Final answer from The Danish Parliamentary Ombudsmand

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After the Terrida family had received the answer from the national board of health through The Danish Parliamentary Ombudsmand in February 2015, denying any responsibility, Marianne and Denis sat down to write a new complaint(1). They were not ready to give up yet. It was still of utmost importance for them, that more suicides like Danilo’s had to be prevented. However, they struggle of the coming years waiting ahead(2), came to weaken their faith in the Danish system and made them doubt if a public entity would ever take responsibility and admit the errors made. Because, what Marianne and Denis experienced, was a system where the different public authorities helped each other covering each other, and where the office supposed to assist and speak on behalf of the little man against exactly the system, chose to trust the word of the system and didn’t have time, opportunity or interest in getting to the core of the case.

Delayed and slow handling of the case

The lawyer of the Terrida family had to push several times for an answer(3) on the investigation from The Danish Parliamentary Ombudsmand – and the family was told several times that the case was delayed.

In June 2015, The Danish Parliamentary Ombudsmand contacted the Ministry of Health to get their explanation on the questions from Marianne and Denis. However when the Ministry had to be pushed for an answer, it was discovered in September 2015, that the Ministry had misplaced the original inquiry from The Danish Parliamentary Ombudsmand(4). As a consequence the inquiry had to be sent again and the process was delayed.

In February 2016 there was still no answer from the Ministry of Health and they were pushed once again for an answer(5). This was done again in the middle of April 2016 and the Ministry promised that there would be an answer in the beginning of the coming week.

The National Board of Health examined themselves for errors

On the 29th of April 2016 the final answer from the Ministry arrived(6). The National Board of Health still believed that it was not possible to determine a clear and precise time for, when there was sufficient knowledge pointing towards, that the general discharge practice in the corresponding context might include a not insignificant risk for the safety of the patient. At the same time the Ministry wrote, that The National Board of Health had also informed in their original response, that the change in the instructions was due to a knowledge built up through several years.

Nothing new under the sun – which was no surprise for Marianne and Denis, as the answer was from the same board, that according to the Terrida family had committed the errors in the first place. It was however a big disappointment for Marianne and Denis that the Independent board, as The Danish Parliamentary Ombudsmand is, didn’t make it’s own investigation into the circumstances of the case, but only went to the accused party for thereafter to accept their version as the final truth. You also do not only ask the accused in a trial!

No complicated cases for The Danish Parliamentary Ombudsmand… Only easy cases, thank you !

In June 2016 the Terrida family therefore maintained their complaint to The Danish Parliamentary Ombudsmand(7) together with an evaluation from The Nordic Cochrane Centre(8), and in August the same year the answer finally arrived(9). The Danish Parliamentary Ombudsmand declined to initiate an investigation, as it would not change the manual already given or have any effect moving forward, as the instruction was already changed at that time. Besides this, the assessments were based on a medical assessment, that The Danish Parliamentary Ombudsmand didn’t feel able to test and verify.

At the end of all this Marianne and Denis are today left with a lot of unanswered questions, which they believed would be the responsibility of The Danish Parliamentary Ombudsmand to help them get answered: What safety are there for the citizens to have a Parliamentary Ombudsmand if this person ‘does not feel able to test and verify’ complicated cases? How are the citizens – that have even fewer resources available than The Parliamentary Ombudsmand – supposed to ever take up the fight against the system, if they believe an error has been committed? Who then has the competence to test and verify the system – or should the system just be allowed to ignore or roll over normal people? This is how the Terrida family feel today. They believe that the need for The Parliamentary Ombudsmand is redundant when this person does not want to investigate terminated conditions: How are the citizens supposed to get the opportunity to prove, when errors are committed by Public Boards in cases like this? And, if the area of health is too difficult to understand for the normal Parliamentary Ombudsmand, then why do we not have Health Parliamentary Ombudsmand – in the same way we are discussing getting an Parliamentary Ombudsmand for the elderly? Is the health area – where it is a matter of life and death – not important enough?

The system is covering up itself

For Marianne and Denis it has been a devastating meeting with the Danish system. Denis, that come from Italy, thought, that if there was anywhere in the world where the citizens would have a chance to be heard, where such a fight could actually be won by the small man, it would have to be Denmark. But he was wrong. And today he is sitting with a feeling of lack of legal safety. Both him and Marianne today have doubts about, where the citizens can go in the Danish legal system, when they experience malpractice and incompetent doctors and boards, as it has happened in Danilos case? Where can citizens that find themselves stuck, get help?

Marianne and Denis thought they could get this help from The Danish Parliamentary Ombudsmand, but today they feel that the Danish Parliamentary Ombudsmand only reached out to the National Board of Health for a statement – is it then even an investigation when The Danish Parliamentary Ombudsmand does not actively do anything themselves? Why has The Danish Parliamentary Ombudsmand only asked The National Board of Health, when it is proven that the board has not listened or used the research on this(10) topic, concluding that antidepressive drugs are dangerous for children and young people?

Research, that has existed for at least 10 years. And why does The Danish Parliamentary Ombudsmand accept, that treatment with anti-depressive drugs are still put into the hands of General Practitioners, that are not academically equipped for the task? Those are some of the questions the Terrida family are stuck with after several years of fighting to correct some of the errors, that lead to the death of their son.

Where are Denis and Marianne today?

Marianne and Denis have exhausted their options to get the Danish system to acknowledge the responsibility for the malpractise of their son, and equally run out of options to get The National Board of Health to make changes in the guidelines for antidepressive drugs. A guideline, that Denis and Marianne believe can cause the death of more young people, because it still opens a door, that allow General Practitioners to prescribe antidepressive drugs even though of the risks that accompany this.

Their wish today is:

  • The National Board of Health acknowledges that they should have intervened prior to November 2014 and changed the guidelines for antidepressive drugs for 18-24 year olds. It is extremely critical, and The National Board of Health has hereby put aside the administrative competence, that The National Board of Health has been given to issue guidelines.
  • The National Board of Health acknowledges, that it is not correct, that it was not possible to establish a specific time for, when there was sufficient knowledge on this area (link til undersøger her).
  • The National Board of Health acknowledges that it is trying to set aside their responsibility, when it is calling its own guidelines an interpretation means for doctors.

The Terrida family is still trying to get some sense out of a meaningless incident. Because of that, they have decided to contact The Danish Parliamentary Ombudsmand directly:

Dear Ombudsmand,

It is important for us, that you understand the injustices we have experienced in connection with the death of Danilo – and that you understand what you do not care about correcting, when refusing to investigate the case further.

This is what for you is indifferent:

  • That doctors prescribe antidepressive drugs without giving a real diagnose
  • That the drugs are prescribed without consent from the patient
  • That there is no follow-up on the patient despite of the dangerous drugs
  • That the antidepressive drugs are prescribed to the young people without informing relatives – even though the guidelines encourages including the family. And that the doctor that treated Danilo is acquitted for this error – not having spoken to the relatives due to the doctor – patient privilege – when in the professional psychiatric world you do the opposite: Encourage to include the relatives
  • That Danilo’s doctor failed to comply with the public journal access – and at the same time changed the journals in the case, when these had to be handed over to the Danish Patient Safety Authority.
  • That the Health Medical Officer never investigated, if the drugs had any part in the suicide of Danilo
  • That the Danish Patient Safety Authority accepted the changes by the doctor in the case documents despite the fact that they were added 5 months after we had asked for public journal access
  • That the Danish Patient Safety Authority gave Danilo a new and worse diagnosis when processing the complaint (to justify the prescription of antidepressive drugs)
  • That the National Board of Health themselves in 2010 report to WHO, that the majority of normal General Practitioners are not suited to diagnose and prescribe antidepressive drugs – and that the board despite this still allow General Practitioners to prescribe the drugs.
  • That the National Board of Health covers over its own flaws and mistakes, when claiming that there until 2014 was not sufficient material on the effect of antidepressants and increased risk of suicide, despite the fact that it had been written in the leaflet for 10 years.
  • That the National Board of Health first in 2014 reacts on the many and powerful warnings towards antidepressants, that was already put forward in 2003, and issues a new guideline.
  • That the new guideline for treating young people with antidepressive drugs still leave a backdoor open for General Practitioners, without the needed knowledge within psychiatry, to be able to prescribe the dangerous drugs under the cover of treating it as an emergency. As long as that option exists in the guideline, the improvements that have already been done are needless.

We don’t feel that you, Ombudsmand, are credible in your office, when you only ask the Board and the Ministry, that support the General Practitioners, that has no specialised knowledge within psychiatry and prescribed the dangerous drug to Danilo. We have documented everything in this case (www.daniloforlivet.dk) – they don’t document anything, but still their words weigh more heavily than ours. Why is that? And why has there never been one single Authority that have agreed to meet us and speak face to face. All communication have been through letters, emails and our attorney. Do you expect normal citizens to have these resources?

Dear Ombudsmand. In the real world, everywhere in society, there are consequences and cuts in your driving license, whenever there is a violation of applicable rules, and in disputes, which comes to your table, you are not afraid to cut through, even against boards, ministers and ministries, but when it comes to Health Care there is not even a real investigation.

In conclusion we would also like to inform you, that there is a lot of knowledge available in this area. We have ourselves, as common people, researched and discovered a lot of thorough and serious investigations – Why have you not made this effort? Our research confirms that, after 2008 and until 2014, there was no new knowledge – it was solely the existing knowledge in the area that was reconfirmed. This, supports our claim that the guideline was only changed in 2014, because of pressure from the media after the circumstances of our sons suicide (2011) had been made public.

We believe, that it can never be your choice, ombudsmand, but on the contrary, your duty, to investigate the case of Danilo and criticise all the injustices and errors made – not just sweep it off with that the World looks different today. Especially when it is as obvious as in this case, where even people with no particular medical profession, can see through and discover the many errors committed.

Dear Danish Parliamentary Ombudsmand, to fail is human, and incompetence, neglect and negligence can be/is criticisable, but there can never be any excuses, when you knowingly and deliberately manipulate the truth, to cover up own actions.

Kind regards,

Marianne and Dennis Terrida