’s.

The fight to be granted an Article 2 Inquest for Tim continues…

Yesterday me and my Mum met with our Solicitor regarding Tim’s Inquest was that the Coroner did not overturn his decision on Article 2 and disclosure was because my brother’s death was classed as been in the community regardless of the fact of him living in Mental Health Supported Housing, apparently Tims Death is a grey area in eyes of Law because he’d not been sectioned or detained he was not classed as immediate risk, he went for help on Monday was seen at A n E but because didn’t come out an Say “I’m Suicidal, I’m going to harm myself, End my life was reason why did not get admitted, I in the past have felt torn one hand want fight my demons on other want give up I also no at times felt want give up wouldn’t tell anyone what my intentions were, fact he’d taken a minor OD suggested he was at some element of risk , the fact 2 days prior reached out again saw his GP and his GP only offering Tea an Biscuits should have again highlighted needed help, highlighted again was a risk but because in the community the grey area he had capacity make choice did, if admitted to hospital till his key worker who became dependant on may have kept him alive, kept him hate say safe because he’d have been took away from what his stressor obsessing about his housing, finances,benefits,low self worth due been unemployed and his death would have been prevented if detained because not detained he stayed been at immediate risk, regardless been in the community, been in hospital the fact remains he was not mentally ok an that meant he was at immediate risk, I’m saddened the coroner didn’t grant because he has all the evidence their say was immediate risk but because 12 months outdated and not reviewed by those who were supposed to coroner has assumption then not an immediate risk, he at that period was , he was for the last 2 1/2 years of his life was an immediate risk an never stopped been adequate an a up to date review would have proved that but wasn’t and why arguing failed in his care it saddens me that powers that are responsible and their actions are now impacting on the legality’s and imposing further on our fight for answers why, we only want answers why to mourn, to heal, so lessons can be learned other families don’t feel our pain, people like Tim be saved, it saddens me more that if wasn’t for Legal Aid funding we wouldn’t have got this far, we’ve to hope now we can get continued funding to take to Judicial review and potentially try bring about new case law and get Article 2 be granted and it’s a fight we want to fight for , the services that were responsible , the ones with all the answers, one who not engaging with us as the family the state has an unlimited money pot for their legal army, talk about them having the unlimited power an control, we as a family should not be saddened, worrying about now the If and If get funding all families who’ve lost a loved an have go through the inquest process should automatically be funded more so when is the state going up against an for us that’s the NHS an local council we’re does anyone get the money to take them on to get the answers, the justice for lessons be learned and I can only pray, hope, wish funding continues if not I don’t know what we’ll do next I only no we won’t be throwing towel in, well come out fighting that bit more.

After what was a shit morning we did however still remain optimistic, plodded on with our day still continued with wanting support NHS England with their Learning From Deaths work and headed down to Quarry house in Leeds to feed into preparations for attending an event in WestMinister to continue an drive the work forward I must admit I took my tension from the morning out on the taxi driver so was composed when went in, sorry to the roadrunners taxi driver, were still optimistic as a family we can try ensure families not treated in same we’ve been , we’re still optimistic we can make something good to come from something terrible, we’re hopeful to that at the event we can be matched with the trust that failed Tim so we can demonstrate that families can work together with them an hope that they see after the event is important to meet with us as a family start the process again work with us to understand the why’s the if’s and importantly us work together on what could have been done differently an would have potentially prevented Tim’s death an hopefully us work with them to prevent deaths like Tims so deaths like his don’t become grey areas and so can only hope too as we continue fight for an Article 2 Inquest that in meantime we can work with the trust and lessons from his death be learned,

As a family we’ve tried be compassionate, empathetic an understanding with the Trust tried listen to potential excuses why failings, funding, staff shortages, difficulty getting access to certain services an continually try engage with them so why’s it hard for them do that as fundamentally they should do that, it’s not them that’s facing pain an heartache we are an should be us not them had choice hide behind closed doors because not ready face but we’ve no choice we have to face to fight and so Tim for you we will continue to do so.

#MH CUTS #MORE LIVES WILL BE LOST #Wheres that £1bn gone.

Last night I was emailed by National Mind as one of their campaigners to submit to them a 20 word tweet that they would tweet today as part of their campaign to stop the #MHCuts and #protectthe #NHS. Today at same time am enroute to London to work with the Royal College of Psychiatry as a service User an Carer board member to their conference as they look at the five year forward and community mental health transformation Pathway and sadly the start of today feels bittersweet an bleak as with every will in the way even with the most passionate people their an even with every bit of negative stories shared to learn from an even stories of good practice that could be implemented service users, carers, family members an 3rd sector, social care and statutory services will be still up against and the money needs to be their, Funding needs to be made available to many lives are currently either been failed or lost due to failings in Mental Health Care, My brother sadly has been one of those lives been lost when he sadly lost his live people did say more needed to be done for Mental Health Services that their was long waiting times, difficulty accessing services, not enough acccess to regular contact with professionals overseeing care, unable access therapy, crisis care an specialised support an at time wasn’t ready listen to that as an excuse or factor in my brother’s death as in today’s society we should be able provide adequate care, funding should be their and so why isn’t it why did our government help assist in my brother taking his own life where were they were was the money that should have got him a bed at a specialist my rehab an recovery unit as it was down to their been a 2 year waiting list and funding why when he an us as a family were turned down for when he first presented needing help, were was our govt when he was unfairly detained in prison due to a mh breakdown an no beds available for him a judge would of spared him that if their had been a bed available for him, my brother thought so hard to recover but he was always up against it passed from service to service, no regular community mental health or social care support became lost in a system designed to protect people, I could stay bitter an hate the system but it does me or my family nor my brother’s memory any good we can only fight for change campaign for and use my brother’s story his memory to ensure no other family goes through what we do, its heart wrenching, gut wrenching an mum I know you’ll read so sorry if upsets you but it is soul destroying knowing your loved one died feeling alone an that apart from his family no one cared for him and that he was made feel that an that no one was going to help him and that after 21/2 years felt exhausted every Avenue and in desperation did something stupid and sadly it cost him his life an it breaks my heart he died alone in a place supposed to be providing him support an care an supposedly their just be funded be private landlords as a sister feeling that pain is unbearable so I ask if on twitter please copy an share my tweet ” My brother’s suicide could have been prevented if had access to specialised support deaths like his can be prevented stop mh cuts. include my name . @KatieAnnSiobhan and share my blog and #Do4Tim #StoptheMHCuts my family and I can’t so Teresa May, Jeremy Corbyn, Jeremy Hunt, The Chief exec of NHS England were’s they money gone, where’s the money to fund #mhcare if don’t provide an deliver sadly more lives will be lost in memory of my brother please don’t let that happen.

Why are Mental Health Services Failing, Why are Lives been Lost.

I was once optimistic Services would improve and improve for the better initiatives an policies around crisis care, no decisions about me made without me were made the NHS an services were to be Liberated the Recovery Bus, Coproduction Bus and Person Centred Care Bus rolled up into town. Did they make a difference, Did they leave people liberated and will the new 5 year forward initiative make a lasting impact I’m sceptical it won’t because I once believed that Services Could Change Improve Lives, Help individuals Regain Control and put the person an those close to them at the centre and provide a whole person approach attitude to care. I was wrong and my optimism that Services Could do that proved to be fatal. In the last few weeks the media has been highlighting cases were deaths are been investigated and a trust is to be investigated in one case. I’ve discovered that my family is not alone as we too are fighting for answers to how our loved one could have lost his life he did not lose his life however in an inpatient setting he lost his in a transitional housing unit a unit that’s supposed to provide care for vulnerable adults who were in crisis, needed mh support, support with homelessness an substance misuse. We put our loved ones care in the trust of services an the local authority that they would ensure an provide the care an support he needed.

We sadly got it wrong we like many other families now are fighting for answers we’ve had reach out too advocacy support, lodge formal NHS complaints, left outside the serious incident review process yet had our hearts ripped wide opened when had the people running come visit us at my mums family home but yet still no answers no been asked did we want input nor told what they will learn or put in place been sent a document though however that supposedly has in can we sign off on it. How can we if you’ve not sat gone through it with us or had us been involved in any of the process no one can make a decision on something not involved in but shouldn’t we have been after all we’re searching for answers to why, why our loved ones death was not prevented. We had to reach out to a charity Inquest because we didn’t know anything about what to expect, how to be involved the types of inquests and if not for them we wouldn’t have been put in touch with a solicitor an barrister but we’ve had to meet criteria for Legal Aid an that only covered representation to help prepare the case for inquest we then had to apply for separate funding for a grant to have barrister representation at the inquest but yet the Services who failed automatically have the money behind them to represent them but for families they have to search an find that help an that’s sad it’s also sad we don’t get automatically represented as do the services as it’s a live been lost here a life that mattered and a death that should be held accountable for and answers need to be answered how could it have happened and why and was enough done theirs also issue you had a duty of care an families put that trust in you and that is why then you become accountable because that trust was put in you. As a family member I witnessed my loved one passed from pillar to post, told to ask for help an when did told couldn’t help so why tell him ask for, I saw pleas from my family ignored, I saw my loved one slowly become even more invisible, dehumanised, made feel unworthy an in end not listened too, not cared for or supported that’s hard to face an accept especiallly when don’t expect from services that were supposed to be their an provide that. Sadly my loved ones passing won’t be the last an that too is hard to accept because you then wonder what will they learn from the incident report carried out an what will they learn from the impending inquest because sadly my brother won’t be last. I also suspect under the area he came under he was sadly not the only individual failed and probably other families going through what we are too. Whilst awaiting I see initiatives around patient safety, suicide prevention an the new buzz one 5 year forward. Will they make a difference I suspect not it’s just a recycled blue print that for last few years keep rewording add a few more charts an statistics an wow a new policy or charter to follow sadly not worth paper printed out on because sadly lives are continuously been failed, no one been held accountable, no lessons been learned from, their lives not mattering. Services are still been under funded, cuts still been made, workforces at breaking point, charity sector organisations stepping up and lifting the burden from you holding you up their the ones trying the best but are not given the credit for nor do you liase with them and assist in supporting someone you just quickly like pass someone on so not on your case load yet you need to work with them they can’t do it all alone but yet as with families you isolate them too. Crisis Care is shocking too the crisis care concordat act did that make a difference if did my brother would not have been turned away twice an also got in housing were living, but sadly their isn’t enough beds in or out of are, not enough home intervention teams and respite places available an thing we’re my brother lived is only 8 crisis beds available. Wasn’t the crisis care concordat act supposed to address that. Vulnerable individuals languish in police cell’s awaiting mh assessment some end up in the prison system locked up unfairly because at crisis committed offences but because not enough beds professionals say can see unwell but doesn’t warrant admission an so under public nuisance an anti social activity get imprisoned as well as many other offences during my brother’s care that too happened just impeded him further. It makes you wonder why as a society are we allowing that to happen why is the police and judiciary system allowing that are they powerless to act against the services can’t they enforce services to act especially when they clearly know difference between a vulnerable an mentally unwell person an hardened criminal. Why is it that over the years what’s published, guidelines not implemented you’ll tweet about, talk about have development meetings about but not implement, no changes be made and very little service improvement. Yet you market yourselves, give fancy awards, and too have buzz weeks fab change week the latest so what will you do what change an implement will you make what will you do to prevent lives been lost, Will you make your services inclusive to all, stop cutting services that matter, work with organisations lifting you up, will you stop labelling an stigmatising people under your care, will you stop turning people away because don’t fit your Dx an recovery models more importantly support loved ones who’ve lost someone under your care. Families shouldn’t have to fight for answers, set up justice groups an campaigns and have to search an fight for the answers because they need compassion an care an time to grieve they don’t just deserve empathy but also deserve be treated with dignity, respect and upmost of all they need the answers so can grief, hate say have closure an make pretending moving on with life’s easier. It’s also now time ask why in this day an age why are services still continuing to fail an sadly lives been lost.