I've been in my
昨晚我一直在自己的
room last night I was crying and crying
房间里哭，哭得
couldn't stop not one member of Staff
无法停止，没有一名工作人员
came in to see if I was okay I've been
进来看看我是否还好。我已经
in the system now for 8 years of my
在这个系统里呆了 8 年了，这对我的
life and it's not
生活没有任何
helped my daughter is never going to be
帮助。女儿永远不会被
misdiagnosed she's never going to be
误诊，她永远不会
hurt she is never going to feel
受伤，她永远不会感觉
different but most importantly she's
不一样，但最重要的是她很
safe and I can't believe that she had to
安全，我不敢相信她必须
die to be
死才能
safe I'm checking
安全，
out when I get out of here that's it for
当我离开这里时我会去看看现在对我来说就是这样了，
me
now I love you all so
我非常爱你们，
much w
into the room with her body in
走进了她的尸体的房间，
it was the hardest thing I've ever done
这是我一生中做过的最艰难的事情，
in my
life I walked in and the police officer
我走进去，警察
was in front of
就在
me and I could see a big
我面前，我可以看到一个很大的东西。
Mound and all I could do was look at the
芒德，我所能做的就是看着警察
police officer and
say
说
happy and she said I think it
高兴，她说我认为是的，
is and um felt like the the most
嗯，感觉这是最
difficult thing to turn my head to the
困难的事情，我的头向右转，
right and it was it was
是
her and she deserved a better life
她，她应该过上更好的生活
[Music]
[音乐]
[音乐] 凯文·彼得斯 (
Kevin
Kevin
Peters Maran
Peters) 马兰·
gasal Glenn
加萨尔 (Glenn
Holmes Terren
Holmes) 特伦 (
Pim Ben
Pim Ben
Morris ARIS
Morris) 阿里斯 (ARIS)
thought there's just so many abig girl
认为有太多大女孩
Smith Abby took her own life in February
史密斯·艾比 (Smith Abby) 在埃塞克斯 (Essex) 精神病房出院后不久就结束了自己的生命，
shortly after being discharged from a
psychiatric ward in
Essex her name is one of the latest to
她的名字是最新的自杀者之一
be added to a memorial page for families
被添加到一个纪念页面，以纪念那些
who believe their relatives were failed
认为自己的亲属因埃塞克斯
by Essex partnership University NHS
大学国民医疗服务体系信托基金而失败的家庭，该信托基金是
trust it was set up by Melanie Lehi who
由梅兰妮·李希 (Melanie Lehi) 设立的，
has been campaigning for answers since
自
her son died on an Essex Ward 10 years
10 年前她的儿子在埃塞克斯病房去世以来，她一直在努力寻找答案。
ago Matthew my
son Matthew was a gentle
温柔、
kind amazing
善良、令人惊奇的
Soul Matthew was in desperate need of
灵魂马修
help when he was admitted to hospital in
在 2012 年入院时迫切需要帮助，
2012 but he died alone in his room 7
但 7 天后他独自在房间里去世，他在
days
later he had no signs of mental illness
up to was about
19 um and was dead by the time he was
19 岁左右时没有任何精神疾病的迹象，当他被送往医院时已经死亡。
20 I was at home the day that he died I
20 他去世那天我在家，我
remember the phone rang and I picked it
记得电话响了，我
up and it was the doctor Matthew
接起电话，是马修
psychiatrist and he says Matthew's been
精神科医生打来的，他说马修被
found hanging it doesn't look
发现上吊了，看起来不太
good he'd already been dead an hour so
好，他已经死了一个小时了，
that was the first lie
所以 2021 年第一个谎言
in 2021 Essex partnership University
埃塞克斯大学
trust was prosecuted and fined for
信托基金因
failing to prevent 11 patient suicides
未能阻止包括马修斯在内的 11 名患者自杀而被起诉并被罚款。
including
Matthews the health and safety secretive
健康与安全秘密机构
prosecuted the trust for the causation
因导致 11 人死亡而起诉该信托基金，
of 11 deaths they got fined 1.5 million
他们被罚款 150 万，
but no one's been held to
但没有人被
account in the same year thanks to a
追究责任。同年，由于
petition by Melanie which received
梅兰妮的请愿书
receiv received over 100,000 signatures
收到了超过 100,000 个签名，
the government announced an inquiry into
政府宣布对
1500 unexpected unexplained and
self-inflicted deaths of Essex
partnership University trust patients
between 2000 and
2000 年至
2020 it's the first independent inquiry
2020 年间埃塞克斯合作大学信托患者的 1500 例意外不明原因和自残死亡事件进行调查，这是
into mental health of its kind and has
对其心理健康状况的首次独立调查友善，并将
put mental health provision across
整个essics的心理健康服务
essics firmly in the
牢牢置于
spotlight but there are no statutory
聚光灯下，但没有法定
powers to compel staff to to give
权力强迫员工提供
evidence so for Melanie it's not
证据，所以对梅兰妮来说，这还
enough s have retired they've resigned
不够，他们已经退休了，他们已经辞职了，
they've changed
他们已经换了
jobs and if they don't work for the NHS
工作，如果他们不这样做为 NHS 工作的人
they can't be brought back those that do
不能被带回来那些
work for the NHS could be asked to give
为 NHS 工作的人如果拒绝提供证据，可能会被要求提供
evidence if they refuse to they could
证据，他们可以
just say not interested you know and
只是说不感兴趣，你知道，这对
it'll look bad on them well that ain't
他们来说会很糟糕，这不好。
good enough
across England there are currently 1.6
英格兰各地目前有 160
million patients receiving mental health
万患者正在接受精神卫生
care but what sets Essex apart from the
保健，但埃塞克斯与
rest of the country is Melanie we're
全国其他地区的不同之处在于梅兰妮，我们
going to Westminster and we're going to
要去威斯敏斯特，我们将
stand outside with our placards and
站在外面举着标语牌和
Banners and make a
横幅，让
noise need staff brought in under Earth
噪音需要工作人员进入地下，
you know until we can get those power
你知道，在我们获得这些权力
straty poers we're not going to get the
策略之前，我们不会得到
accountability or the change we need
责任或我们需要的改变，
I friend at least another 40 bereaved
我的朋友，至少还有 40 个失去亲人的
families have joined melan's
家庭加入了梅兰的
campaign because they believe their
竞选活动，因为他们相信他们的
vulnerable relatives deaths should have
弱势亲属死亡本应
been prevented by a trust that has
通过一个信托机构来预防，该信托机构
repeatedly promised to do more to keep
一再承诺采取更多措施来保证
patients safe promises then not
患者的安全，但后来却没有被
convinced
说服，
by unless we unite and force the change
除非我们团结起来，迫使
is needed to this country's psychiatric
这个国家的精神
mental health system the deaths will
心理健康系统需要改变，否则死亡将
continue
继续困扰
got moms that are
bereaved I got fathers that are bereaved
失去亲人的妈妈们。有失去亲人的父亲
I got staff that worked in the system
我有在系统中工作的工作人员
that want to force
想要推动
change so we stand here today fighting
变革，所以我们今天站在这里，
to make history and to force change
为创造历史并
across our
在我们的
land despite the spotlight of the
土地上推动变革而奋斗，尽管
inquiry and promises made by Essex
埃塞克斯伙伴关系的调查和承诺受到关注，但
partnership University trust vulnerable
大学信任弱势
people like Abby Smith
群体像艾比·史密斯一样
are still dying whilst under their
在他们的照顾下仍然濒临死亡，
care and we have evidence to suggest
我们有证据表
that Wards are still
明沃德仍然
unsafe so we asked a retired police
不安全，因此我们要求一名退休
officer to train as an NHS healthc care
警官接受 NHS 医疗保健
assistant and go undercover in Essex to
助理的培训，并在埃塞克斯卧底，
see if patients are still at risk
看看患者是否仍然处于危险
despite promises made by Essex
之中埃塞克斯
partnership University trust to improve
大学合作伙伴做出的承诺，以提高
patient safety
患者安全，
the job pays around 12 an hour and
这项工作的工资约为每小时 12 点，并
requires a person to complete online
要求一个人完成在线
courses and a week's face-to-face
课程和一周的面对面
training I cannot stress this enough the
培训，我不能再强调这一点了，关于
three stage care plans that was spoken
三阶段护理计划
about on Monday are crucially important
周一至关重要，
the trust has strict guidelines on
信托机构对安全和治疗护理有严格的指导方针，
safety and therapeutic care and Dawn's
黎明的
training was in line with this because
训练符合这一点，因为
the safest restraint guys is not
最安全的约束人员没有受到
restrained
约束，
but would the training match reality on
但在资格赛后，病房里的训练比赛现实是否
the
wards okay after qualifying Dawn worked
还好黎明在
13 shifts in Essex between April and
四月份期间在埃塞克斯工作了 13 个轮班
June her first day was on Willow Ward a
六月，她的第一天是在罗奇福德的柳树病房，这是一个为
psychiatric unit for adult women in
成年女性提供服务的精神病科。
Rochford morning I'm here for the day sh
早上，我来这里是为了这一天，我来这里是
I'm here for the Dai okay
为了戴，好吧，
coming and she's here for the first time
她是第一次来这里，
like so we need to explain certain
所以我们需要解释一些
things one of the biggest threats in
事情精神病院最大的威胁之一
psychiatric hospitals is patients trying
是病人试图
to asfixiate themselves using another
用另一个物体来固定自己，
object this is called a ligature this is
这就是所谓的结扎线，这
so this is the
ligature these are just the
结扎线，这些只是
liat CES what we use in Cas someone
CES我们在Cas中使用的东西，有人
strangle thems we use this you know this
勒死他们，我们用这个，你知道这
is what we use to like cut all sort of
是我们过去喜欢剪的所有东西，
you know some of them sometime like some
你知道其中一些有时就像其中一些
of them oh I'm going to kill myself and
哦，我要自杀，
before you get there sometimes it's
在你到达那里之前，有时这种情况
happen so many times that you see some
发生了很多次，你看到其中一些
of them even turning red yellow and all
甚至变成红色黄色等等
of it all patients are risk assessed
其中所有患者
during their time on the ward if they're
在病房期间都会接受风险评估，如果他们
at risk of self Haring they're assigned
有自我危险的话，他们会被指派
a member of Staff or sometimes two to
一名工作人员或有时两名工作人员
watch them at all times these are known
随时监视他们，这被
as one: one or 2 to one observations hi
称为一对一：一对一或二对一观察结果嗨，
you now
你现在是的，
yes a few hours into Dawn's first shift
黎明第一班的几个小时后，
the alarm sounds alerting staff to
警报响起，提醒工作人员注意发生了
attend a serious
严重
incident what's going
事件，发生了什么事
on n n that's what she's gone for
nn这就是她去的
we call the ref
我们称裁判
[Applause]
[掌声]
get in the chaos one of the healthcare
陷入混乱一名医疗
assistants has brought the wrong
助理拿了错误的
ligature knife to cut the patient free
结扎刀来割伤病人我们
we're getting a cut we got the ligature
正在被割伤我们拿到了结扎
bag dor runs to get the rest of the
袋请跑去拿剩下的
cutters
切割器
no don't worry don't worry I got
不，别担心，别担心，我听到
you the patient was on a one toone
你，病人正在进行一对一
observation and should have been within
观察，应该一直在视线范围内，
eyesight at all
times she made the attempt on her life
她
in the bathroom while the male worker
在浴室里试图自杀，而分配看护她的男工作人员在
assigned to watch her was waiting
outside he should have called for a
外面等着，他应该叫一名
female staff member to take over from
女工作人员接替他的工作人员
him bring
带来了
thees why
这些为什么
take take all this stuff
out in training daor was told it should
在培训中将所有这些东西拿出来，达奥被告知，在这次事件中，从
take no more than 10 seconds between
getting the grab bag with the ligature
拿到装有结扎刀的抓斗袋
Cutters in it to reaching the
到到达
patient in this incident it takes 1
患者手中之间的时间不应超过10秒需要 1
minute and 53 seconds to get the right
分 53 秒才能让正确的
Cutters to the
切割者到达非常
scene that was quite
frightening and
可怕和
chaotic oh God you wrong the very person
混乱的场景哦上帝你错了
that had told me that if someone's
那个告诉我如果有人
ligature to take the whole bag and
结扎拿走整个袋子并且
you're instructed to do when you do your
你被指示这样做的人做你的
training she actually brought one
训练时，她实际上带了一把
ligature cutter back rather than
结扎刀回来，而不是
bringing the whole
带回整个
bag Andrew McDonald a professor of
包安德鲁·麦克唐纳（Andrew McDonald）是一位
Clinic psychology and former NHS manager
临床心理学教授，也是前国民医疗服务体系（NHS）经理，
watch Dawn's
观看了黎明（Dawn）的
footage it seemed pretty chaotic how
镜头，
they responded to somebody with a
他们对带有
ligature not getting the Cutters not
结扎器的人的反应似乎很混乱，没有得到切割器
being very clear about that you need to
非常清楚，
have as few people around somebody in a
在危机情况下，你需要让某人周围的人
crisis situation as possible you need to
尽可能少，你需要
be calm you need to talk slowly you
保持冷静，你需要慢慢地说话，你
don't talk across people you know it
不要与你认识的人交谈，
said there were a lot of people talking
据说有很多人不与之交谈
not to the individual but they were
talking amongst themselves about what to
do
we also showed it to Julie reer a former
我们还向朱莉·雷尔（Julie Reer）展示了它，她是一位前
mental health nurse and manager who's
心理健康护士和经理，
now director of imro an organization
现在是 imro 的主管，这是一个
that supports services to improve the
支持服务以改善
experience of people using them they
使用它们的人的体验的组织，他们
seem to have developed mechanisms for
似乎已经开发了机制为了
coping with that high level of distress
应对那种高度的痛苦，
which which are about s of detaching
这种痛苦涉及
themselves from the person but obviously
与人分离，但显然是
for yourself as as this person who feels
为了你自己，因为这个人觉得
compelled to do this and for your family
有必要这样做，为了你的家人
and for the viewing public this is a
和观众，这是一个
major
重大的
event when I was first approached about
事件当我第一次接触到
doing the undercover filming I was quite
进行卧底拍摄时，我对此非常
reticent about doing it because I have a
谨慎，因为我非常
lot of respect for the
尊重
NHS um I didn't want to particularly get
NHS，嗯，我不想特别让
anyone into trouble um I think they do a
任何人陷入麻烦，嗯，我认为他们
fantastic job under very difficult
在非常困难的情况下做得非常出色。
circumstance
情况虽然
stes but the fact of the matter remains
如此，但事实仍然是，
thoughts of people have died when they
人们本
should have been being looked
应得到照顾，但他们却已经死亡。
after the patient who ligatured on
在
Dawn's first shift
黎明号第一班结扎的患者
survived but the incident raises serious
幸存下来，但这一事件引发了人们对埃塞克斯合作大学照顾的
questions about the safety of vulnerable
弱势患者安全的严重质疑。
patients in the care of Essex
partnership University
trust following their prosecution for
信托公司因
failures relating to 11 patient deaths
including Melanie's son Matthew the
与包括梅兰妮的儿子马修在内的 11 名患者死亡有关的失败而被起诉，
chief executive of the trust Paul Scott
信托公司首席执行官保罗·斯科特 (Paul Scott)
apologized and said he was fully
道歉，并表示他完全
committed to ensuring every lesson is
致力于确保汲取每一次教训，但
learned pointless we've had enough we've
毫无意义，我们已经受够了，我们已经
got recommendations I think if we put
收到了建议我认为，如果我们把
all the inquests together and all the
所有的调查放在一起，把
reports together and all the
所有的报告放在一起，把所有的
recommendations together we' have a pile
建议放在一起，我们就会得到一堆
of the same
相同的
recommendations we don't want more
建议，我们不需要更多的
recommendations we want meaningful
建议，我们想要有意义的
change and accountability
改变和责任
this one is aby's baby book which as a
这是艾比的婴儿书作为一个
soy parent I um kept I had her birth
大豆家长，我保留着她的出生
card that was her scan photo and Abby
卡，那是她的扫描照片，艾比
Got Her diagnosis of learning
difficulties when she was about 3 and
在她大约 3 岁时被诊断出学习困难，
eventually at 10 and a half Abby was
最终在 10 岁半时艾比被
diagnosed with
诊断出患有
autism when she was 15 her school found
自闭症，她的学校发现她在 15 岁时被诊断出患有自闭症
someone who could come and assess her
有人可以来评估她的
mental health Abby was admitted for what
心理健康状况艾比因
I was told was going to be a twoe
我被告知将进行两次
residential assessment um and 2 years
住宿评估而入院，嗯，两年
later she was still
后她仍然在那里
there Abby was restrained many many
艾比被限制了很多
times beyond my count I know that she
次，超出了我的计数我知道她
was being held down that she was being
被拘留了得知她正在接受
injected it was only uh three months
注射，就
before she died that Abby wrote a note
在她去世前三个月，艾比写了一张
about her treatment on that unit the
关于她在该病房接受治疗的便条，该
unit is the St Orbin Center a
病房是圣奥尔宾中心，是
psychiatric ward for teenagers run by
由埃塞克斯大学信托基金管理的青少年精神病房，
Essex partnership University trust I had
我有
so many staff holding me down but that
很多工作人员持有我很沮丧，但那位
staff member came in and she knelt
工作人员进来了，她跪在
beside me and stroked my head and said
我旁边，抚摸我的头，说来吧，
come on guys get off her now all she
大家从她身上下来，现在她
needs is a hug and the staff eventually
需要的只是一个拥抱，工作人员最终从
got off me and that staff member gave me
我身上下来，那位工作人员给了我
a hug but I didn't deserve to be
一个拥抱，但我没有我不应该受到
mistreated and tortured I thought it was
虐待和折磨，我以为这是为了
meant to help people get better and
帮助人们变得更好和
recover but instead this has left me
康复，但这却让我
broken not being able to ring my mom and
心碎，无法给我妈妈打电话，
tell her about what really went on
告诉她关起门来到底发生了什么，
behind closed
doors I truly believe she has
我真的相信她已经她
post-traumatic stress disorder from her
time on that unit she never recovered
在该单位期间患有创伤后应激障碍，她从未康复
one of the failures being investigated
as part of the current independent
作为当前独立
inquiry is the overuse of
调查的一部分正在调查的失败之一是过度使用
restraints something Essex partnership
限制，埃塞克斯合作
University trust has been criticized for
大学信托基金
in the past by regulators and
过去
coroners in training our undercover
在培训中曾因监管机构和验尸官的批评而受到批评。我们的卧底
reporter Dawn was told restraint should
记者 Dawn 被告知克制应该
be a last
是最后的
resort yet she witnessed restraints
手段，但她在 Willow 的九个轮班中有 7 个目睹了克制，有好
during seven out of nine shifts on
Willow w
on several occasions the same patients
几次，同一个病人
were restrained multiple times sometimes
被多次克制，有时
for close to an
接近一个
hour I'm quite it's not nerves I suppose
小时，我很确定这不是紧张，我想
because I think I've overcome those now
因为我想我已经克服了那些现在在
having having worked there a few shifts
那里工作了几个轮班的问题，
but the underlying kind of feeling is
但潜在的感觉是
what am I going to be faced with today
我今天将要面对什么
what's
happened door open I need to she quickly
发生了什么门打开我需要她快点
we should
我们
doing no one in this place understands
不应该做任何人这个地方了解
eating disord so I need to get out yes
饮食失调，所以我需要出去，是的，
they do you they
他们做你的，他们
do the patient attempted to escape is
做的，病人试图逃跑，他很
Young and
年轻，
vulnerable get me away I just want not
很脆弱，让我离开，我只是不
listen if you're going to do all this
想听，如果你现在要做这一切，
now I'm going to stop you from going out
我要停止如果你不去
in the garden then the only person
花园，那么
you're going to be ruining it for is
你唯一会毁掉花园的人就是
yourself okay so come on let's get up
你自己，好吧，来吧，我们站起来，我们
let's go no no don't be shaking your
走吧，不，不，不要
head because the answer is you're going
摇头，因为答案是你要
inside whe you like it or not yes you
进去…… 你喜欢与否，是的，你
are I'm not playing games with
是，我不和你玩游戏，
you you're grown up and you want to
你已经长大了，你想
grown
up if you listen at the phrases they're
长大，如果你听他们
using you're an adult it's not the way
使用的短语，你是一个成年人，这不是
to manage crisis when somebody's melting
处理危机的方式有人
down like that they're not thinking
崩溃了，他们没有把
things through Straight they need
事情想清楚，他们需要
reassurance from people otherwise you're
人们的保证，否则你
not going to deescalate the
不会让局势缓和
situations
do open the
打开
door open the door going back
门，打开门回去
I I it slightly
我我稍微
open once the patient is back inside the
打开病人一回到病房内，
unit she is restrained by five members
她就被五名
of
Staff 11 minutes later she is
工作人员制服。 11 分钟后，她
hyperventilated
after over 20 minutes on the floor the
在地板上躺了 20 多分钟，呼吸过度。
patient is
released you fing bit no a few minutes
几分钟
later she is triggered by another
后，她被另一名
patient and gets restrained
病人触发并再次受到限制，
again another patient is also restrained
另一名患者也被限制
for joining
加入，
in when she was by the door there was no
当她在门口时，没有
immediate wrist air that I could see
立即手腕空气，我可以看到
what was the urg and need to get her
什么是冲动，需要让她
back in to the main lounging area and
回到主要休息区，
it's quite significant that they do that
这是非常重要的，他们这样做，
and then ultimately another incident
然后最终又
takes place with another Resident cuz
发生了另一起与另一名居民有关的事件，因为
she's still in a very volatile State I I
她仍然处于非常不稳定的状态，我
cannot say and I'm going to be
不能说，我将
unequivocal that's just plain bad
明确表示，这只是一种不好的
practice a decision is made to forcibly
做法，因此决定强行将
remove the patient and take her back to
患者转移并带回她
her room
她的房间
no no no no
不不不不
no when they began dragging the
不，当他们开始拖拽病人时，
patient I was quite
我感到非常
shocked in we were Tau that you're not
震惊，因为我们是 Tau，你不
supposed to move people obviously it can
应该移动人，显然这会对
cause injury to the patient and to other
病人和其他人造成伤害
patients and potentially the staff
病人和潜在的工作人员
members
成员
Beau
Beau
beautiful I still get angry when I see
beautiful 当我看到不必要的武力和约束时，我仍然会生气
unnecessary use of force and restraint
you saw two different things going on
你看到那里发生了两种不同的事情，
there and I am really annoyed about this
我对此真的很恼火
we have standard s around restraint
我们有关于约束的标准
there's no protocols I know that says
我知道没有协议这说的是
you drag someone or carry and I'll use
你拖拽某人或携带某人，我会
the word manhandle someone in that
在这个过程中经常使用“粗暴对待某人”这个词，
process now often when people do that
当人们这样做时，
whether they're aware of it or not
无论他们是否意识到，
they're doing it as a form of subtle
他们这样做都是作为一种微妙的
punishment all Psychiatric Services are
惩罚形式，所有精神科服务都受到
bound by regulations which state that
约束根据规定，
unnecessary and disproportionate
restraint should never be used
绝不应使用不必要和不成比例的限制
I've really been surprised how much I've
我真的很惊讶，当
thought about the patience while I've
我过着正常的生活时，我对耐心的思考程度，
been living my normal
life not only have they got their mental
不仅让他们的心理
health problems to deal with but they've
健康问题得到解决但他们已经知道，
got the fact that they in a prison-like
他们在类似监狱的
environment but they just want a little
环境中，但他们只想要一
bit of empathy and a little bit of
点点同理心、一点点
understanding and a little bit of
理解和一点点
care while they
关心，同时他们
hopefully get
希望能
better I think we need to have more
好起来，我认为我们需要更多
emphasis placed on
强调
care I feel that
关怀我觉得
the thing that's
missing from this letter that Abby wrote
艾比写的这封信中缺少的
is care the staff don't give a [\h__\h]
是关怀，工作人员根本
about you um at
不在乎你，嗯，
all but we we all support each other in
但我们在这里互相支持，
here and I think that's what like we we
我认为这就是我们
stay strong for each
留下来的原因彼此都很坚强，
other but at the end of the
但到了一天结束的时候，
day it's not getting anyone anywhere
没有人能到达任何地方
during another shift on Willow Ward the
在柳树病房的另一个轮班期间，被
patient who was dragged to her room has
拖到她房间的病人试图
attempted to
ligature
结扎
want I'll take you that
想要我会带你去，
people restrain the patient on the floor
人们限制了地板上的病人
she has an eating
她有饮食
disorder we
失调症，我们
finished next
接下来就结束了
I've lost 2 and 2 and2 lb in 2 weeks I'm
我在两周内减掉了2磅和2磅，我很
sry a lot more
抱歉更多
you
你
me [\h__\h] trigger stop
我他妈的触发停止
just you were just talking
只是你刚刚在谈论
about
fing I to you
我对你说[
音乐]
not
good has got problems with food she's
不好，她的食物有问题，她患有
anorexic that's not a good idea to be
厌食症，
talking about food in front of her she
在她面前谈论食物不是一个好主意，她
can hear everything that's going
可以听到正在发生的一切
on oh despair I really
哦，绝望，我真的
don't so this could be used as a
不这样做，所以这可以用作
training
培训
video because honestly if you were going
视频，因为老实说，如果你要向
to show people how not to do it this
人们展示如何不这样做，那
would be it I mean it's not that they're
就是我的意思是，这不是他们
physically hurting her but they it's
在身体上伤害她，而是他们
literally abusive isn't
实际上是虐待是
it I have to say I've seen some things
不是我不得不说，我见过一些非常
that are pretty bad but somebody tapping
糟糕的事情，但有人
out a rhythm like it's a song her
敲出节奏，就像这是一首歌，她
hyperventilating you know I used to be
喘不过气来，你知道，我
manager in the Health Service many years
多年前曾是卫生服务部门的经理，
ago that would have been suspension
那会直接被停职
straight away they're just simply
他们只是简单地
talking to each other and forgotten that
互相交谈，却忘记了内心
underneath that there is a living
深处还有一种活生生的
breathing feeling human
呼吸感觉，
being the needs to change is
人类迫切需要改变。
urgent Abby Smith was 26 when she took
艾比·史密斯 (Abby Smith) 在埃塞克斯郡精神病房出院
her own life in February after being
后于二月份结束了自己的生命，当时她才 26 岁
discharged from a psychiatric ward in
Essex her mom Lisa is one of a growing
她的妈妈丽莎是越来越多的
number of families who believe their
家庭之一，他们相信自己的
loved ones were let down as a result of
亲人因
repeat failings by
partnership University trust Abby was
合作伙伴关系一再失败而感到失望。大学信托机构艾比被
transferred into a mixed sex adult Ward
转移到一个男女混合的成人病房，
she went into a ward with 40 and 50y old
她住进的病房里有 40 岁和 50 岁的
men who were behaving sexually
老人，
inappropriately towards her and one of
对她进行了不恰当的性行为，其中一人
them also punched her and uh the police
还打了她，呃，警察
had to be called the adult facility was
不得不称其为成人设施，是
the Linden Center at Broomfield Hospital
布鲁姆菲尔德医院的林登中心，是
part of es partnership University trust
es 合作伙伴大学信托的一部分，
it's where Matthew Lehi died in 2012
马修·李海 (Matthew Lehi) 于 2012 年在此去世，
his mom Melanie has been fighting for
他的母亲梅兰妮 (Melanie) 一直在战斗。
accountability and change ever
since he ends up in the Lyon Center um
自从他来到里昂中心以来，为了责任和改变，嗯，
he was scared he used to say to me mom
他很害怕，他曾经对我说，妈妈
is hell in here this is absolute
在这里是地狱，这绝对是
hell you just go in there as a mom
地狱，你只是作为一个妈妈去那里，
thinking the kids are safe and they're
认为孩子们是安全的，但他们
not Matthew was found dead in his
并不安全自2004年以来，马修被发现死在自己的
room since 2004 at least six people have
房间里，里昂中心至少有六人
died from ligatures at the lyen center
死于结扎，
several others have died after
另有几人在
absconding or being
潜逃或
discharged after an investigation by the
出院后死亡，在
health ombudsman the Lyon Center
健康监察员调查后里昂中心
admitted to failings in Matthew's care
承认马修的护理失败，
and said changes have been made to
并表示变化已经这样做是为了
prevent a similar death happening
防止类似的死亡
again it shouldn't have happened
再次发生，这不应该发生，
I was told the day before he's in a safe
前一天我被告知他现在在一个安全的
place now and like you know you've been
地方，就像你知道你已经
for a lot just relaxed for the weekend
放松了很多周末，
and I feel bad cuz I didn't call up on
我感觉很糟糕，因为我没有周五不要打电话来
the Friday to sub
接替
him Jaden burov was sectioned in October
他 Jaden Burov 在 10 月份被分尸，
but managed to escape from the lyen
但设法从
center in chelsford it's run by Mental
切尔斯福德的莱恩中心逃脱，该中心由心理
Health Trust which is already being
健康信托基金管理，该信托基金已因
prosecuted for safety failings relating
to the deaths of 11 other patients
two years after the lyen center was
两年来与另外 11 名患者死亡有关的安全失误而受到起诉莱恩中心被
found to be failing patience and
发现缺乏耐心，并
promised to do better Michelle borof
承诺会做得更好。米歇尔·博罗夫 (Michelle borof) 的
another Essex mom was struggling to get
另一位埃塞克斯妈妈正在努力
help for her 23-year-old son
为她 23 岁的儿子寻求帮助。
Jaden Jaden was a very loving
贾登 (Jaden) 是一个非常可爱的
son he'd always be singing in the shower
儿子，他总是在淋浴时唱歌。
on the piano um pretty much every single
钢琴嗯几乎每天都会
day making up songs we' sing together s
创作我们一起唱的歌曲，
he very very talented and then he joined
他非常非常有才华，然后他加入了
the local amateur dramatic group and uh
当地的业余戏剧团体，呃在那里
got the big part there of Joseph where
得到了约瑟夫的重要角色，
he just wowed the audiences every night
他每晚都让观众惊叹不已，
and um was Prett proud moment behind his
嗯是普雷特自信外表背后的骄傲时刻
confident exterior Jaden was suffering
贾登患有
mental health issues he began
心理健康问题，他开始
withdrawing from friends and family it
与朋友和家人保持距离
started off of you know him showing
clear signs of psychosis and then me
reaching out for help and being turned
away and then reaching out for help
being turned away I think his mental
我认为他的心理
health was allowed to decline slowly
健康状况被允许慢慢地慢慢下降，
slowly slowly until it came to that
直到达到
crunch point
of when he Jaden was completely lost
贾登完全迷失的关键点
and
，
yeah finally he was given a bed at the
是的，最后他在林登中心得到了一张床位，
Lindon Center I didn't know much about
我对
the Lyon Center at the time and I saw
里昂中心不太了解当时我看到
that they were under scrutiny and I
他们正在接受审查，我
thought well that's good because at
想这很好，因为
least they will be working harder and
至少他们会更加努力地工作并
making sure you know that he he should
确保你知道他应该得到
be being looked after properly and uh I
适当的照顾，呃我
got the phone call from his psychosis
接到了他的精神病
team and they said like Jane's very very
团队的电话，他们说简非常非常
unwell and um that he's going to be in
不舒服，嗯，他要在
here for a few months and then I was
这里呆几个月，然后我被
told that he's in a safe place now have
告知他在一个安全的地方，现在
a break cuz you've been through a
休息一下，因为你
lot that's on the
Monday on the Friday I got a phone call
周一和周五经历了很多事情我接到一个电话
and it was from the lyen center and
，是里恩中心打来的，
actually the first thing I said is he's
实际上我说的第一句话是他
dead isn't he and um she said no but
死了，不是吗，嗯，她说没有，但
he's
他
absconded I did question how because I
潜逃了，我确实有疑问，因为我
was told he was um you know being
被告知他，嗯，你知道被
monitored um on one of the higher
监视了，嗯根据一项更高的
observations and um and I said this a
观察结果，嗯，我说这是一个
secure
安全的
Ward called a train station and we said
病房，称为火车站，我们说
my son could be heading here their
我的儿子可能会前往这里，他们的
reaction was oh not another one from the
反应是哦，不是来自里昂中心的另一架，
Lyon Center
and then I saw the helicopter and I
然后我看到了直升机，我
thought oh good the helicopter's here
想哦，很好直升飞机就在这里，
like you know they're searching for him
就像你知道他们正在寻找他一样，
that's good I went out searching for him
这很好，我出去寻找他，
searching all through um Hedges and
搜索了整个嗯树篱，
things like just saying Jaden Jaden like
就像只是说贾登·贾登之类的，
if you're there don't worry I'm not
如果你在那里，别担心，我不会
going to take you
带你走
back but then I walked in the front door
回来，但后来我走进前门，
and then my daughter was standing in the
然后我的女儿站在厨房里，
kitchen and my son and sorry step sister
我的儿子和对不起的继妹
Lucy and then they all looked at me then
露西，然后他们都看着我，然后
they just shook their heads I
他们只是摇摇头，我
knew and then I came in here and then
知道，然后我进来了这里然后
there was a lady and then she said she
那里是一位女士，然后她说她
was British transport please oh no no no
是英国交通工具，请哦
no cuz I knew what that meant and I said
不不不不，因为我知道这意味着什么，我
I told I tried to tell
说我告诉过我试图告诉
you it's horrible knowing that it's only
你，知道现在只有
20
20
23 and I you know he was born into my
23 很可怕，我你知道他出生在我的国家
arms loving nurturing and then he
died alone scared probably
crying after Jaden died in 2020 the care
2020 年贾登去世后，护理
and quality commission inspected the
和质量委员会检查了
Lyon Center and found staff was still
里昂中心，发现工作人员仍然
still not taking adequate precautions to
没有采取足够的预防措施来
keep patients
保证患者的
safe Essex partnership University trust
安全，埃塞克斯合作大学信托基金
responded saying that they had taken
回应说，他们已
immediate action to improve security
立即采取行动改善安全措施，
measures but as our undercover reporter
但我们的卧底记者
would find out patients lives are still
会发现中心的病人仍然
at risk at the
面临生命危险
center morning here for day shift my
早上在这里上白班我
first day well can't I sit over here
第一天就不能坐在
here just over an hour into her first
这里刚开始她的第一个班次一个多小时
shift on the ward dor is asked to
在病房里，多尔被要求
observe patience in the dining
在就餐区保持耐心
area with okay who
，好，
who where she gone should I go and get
谁，她去了哪里，我应该
her you want me to follow her
去接她吗？你想让我跟着她，
no once I come past the barrier okay can
不，一旦我越过了栅栏，我可以
I get back
回去吗？
in yeah she's gone here she went over
是的，她已经走了这里，她去了
there no she was sitting there here
那里，不，她坐在那里，
isn't it I think sh noticed the door was
不是吗？我想她注意到门是
open she
开着的，她
was you used to have to have a c to get
是的，你过去必须有一个c才能
out that main door yeah but some of
走出那扇大门，是的，但由于某些
reason it it stopped working so Hand
原因，它停止工作了，所以手
she's obviously yeah yeah she
她显然是的，是的，
has yeah she must have done
是的，是的，她一定做了，
yeah how long have you worked here years
是的，你在这里工作了多久，第一次
that the first time anyone's gone out
有人出去，
that
why the patient is found nearby and
为什么病人在附近被发现并
brought back to the ward she's in that
带回病房，她就在
room there she later told Dawn she was
那里的那个房间里，她后来告诉黎明，她是
trying to find a place where she could
试图找到一个地方让她
take her own
结束自己的
life I think there's an issue here about
生命我认为这里存在一个关于
organizations and how they try to learn
组织的问题以及他们如何尝试学习
or not learn know we should be learning
或不学习知道我们应该
from these these erors this is a place
从这些错误中学习这是一个据
that as from I can gather is still under
我所知仍然是的地方在
a spotlight so you would expect people
聚光灯下，所以你会期望人们
to put their best feet forward in those
在这种情况下表现出最好的一面，
circumstances what you sh me today
你今天向我展示的东西
doesn't necessarily imply that we
并不一定意味着我们
submitted Freedom of Information
requests to every Mental Health Trust in
向英格兰的每个心理健康信托基金提交了信息自由请求，
England asking for their impatient
要求他们不耐烦的
mental health absconsion rates of the 33
心理健康逃逸率 2019 年至 2021 年间，
that responded esex partnership
回应 esex 伙伴关系
University trust had the fifth highest
大学信托的 33 名患者
rate of
的比例排名第五，为
857 between 2019 and
857 人，
2021 this includes patients who escaped
其中包括逃离
from the Ward or fail to return to the
病房或在休假
ward on time following a period of
一段时间后未能按时返回病房的患者，其中
leave 166 of these absconsion occurred
166 人发生
in 2021 the year after Jaden's death so
在 2021 年贾登死后，
despite deaths from patient absconsion
尽管患者因逃亡而死亡，
and assurances from the trust that they
而且信托公司也保证他们
are addressing safety concerns how are
正在解决安全问题，但
vulnerable patients still able to Escape
脆弱的患者现在如何仍然能够逃脱，
right now this Lessons Learned thing is
这种吸取教训的
not working all these families
做法不起作用，所有这些家庭，
all devastated lives ruined people their
所有被摧毁的生活，毁了人们，他们的
lives will just cut short needlessly
生活将被削减由于失败而不必要地简短，
because of
failings and you know within the same
你知道在同一个
system and so yeah lessons are not
系统内，所以是的，没有
learned Dawn is back on Willow
吸取教训黎明回到了柳树
Ward where the young woman who is being
病房，在那里，
restrained on her last shift has managed
在最后一个轮班时被限制的年轻女子成功地
to film a member of Staff sleeping
拍摄了一名工作人员
during a onetoone observation oh yeah
在单人观察期间睡觉的情况哦，是的，
want to say she shows Dawn the footage
想说她给黎明看了录像，
yeah he full that's not asleep a little
是的，他完全没有睡着，这是一件
bit good thing on on an incident free
好事，没有发生任何
streak otherwise I'd be [\h__\h] dead it
事故，否则我就他妈的死了，这
is a good
是一个很好的
job dawn has also recorded footage of
工作，黎明还记录了
Staff asleep on the ward when they
工作人员在病房睡觉的录像当他们
should have been observing patience
应该保持耐心的时候，
huh sleep you're
嗯，睡觉，你在
sleeping why you
睡觉，为什么你
sleeping oh
睡觉哦，
right didn't think you could sleep on
对了，我不认为你可以睡在
these I didn't think you could sleep
这些上，我不认为你可以在
while you're sitting here oh she
你坐在这里的时候睡觉哦，她
sleeping
睡觉
just to be outside got sleep as well
只是为了在外面睡觉
then isn't
那么
it this is a highrisk area with
这不是一个高风险区域，
individuals who've got very distressed
人们的行为非常痛苦，
behaviors the staff are there even to
工作人员甚至会在那里
observe people if you imagine you're
观察人们，如果你想象你正在
observing someone and you're falling off
观察某人并且你正在
asleep then by definition how long does
睡着，那么根据定义需要多长时间
it take for someone to self harm how
某人自残需要多
long would it take for someone to
长时间有人
assault a member of Staff who's asleep
攻击
on the other side the incident recorded
在另一侧睡着的工作人员需要多长时间患者记录的事件
by the patient is raised in a staff
在一次员工会议上提出，这是
meeting where for the first time since
Dawn started 3 weeks ago staff are told
三周前黎明开始以来第一次出现被告知
not to use phones on the ward obviously
不要在病房使用手机，显然
being very Vigilant with we don't want
非常警惕，我们不需要
any PL please don't use your Mobile
任何PL，请不要使用
phones in fact dawn has captured staff
手机，事实上，黎明已经捕捉到工作人员
using phones on almost every
几乎每个班次都使用手机，
shift it's almost like they're putting
这几乎就像他们
bombs on seats but actually are they fit
在放炸弹一样座位，但实际上它们是否适合
for purpose I would argue no they're
目的，我认为不，他们
not having said that I think it's a hard
没有说过我认为这是一种
way to earn a living and it's a job
谋生的艰难方式，而且这是一份从去年
that's not really very well rewarded
between June last year and June this
六月到今年六月之间没有得到很好回报的工作
year Essex partnership University trust
埃塞克斯伙伴关系大学信任
used agency staff for over 4,000 shifts
使用机构工作人员进行了 4,000 多个轮班，
it's a reflection of a wider crisis in
这反映了整个 NHS 中更广泛的招聘危机。
recruitment across the NHS there are
massive issues in the health service at
目前，卫生服务部门在
the moment around Staffing but sometimes
人员配置方面存在巨大问题，但有时
that drowns out the other issues I think
这会掩盖其他问题，我认为
we need to get people to understand that
我们需要让人们理解
you know no death in care is acceptable
你知道在护理中没有死亡是可以接受的，
and we need people to accept that our
我们需要人们接受我们的
practice is not consistent and good
做法不够一致和不够好，
enough
after two months daor has completed her
两个月后达奥在病房完成了她的
time on the
时间，
wards I've found it tiring mentally
我发现这很累，精神
exhausting and sad mentally exhausting
疲惫，悲伤精神疲惫，
because I've wanted to do the best I can
因为我'
while I've been on
当我在
there sad
那里悲伤时，我想尽我所能，
because I personally think if that was
因为我个人认为，如果那是
any of my friends or family that was on
我的任何朋友或家人在
one of these Wards I would not not want
这些病房之一，我不会不希望
them to be
他们在
there and that's not a reflection on
那里，这不是一种反映
anybody in particular but just the whole
setup Geraldine STD the chair of the
current inquiry into mental health
deaths in Essex has said some of the
埃塞克斯郡精神健康死亡调查的主席杰拉尔丁·STD表示，
evidence gathered has been distressing
收集到的一些证据令人痛苦，
including accounts of safety failings
包括安全问题的描述，
and family has been given too little
而家人得到的信息太少了，
information it felt like once that
感觉就像以前一样那个
system had Abby she was lost to me
系统让艾比她永远失去了我，
forever I was to be disregarded um and I
我被忽视了，我
was to be um excluded from aby's life is
被排除在艾比的生活之外，这就是
how it
felt shortly before Abby was discharged
艾比最后一次出院前不久的感觉，
for the last time Lisa wrote to Abby
丽莎写信给艾比
psychiatrist asking him to consider
精神科医生，要求他考虑
seeking advice from a specialist Autism
寻求建议哈林出院后，自闭症专业
unit on how to reduce aby's self Haring
科室就如何减少阿比的自我进行了咨询，
once she was
discharged she didn't get a reply
她没有得到回复，
I have got no idea why the psychiatrist
我不知道精神科医生为什么让
discharged her um the last communication
她出院，
I'd had with him was to say can we
我与他的最后一次沟通是说我们可以
please contact at least the Kon unit to
联系吗至少 Kon 单位要
talk about um facilitating a discharge
谈论嗯，促进一项
plan that works for her um
适合她的出院计划，嗯，
and the next thing I know I get that
接下来我收到
text from Abby saying hey Mom I'm on my
艾比发来的短信，说嘿妈妈，我在
way home within 2 days she had killed
回家的路上，她
herself in an Essex Park
在埃塞克斯自杀了两天帕克·
Geraldine strathy has said families have
杰拉尔丁·斯特拉西 (Park Geraldine Strathy) 表示，家庭
suffered unimaginable pain and heartache
遭受了难以想象的痛苦和心痛，
and that major changes are
needed some days I can be coping okay
需要做出重大改变，有时我可以应付得很好，
and then all of a sudden it's like
然后突然间，就像
someone knocks on the door and just to
有人敲门，只是
remind you to say oh by the way your
提醒你说“哦，顺便说一句，你的家人”。
son's dead and he died in a horrific way
儿子死了，死得很可怕
and he didn't need to die he could still
，他不需要死，他仍然可以
be here with you it's just he was at a
和你在一起，只是他正处于
time of crisis where he was very unwell
危机时刻，身体非常不适
and needed treatment and was sent to the
，需要治疗，并被送往
right place to get that treatment and if
正确的地方接受治疗如果
things had been better then he would
情况更好的话，他
still be here
today in July an urgent appeal was made
七月的今天仍然会在这里，紧急呼吁
for more NHS staff to come forward to
更多的 NHS 工作人员站出来为
give evidence to the inquiry it's due to
调查提供证据，该调查定于
conclude sometime next year but bereaved
明年某个时候结束，但死者
families fear it won't go far enough to
家属担心不会走得足够远，
initiate real change
发起真正的改变，
there are many many families that could
有很多家庭可以
be sitting here alongside me I could
坐在我身边，我可以
fill this house let alone
填满这个房子，更不用说
room
房间了，
and they would all want the same thing
他们都想要同样的东西，
they would want transparency they would
他们想要透明度，他们
want an investigation that uncovered the
想要一项调查，揭露
truth I don't think that change can be
我不知道的真相除非是法定调查，否则不会认为改变会
affected unless it is a statutory
受到影响，
inquiry
it's it's what's needed in order to try
这是为了试图
and prevent this from happening again it
防止这种情况再次发生所需要的，这很
hurts because it's
痛苦，因为嗯，
um anything happened after Matthew
马修之后发生的任何事情
should not have happened and they should
都不应该发生，而且它们
still not be
仍然不应该
happening um it's a pain that I tried to
发生，嗯，这是一种我
hide most of the time I go to bed and I
大部分时间都试图隐藏的痛苦，我上床睡觉时，我
have silent screams
会无声地尖叫，
silent where you then if you ever cried
如果你曾经哭过，
where you just can't get your breath
你会无法呼吸，
um and then I get
嗯，然后我
on and fight because I
继续战斗，因为我
think all of these guys that have
认为所有的一切这些已经
died they'll deserve a voice they were
去世的人，他们应该有一个声音，他们都很
all
important I just I I wish things could
重要，我只是我，我希望事情能有所
be
different but they they never are and
不同，但他们永远不会，也永远不会
then never will
be a spokesperson for Essex partnership
成为埃塞克斯合作伙伴
University NHS trusts said the care and
大学国民医疗服务信托的发言人，表示照顾和
safety of patients is our number one
安全患者是我们的首要
priority we are taking the allegations
任务，我们
raised extremely seriously and we
非常严肃地对待所提出的指控，我们
understand how distressing this is for
理解这对
patients their families and carers when
患者及其家人和护理人员来说是多么痛苦，
contacted we took immediate action to
我们立即采取行动
protect patient safety and commissioned
保护患者安全，并委托进行
a full investigation we have informed
全面调查，我们已通知
our Regulators safeguarding partners and
我们的监管机构，保护合作伙伴和
partner organizations and will continue
合作伙伴组织，并将继续
to work with them on the actions we are
与他们合作采取我们正在
taking as a result the Care Quality
采取的行动，因此护理质量
commission told us these allegations are
委员会告诉我们，这些指控
extremely concerning we have repeatedly
非常令人担忧，我们已多次
held the trust to account with regards
要求信托机构对其
to the quality and safety of its
services and have been clear where it
服务的质量和安全负责，并已明确必须在哪些方面
must take action to ensure standards are
采取行动以确保
met a further unannounced inspection of
符合标准 10 月 5 日和 6 日对
the trust's acute adult and psychiatric
信托的急性成人和精神重症
Intensive Care Unit Services took place
监护室服务进行了进一步的突击检查，
on the 5ifth and 6th of October and we
will publish the findings from that
将尽快公布检查结果
inspection as soon as we are able to
that service is currently rated as
该服务目前被评为
requires Improvement and subject to
需要改进并受到
close monitoring and we will take
密切监控，如有必要，我们将采取
further action to protect people using
进一步行动来保护使用
this service if necessary a
该服务的人们。
representative of the independent
独立调查的代表
inquiry said the inquiry will be
表示，调查将
watching the program with interest and
饶有兴趣地关注该计划，
will review any information or evidence
并将审查任何信息或
revealed as part of our
作为我们调查的一部分，证据显示，
investigations this
这
is this is Abby she's in here and I talk
是艾比，她在这里，我
to her all the time it's been six months
一直和她说话，现在已经六个月了，
now sometimes I think it feels like 10
有时我觉得感觉像是 10
days and other times I think think it
天，有时我觉得
feels like four years Abby wanted to go
感觉像是四年了艾比想要去
on holiday Abby never got to go on a
度假艾比作为一个成年人从来没有去过一个
proper holiday as an adult and she
像样的假期，她
always wanted to she and she would have
一直想去，而且她
loved to have seen Dolphins it was her
很想看到海豚，这是她
big thing she wanted to see a dolphin so
最重要的事情，她想看到海豚，所以
we found out that you can go on a cruise
我们发现你可以继续一次游轮
and that you can be given permission to
，你可以被允许
release ashes at Sea and we did consider
在海上撒骨灰，我们确实考虑
going on a cruise and releasing her
过一次游轮，并在海上撒下她的
ashes at Sea where we know there are
骨灰，我们知道那里有
dolphins
海豚，
but
但
selfishly I don't know if I can do that
自私的是，我不知道我是否能做到这一点
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