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‘I had no voice': black mental health patients on surviving a care system they say is racialised

‘I had no voice': black mental health patients on surviving a care system they say is racialised

The Guardian13-03-2025
It has been more than four decades since Devon Marston, a 66-year-old community organiser and musician, was taken to a psychiatric hospital where he was restrained, injected and forced to take medication. He was diagnosed with paranoid schizophrenia.
'Everything was said around me and about me, but no one asked me how I was doing,' he said. 'I had no voice, and there was no one to say: 'Don't do that to him,' or: 'Listen to him, hear what he has to say.''
The experience had a profound impact on his life and put him on a path to campaign for better care for minority ethnic people experiencing mental distress. However, progress has been painfully slow.
'Nothing has changed. Everything is still the same – only it's more covered up now by clauses in the Mental Health Act that make it look fair but the equality and justice are not there,' he said.
The most recent data paints a frightening picture. Findings from the Care Quality Commission's (CQC) latest report show that the number of adults sent for very urgent mental health care from crisis teams more than doubled between 2023 and 2024.
The report, published on Thursday, also raised concerns about the overrepresentation of black people being detained under the act, finding they are 3.5 times more likely to be detained than white people.
The damning report warned people are becoming more unwell while waiting for help and are stuck in a 'damaging cycle' of hospital readmission.
Tiwa, 22, described her experience with mental health support services as 'incredibly traumatic'. Her struggle with her mental health began when she was 13 and began self-harming. She was diagnosed with depression, anxiety disorders, suicidal ideation, as well as an eating disorder. She still has nightmares about the time she spent in a children's mental health unit.
'It was a horrible experience that I wouldn't wish on anyone,' she said. She points to the use of restrictive practices, restraints, as well as the use of forced medication.
'There were nights where there were maybe four staff looking after 12 to 15 young people who were just constantly having very dangerous incidents of self-harm. So we would be the ones having to run into our friends' rooms, help them, save them, and scream for staff,' Tiwa said.
Her discharge from hospital was meant to be a significant milestone in her recovery. But, she said: 'Every single night, I was waking up sweating and so scared, having nightmares of being restrained and incidents on the ward.'
Both Devon and Tiwi believe their race influenced the care that they received. 'There were times when situations escalated so much quicker and unnecessarily – situations where maybe force was used when it wasn't necessary, or I was seen as being aggressive when I wasn't. In my opinion, it had a clear racial undertone,' Tiwi said.
Devon still vividly remembers the first night he was sectioned. He ended up in hospital after his mother, who was concerned about his wellbeing, but did not fully understand mental health, Devon says, called a doctor. The doctor arrived with the police and an ambulance to take him to a psychiatric hospital.
'I went over to the office where the night nurse was and I said: 'Excuse me, love, I think you've got the wrong person, I shouldn't be here,'' Devon said. 'All of a sudden I see two or four big white men come down the corridor after me, run me down on the ground … They injected me and I was knocked out for four days.'
His life had changed completely. 'I couldn't breathe. I was dribbling from my mouth. I couldn't eat properly. I saw people around me in a similar atmosphere. I thought, I'm going to heaven. I'm going to die. When I looked through the window, I could see the big ground where the ward was situated in the building and the flowers were growing and everything was serene. I never understood the experience but as the years passed by and looking back, I realised what happened. They gave me psychiatric drugs to quiet me down.'
He added: 'Anyone who's accused of having mental problems or becoming violent or being black and dangerous in community, they give you tranquilliser … These tranquillisers and drugs the professionals are giving to me and to us are different from the ones they give to the younger white guys. They don't get the same ones that a black guy gets.'
Dr Sarah Hughes, the chief executive of Mind, said: 'The common threads between Devon and Tiwa's stories, which span several decades and transcend generations and genders, show how far we still have to go on stamping out racism in mental health care.'
While Hughes welcomes Thursday's report from the CQC, saying it shows some positive early progress on implementing the Patient and Carer Race Equality Framework, she says: 'it is ultimately more damning evidence of the barriers that people from racialised communities face while trying to get help and recover.'
For Devon, recovery was possible thanks to music. A nurse who had recognised his talent arranged for him to start a music workshop for other black men struggling with mental health issues. In 1992 he co-founded Sound Minds.
When asked what needs to happen next, Tiwi, now a young campaigner who works with institutions on reforming mental health care, said discussions of change must centre on people's lived experiences. 'If anyone knows what it's like to be part of the system, it's the people who have experienced it … It wouldn't make sense for these people not to be a part of the change.'
Devon agreed: 'Listen to us. Ask what we need, and we'll tell you.'
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Mum treated like 'rabid dog' before choking to death on paper
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Mum treated like 'rabid dog' before choking to death on paper

Margaret Mary Picton, known as Rita, died of aspiration pneumonia. A woman said her vulnerable mum was 'left like a dog' and mocked by staff in a mental health facility. An inquest found that neglect she suffered contributed to Margaret Mary Picton's painful and traumatic death. ‌ She died of aspiration pneumonia after choking on paper in September 2022. While Margaret, known as Rita, from St Helens, died nearly three years ago, her devastated family had to wait until earlier this year for an inquest that would shed light on the shocking neglect she suffered on the Fern Ward at Leigh Moss Hospital in Liverpool, which is operated by the region's Mersey Care mental health trust and specifically cares for patients with dementia. ‌ Rita was 76 when she died but her health had been declining for some years after she began suffering from vascular dementia, reports the ECHO. ‌ "Mum was a very straightforward person, she would always tell it like it is," explained Rita's daughter, Rachel Burkey, 51. "She was very good natured and would always give her kids whatever we needed. She was a really good mum. "But a few years ago I noticed changes in her behaviour and her mood. Then my sister called to say she was confused and had come at her with a knife. It was horrendous." Having been in a care home in St Helens for some time, Rita's unpredictable and at times aggressive behaviour led to her being sectioned sectioned under the Mental Health Act and taken to Leigh Moss on September 10 at 3am. ‌ "We got the call to say they wanted to section her," explained Rachel. "Obviously her needs would go ahead whatever we wanted and we said if this is what mum needed in order to get help then we weren't against it." On admission to the ward, it was decided that Rita should be observed by staff at least every 15 minutes because of her changing mood and previous incidents of self harming. The inquest at Liverpool Coroner's Court in January heard that staff on the ward missed opportunities to respond to Rita's erratic and dangerous behaviour, including stabbing herself with a pen. Staff did not escalate the incidents and observations were not correctly carried out. ‌ One particular staff member, who was responsible for engaging with Rita on the wards, did not make any "meaningful attempts to engage positively" with her, the inquest concluded. Worse than that, he was described as "unprofessional and disrespectful" when making gestures towards her. Rachel elaborated on the behaviour of this staff member having seen CCTV images during the inquest. She added: "On the CCTV I have seen, she is in the corner, she looks like she has been there for hours. To me, she looked like she had been left like a dog with rabies. ‌ "He (the staff member) was pretending to shoot a bow and arrow at her and pretending to shoot himself in the head. He even mimicked her when she was eating paper." The coroner Helen Rimmer concluded that Rita's observations were "limited and of poor quality", meaning further opportunities were missed to identify a deterioration in her behaviour and to escalate concerns. For one hour there were no observations of her at all due to a "communication breakdown" between staff. The coroner stated: "This was fundamental basic care and supervision, which more likely than not would have led to an escalation and review of Rita's behaviour and presentation at that time had the requisite observations been undertaken." ‌ The inquest was told that CCTV footage then showed at least five, possibly six occasions where Rita could be seen placing paper in her mouth, with staff present on all occasions. While they did intervene and remove some paper from her, they again did not escalate concerns. 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Rita collapsed shortly afterwards and shockingly the staff who had seen her eating paper did not tell those performing CPR on her about this, so choking prevention measures were not considered. Paramedics were called but were delayed by being locked out of the hospital building. When they did arrive, CPR had been ongoing for 25 minutes and Rita had gone into cardiac arrest twice before the paramedics were told that Rita had been eating paper prior to her collapsing. This delayed the paramedics from removing the paper, which was causing a blockage in Rita's airway. ‌ The coroner stated: "This was basic care and treatment that should have been undertaken and raised sooner. Not to have provided this basic care and information to professionals treating Rita was a gross failure which more likely than not hastened Rita's death." Rachel described these failures as "sickening", adding: "I can't believe they didn't even tell the paramedics that she had chewed paper until the very end. She had two cardiac arrests before they said anything. It is hard to think of that being her end." Rita was taken to the Royal Liverpool Hospital where she went onto develop aspiration pneumonia and died on September 26 2022. ‌ The coroner stated: "The aspiration pneumonia was more likely than not caused by Rita eating the paper, the resuscitation efforts that followed Rita eating the paper and collapsing or a combination of both. The failure to immediately notify staff and paramedics that Rita had ingested paper prior to her collapse represented a failure to render care that would more likely than not have prolonged her life. Ms Rimmer added: "Having identified a specific gross failure which clearly amounts to neglect, it is also found that the accumulation of the catalogue of missed opportunities throughout the care of Rita by those involved in her care at Leigh Moss Hospital, namely the acts and omissions mentioned above, have as a whole also amounted to neglect." 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She shouldn't have been left like a dog in the corner, with no one doing anything except teasing her and basically watching her die. ‌ But I think mum would be looking down now and saying 'good on you girls' for us fighting like this. I can see her saying that, she was really feisty. She was a lovely mum and a strong woman who wouldn't back down from what she thought was right." In a statement, A Mersey Care NHS Foundation Trust spokesperson said, 'We'd like to again offer our sincere condolences to the family, friends and loved ones of Margaret Mary Picton. While we are unable to comment on individual patient care because of rules governing patient confidentiality, we can confirm that we fully co-operated with the Coroner's investigation. We also accept the findings of the Assistant Coroner, Helen Rimmer and would like to sincerely apologise for the shortcomings in care. 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'Mum was left like a rabid dog and then mocked before dying'
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time11 hours ago

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'Mum was left like a rabid dog and then mocked before dying'

Margaret 'Rita' Picton died a painful and traumatic death at Fern Ward at Leigh Moss Hospital in Liverpool with a coroner at her inquest telling of "gross failures" A mum was "left like a dog with rabies" in a mental health facility where she was mocked by staff, says her daughter, and an inquest found that neglect contributed to her painful and traumatic death. ‌ Margaret Mary Picton, known as Rita, died of aspiration pneumonia after choking on paper in September, 2022. While Rita, from St Helens, Merseyside died nearly three years ago, her devastated family had to wait until earlier this year for an inquest that would shed light on the neglect she suffered on the Fern Ward at Leigh Moss Hospital in Liverpool, which is operated by the region's Mersey Care mental health trust and specifically cares for patients with dementia. ‌ Rita was 76 when she died but her health had been declining for some years after she began suffering from vascular dementia. 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Staff did not escalate the incidents and observations were not correctly carried out. One staff member, who was responsible for engaging with Rita on the wards did not make any "meaningful attempts to engage positively" with her, the inquest concluded. Worse than that, he was described as "unprofessional and disrespectful" when making gestures towards her. Rachel elaborated on the behaviour of this staff member having seen CCTV images during the inquest. She added: "On the CCTV I have seen, she is in the corner, she looks like she has been there for hours. To me, she looked like she had been left like a dog with rabies. ‌ "He (the staff member) was pretending to shoot a bow and arrow at her and pretending to shoot himself in the head. He even mimicked her when she was eating paper." 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He then sat with his back to Rita, failing to properly supervise or monitor her. In her record of inquest, the coroner states: "Staff were aware of the choking risk of paper eating but failed to escalate matters, intervene, and appropriately monitor Rita. ‌ She added: "It is more likely than not that had staff been appropriately observing and supporting Rita, they would have removed all paper from her or in the alternative escalated concerns about Rita eating paper earlier with the nurse in charge who would then have removed any paper from Rita, identified any continuing concerns and reviewed risks, which would have included consideration of the level of Rita's supportive observations. This would have more likely than not prevented Rita from eating paper and subsequently choking." Soon after, Rita collapsed and shockingly the staff who had seen her eating paper did not tell those performing CPR on her about this, so choking prevention measures were not considered. 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Knowing that there had been failures in her mum's care, Rachel and her sister Jak fought for justice but had to wait years for the inquest to take place because of various delays. They instructed a barrister for the hearing to ensure they got the right result for their mum. ‌ "I thought, I am going to get my mum justice," added Rachel. "I am going to make them tell me what they did. This was about accountability. "We came out of that inquest and we said 'we've done you proud mum', she was neglected and people will know that. I feel like we got justice and by sharing it with the ECHO everyone will know what happened." Rachel added: "Mum was a fighter, even on that day on the CCTV she was still giving as good as she got. We will remember her fight and her spirit, she went through a lot and that's the sad thing. She shouldn't have been left like a dog in the corner, with no one doing anything except teasing her and basically watching her die. ‌ But I think mum would be looking down now and saying 'good on you girls' for us fighting like this. I can see her saying that, she was really feisty. She was a lovely mum and a strong woman who wouldn't back down from what she thought was right." In a statement, A Mersey Care NHS Foundation Trust spokesperson said, 'We'd like to again offer our sincere condolences to the family, friends and loved ones of Margaret Mary Picton. While we are unable to comment on individual patient care because of rules governing patient confidentiality, we can confirm that we fully co-operated with the Coroner's investigation. We also accept the findings of the Assistant Coroner, Helen Rimmer and would like to sincerely apologise for the shortcomings in care. 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New reports on inadequate care homes in Dewsbury and Huddersfield
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New reports on inadequate care homes in Dewsbury and Huddersfield

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