Presentation is loading. Please wait.

Presentation is loading. Please wait.

Joanne’s Story: A Reason to Act What’s Going Wrong ? Presented by Chris Bingley Charity Registration Number: 1141638.

Similar presentations


Presentation on theme: "Joanne’s Story: A Reason to Act What’s Going Wrong ? Presented by Chris Bingley Charity Registration Number: 1141638."— Presentation transcript:

1 Joanne’s Story: A Reason to Act What’s Going Wrong ? Presented by Chris Bingley Charity Registration Number:

2 JBMF – Founders Statement “The Joanne Bingley Memorial Foundation is a charity that exists to ensure future generations such as my daughter have access to the appropriate care and support, that services adhere to care quality standards and to inspire sustainable change in the perception and provision of maternal mental health services in the UK” Joanne, or Joe as she preferred to be called, was a nurse with over 20 years experience. She was dedicated, caring and diligent as are most health care professionals I have met. But Joanne was let down by the very NHS organisation that she gave everything to and just 10 short weeks after giving birth to her much longed for daughter Emily, whilst being treated at home for severe postnatal depression she took her own life.

3 Daksha Emson Public Enquiry In 2003 following the release of the public enquiry into the suicide of the psychiatrist Dr Daksha Emson and infanticide of her child, the government made promises that the NHS would deliver “Specialists In Perinatal Mental Health” to care for women in crisis who suffer from postnatal depression. The Royal College of Psychiatry created the faculty of Perinatal Mental Health as a specialism. Yet more than 10 years after the Public Enquiry: More than 35,000 mums are left suffering in silence every year Mums are too scared to come forward for treatment for fear of having their child taken away Dads are left supporting Mums who are too scared to seek help or turn to health care professionals Health Care Professionals are still asking for “Specialists In Perinatal Mental Health” and access to services so that they can support mums, dads and families suffering the mental trauma and crisis

4 Confidential Enquiries The Confidential Enquiries into Maternal Death are recognised as the “gold standard” in in investigating the cause of mums death and they detail how Postnatal Depression is not a new problem: 2002 Confidential Enquiry into Maternal Deaths highlights suicide as a result of postnatal depression a leading cause of maternal death. A plethora of policies, guidelines and legislations follow: Carers Acts 1990, 1995, 2000, 2005 Specialised Mental Health Services (2004) National Service Framework Maternity Standard 11 (2004) Perinatal Healthcare in Prison – A Scoping Review of Policy and Provision (2006) NICE Guidelines CG90 Depression in Adults (2007) revised (2009) NICE Guidelines CG45 Antenatal and Postnatal Mental Health (2007) NHS Acts, Human Rights Act, The NHS Constitution (Health Act 2009) 2011 Confidential Enquiry into Maternal Deaths - suicide is still the leading cause of maternal death.

5 Joe’s Pathway to Despair...1 of 3 Pre-Natal Previous termination, miscarriages and treatment for depression in documented in Health Visitor records – BUT NONE of the 5 mental health risk assessments completed, as described in the Kirklees Maternal Mental Health Care Pathway as the responsibility of Health Visitors, a breach of care quality standards and safe systems of work. 18 Feb 2010 Emily Jane Bingley Born after 5 days in labour 22 Feb 2010 Breast Feeding problems – 1 st Hospital stay with positive results 10 Mar 2010 Breast Feeding problems – 2 nd Hospital stay The medical records detail Joe’s un-consolable crying, anxiety, feelings of failure and the suspicions of Midwife she was suffering postnatal depression. But no clinical risk assessments completed, no referral and no information given to patient or husband Treatment for her lack of hind milk and crying baby was to have Joe connected to a milk pump between feeds with intent to increase milk production over 10 days. Treatment concentrated solely on the problems of Joe continuing to breast feed. 14 Apr 2010 Easter Holiday emotional breakdown GP diagnosis and starts drug treatment for Postnatal Depression and lack of sleep 22 Apr 2010 Suicidal feelings and intent – plans to drive herself and baby into a wall GP listens to options considered but ruled out as they would not guarantee death Mental Health Crisis Team contacted, diagnosis severe postnatal depression

6 Joe’s Pathway to Despair …2 of 3 22 nd April - At initial assessment home care recommended as course of treatment with no other treatment options considered or discussed. No written information of any kind provided nor any information on support groups or how to care for wife. 23 rd April - Care Plan provided to the patient and the husband marked as provided to ‘The Carer’. No information provided about ‘Carer Rights’ and no ‘Carers Risks Assessment’ as required by The Carers Acts, in breach care quality standards At no point is any referral made to specialist perinatal psychiatric services or to a consultant of any kind, in beach of care quality standards and NHS Frameworks 27th April – The Independent Investigation states that the clinical evidence substantiates that Joe should have been hospitalised at least 3 days before she died: Coroners Evidence regarding the visit by the Care Team that day: When Joe requested “ please take me with you ” her request was ignored and brushed aside by the care worker treating her that day. and Joe left the session in frustration (withdrawing from the treatment). Despite Joe ’ s medical record detailing her suicidal plans, a decline in mental health and her obvious state of anxiety the care worker never explored Joe ’ s state of mind even though she admitted to recognising a break-down in Joe’s relationship with her husband. Whilst sat in her car ready to leave, the husband (Chris) knocked on the care workers window to explain Joe had left the property without telling anyone. Despite having recorded the husband ’ s anxiety and distress in her notes, knowing his wife was suicidal, she told him to contact the police if his wife did not return and then drove away!

7 Joe’s Pathway to Despair …3 of 3 29 th April AM visit by Mental Health Crisis Team Dr and Nurse – husband (The Carer) not attending but patients mother in attendance: The Dr for the first and only time during the entire treatment records signs of improvement, and decides there is no need to discuss alternate treatments PM visit by Health Visitors - husband (The Carer) not attending but paternal grandparents in attendance: Recorded high levels of anxiety, despair, inability to cope, her feelings that mental health service wasting her time and her intent to withdraw from care HV contacts Crisis Team Manager who over rules HV concern and ignores risks HV raises her concerns of HV’s being unable to cope when told Crisis Team is planning to stop providing support, and HV contacts her manager to log risks. No-one contacts Husband (The Carer) to discuss risks, inquire of patients state or to check if he “the carer” is able to cope prior to the Bank Holiday weekend. 30 th April Joanne walks on railway tracks, throwing herself under a train 4 th May On her first day back at work following Bank Holiday, at 9:05am the Crisis Team Manager contacts the Health Visitors, the medical records detail the purpose was to explain that at no time did Joanne show suicidal intent else they (The Crisis Team) would have taken action.

8 NHS Responses after Joe died Huddersfield Royal Infirmary - Excess stamp duty to pay for …… - Letter of condolences and apology for your loss Mental Health Crisis Team Admin Dept - Request to compete Patient Satisfaction Questionaire - Reminder to complete Patient Satisfaction Questionaire Mental Health Crisis Team Manager - in a discussion recorded by Health Visitors: - Patients husband has family support so do not contact for 6 to 8 weeks - Support for Crisis Team staff and HV staff affected by Joe’s death to be organised through normal channels Mental Health Crisis Team Director and Manager - in a meeting held in the patients home with her husband and GP friend, prior to their investigating Joe’s death: “Guidelines are just guidelines we don’t have to follow guidelines” “ These things just happen”

9 NHS Internal Reviews Huddersfield Royal Infirmary - Maternity Care The report fails to address key issues and aspects of the treatment, failed to interview key persons who treated the patient, in particular the 2 Breast Feeding Midwives who were encouraging a course of treatment when it was suspected she was showing signs and symptoms of Post Natal Depression. The conclusions are fundamentally flawed, stating “we could not have known she was suffering from postnatal depression”, contrary to the written evidence in the medical records and statements of the midwives. Kirklees Community Healthcare – Health Visitor Maternity Services The report was written on the 4th May as an ‘Internal Review’ without reference to any specific terms of reference or other guidance. The report fails to cover key issues (Joe’s previous history and treatment for PND, the failure to perform 5 clinical risk assessments, etc.) making NO conclusions. South West Yorkshire Partnership Foundation Trust – Mental Health Services Finds “internal processes” were followed and concludes whilst key things need to be improved nothing that was wrong contributed to the death. The report fails to cover key issues and aspects of the treatment and care; concentrates on “internal policies and process” failing to cover independent investigations, legislation, etc; report emphasises “the reliance on the family”

10 The Independent Investigation Due to time constraints placed upon the investigation by the NHS it was agreed: The investigation team was only able to review the clinical documentation, policy documents and staff written statements and records, without the benefit of investigators interviewing staff. As the NHS were unable to identify investigators in Midwifery or Health Visiting, these areas were supposed to be reviewed and investigated at a later stage. The Results: 21 recommendations and actions for change including: Specialist Perinatal Psychiatric Resource New strategies and policies compliant to care quality standards New and improved systems, processes and safe systems of working Provision of written information to patients and carers Mandatory contractual care standards and compliance measures The Independent Investigation concludes: “From the documentation there is evidence that Joanne Bingley should have been hospitalised on the 27 th of April 2010 at least 3 days before her death. Further if she had been so treated would probably have made a full recovery”

11 Results of Previous Investigations 19 Previous Independent Investigations conducted by the Yorkshire and Humber Strategic Health Authority are available to the public. These show recurring failures in the treatment and care of patients and Carers consistent with Joanne Bingley.

12 Coroners Inquest – Oct 2011 The criminal standard of proof beyond reasonable doubt, represents the evidential hurdle or threshold that the coroner had to consider for suicide or unlawful killing. He resolved to return a narrative verdict, and his 21 statements of fact include: A personal and family history of mental health problems as well as significant adverse life events befalling her in the last 5 years of her life. (Including prior treatment for PND) By the 22nd April her condition was such that she was referred to the Mental Health Services who responded promptly. At and around this time she was expressing suicidal ideation, low mood, anxiety and a poor sleep pattern. At a meeting it was determined she could be treated at home. I have found as fact that no discussion of other therapeutic options took place……… informed consent has not been obtained. Independent medical care advice commissioned from Dr Oates and Mr Ketteringham. I have accepted their view that the possibility of admission should have been part of the initial treatment care plan and discussed with the patient and her husband as a treatment option if she either became worse or did not improve. I find as fact that her health fluctuated and did not improve. It is also their evidence that on the 27 April, if not before, there was clinical indication to be admitted to a Mother and Baby Unit. (i.e. 3 days before she died) It would follow from this opinion that if admission had taken place Joanne Bingley in all probability would not have died on the date or in the manner that she did.

13 Negligence Claims (Joe Bingley) and NHS Legal Costs In December 2013, a little under 4 years after her death, the Director of Nursing from the NHS trust that treated Joanne (Joe) Bingley finally admitted fault. 2 years after the Coroner issued his “Statement of Facts”, In a statement issued into court the NHS accepted that: In all probability had specialist perinatal psychiatric treatment been offered, including the admittance to hospital in a specialist mother and baby unit, it would have been accepted. Had specialist treatment been provided the patient, Joanne Bingley, would have been expected to make a full recovery. Their (NHS Trusts) breach in duty of care was the probable cause of death 1/5th the NHS budget currently goes to cover negligence claims with £1.8bn spent annually in legal costs defending negligence claims ………. Whilst stating their desire to settle the claim, 4 years after her death NHS lawyers have yet to agree “heads of agreement” prior to discussing the value of any claim Joe’s husband had the family home repossessed and faces bankruptcy with his own legal costs currently in excess of £400,000, with estimates of total legal costs > £1m.

14 Mums continue to die as Lessons Learned not Implemented The Independent Investigation into Joanne (Joe) Bingley’s death resulted in 21 recommendations for improvement i.e. “lessons learned”, which the NHS trusts agreed in an action plan with her husband Chris to implement in full the by September After being told by NHS staff actions had not been implemented as the NHS trust had told him, Chris’ requested the Care Quality Commission to investigate. In April 2012 the Care Quality Commission, following complaints raised by the husband of a patient who had deceased, reported on the NHS Trust that treated Joe: their investigation found the NHS Trust had “failed to implement” many of the “Lessons Learned” and many “failed to meet acceptable care standards” Mums suffering severe PND – “ Women in this specific user group at risk ” 3 Deaths in 4 years of mums referred as patients to the same NHS Mental Health Trust Following the CQC report, at least 2 further mums died whilst suffering from severe postnatal depression / psychosis receiving treatment at home by the same NHS Trust. Jan 2013Clair Tuprin, Sheffield Treated at home for severe PND, jumps from John Lewis building in Sheffield Dec 2013Roaseanne Hinchlife, Treated at home for puerperal psychosis, sneaks out and Jumps from Cliffs at Whitby

15 The NHS Constitution (Health Act 2009) On 19 January 2010 The Health Act 2009 came into force placing a statutory duty on NHS bodies, primary care services, independent and third sector organisations in England. The Constitution clarifies “patient rights” such as: Informed Consent To be able to give valid consent to treatment is a fundamental right and absolutely central in all forms of health care. You have the right to be involved in discussions and decisions about your healthcare, and to be given information to enable you to do this. So a patient can make “informed decisions” they need access to impartial, evidence based, accurate, readable, information. This is especially important when a person has severe depression. Treatment Options Patients have the right to be treated with a professional standard of care, by appropriately qualified and experienced staff. You have the right to drugs and treatments that have been recommended by NICE for use in the NHS, if your doctor says they are clinically appropriate for you. You have the right to be given information about your proposed treatment in advance. Learning by Experience You have the right to expect NHS organisations to monitor, and make efforts to improve, the quality of healthcare they commission or provide. In the case of an NHS body or private organisation, it must take reasonable care to ensure a safe system of healthcare – using appropriately qualified and experienced staff.

16 The Francis Enquiry For the NHS to ‘place the quality of patient care, especially patient safety, above all other aims’ we must have candour when mistakes happen and acknowledge all medical errors. Only 24 per cent of the 140 possible contributory factors identified by the inquiry team had been identified in local investigations at the time of the incidents. So 76 per cent of the learning from the incidents had been missed; a situation that there is an urgent need to improve. As well as the new statutory duty of candour, greater use will be made of incident data, including a commitment for CQC to consider each hospital’s review of serious untoward incidents as part of its pre-inspection activity. NHS England is to launch a program of new patient safety collaboratives, which will be expected to provide expertise on learning from mistakes and help to provide a ‘rigorous approach to transforming patient safety’.

17 The Consequences of Failure The death of Joanne (Joe) Bingley caused horrific trauma to her husband, to Joe’s family and to her friends. But it also had a significant impact on the lives of many others. Following his wife’s death Chris was driven by his own grief and the despair to find out answers to his questions ……. Why? At the Coroner’s Inquest the true consequences and costs of the failure to prevent what was an “avoidable death” was brought home to him when told of the many others affected, including the 7 year old child who witnessed Joe’s death ! Many of those who witnessed Joe’s body being torn apart by the train, her internal organs being spread across the tracks, the blood pool that resulted and her upper torso being dragged along the tracks, until the train came to rest. were traumatised:  The 2 train drivers off work needing treatment  The members of public, off work needing treatment  The 7 year old child waiting on the platform to go to school  And many other people who had to deal with the incident All this suffering as a result of the NHS staff failing to obtain “informed consent”, failing to provide access to specialist perinatal health services and failing to admit Joe to a specialist Mother and Baby Unit, even though places were available at the time of her death in Leeds, Manchester and Nottingham.

18 The True Costs of Failure The costs of just one “avoidable death” like Joe’s would cover the costs of providing all mums and dads with the information they require and the extra mother and baby unit beds needed. The estimated cost of the emergency response (£2m) and the economic costs of closing the Trans-Peninne train line for several hours (£20m), hardly feels relevant when compared to the widespread human costs. Proper care would have cost: 15p for the JBMF information card for mums & dads (900,000 *25p = £176,000 per year for all mums) 2p for the JBMF Severe Postnatal Depression checklist/leaflet 5p = £1,000 for all sufferers) just £17,000 for the 56 days treatment Joe needed to live! £318 per day for treatment in a Mother and Baby Unit Bed The sad fact is each year there are up to 66 maternal suicides due to psychiatric causes of which 86% are “Avoidable Deaths” (diagnosis and treatment was possible). A single “Avoidable Death” such as Joanne Bingley can cost the economy in excess of £22m and can cost the NHS over £millions in legal fees defending for years the negligence claims, irrespective of any payout after finally admitting to a breach in duty of care.

19 A National Scandal The death of Joanne (Joe) Bingley highlights a national scandal Despite Ministerial promises, NHS Service Frameworks, NICE Care Standards and various Guidelines. ………… the NHS failed to commission Perinatal Mental Health Services across most of the UK. The Patients Association Survey in 2011 found more than 50% of Mental Health Services acting in breach of care standards – failing to follow care quality standards,, – failing to employ the required specialist perinatal psychiatrists, – failing to provide information to patients – NICE guidelines specify that those who suffer severe postnatal depression should be referred to a specialist perinatal psychiatrist – less than 37% of PCTs commissioned specialist services. – NICE Guidelines state the preferred treatment for severe PND or Puerperal Psychosis is hospitalisation in Mother and Baby Units (MBUs) – less than 91 beds exist with places for a maximum of 593 mums – 10% Dads suffer Postnatal Depression, Dads are not recognised by NICE – no specialist services are available for Dads either as Sufferers or Carers

20 Mums and Dads at Risk Statistics on postnatal depression show that: 2/3rds of mums will suffer a mood disorder during or after pregnancy: Based upon 201 ONS Birth Rates UK East Midlands 1 in 2 mums suffer Baby Blues403,88827,689 15% Mums suffer Postnatal Depression121,166 8,307 3% Mums suffer Severe Postnatal Depression 24,233 1,661 1 in 500 Mums suffer Puerperal Psychosis 1, Maternal OCD Maternal PTSD 10% Dads who suffer from PND without treatment 80,778 5,538 50% Mums suffering in silence too afraid to seek help 60,583 4,153 35,000 mums suffering in silence every year too scared to seek help (i.e. half of all mums affected by mild to moderate postnatal depression). 86% of mums suicides whilst suffering mental illness are “avoidable deaths” 10% of Dads suffer from PND but the NHS provides no support

21 Best Practice & Care Standards The Baby Blues 50% of Mums Severe Postnatal Depression 3% of Mums Mild to Moderate Postnatal Depression 10% to 15% of Mums 353,124 per annum 84,750 per annum 21,187 per annum 1,412 per annum Specialist Perinatal Mental Health Services Mother & Baby Units Specialist Perinatal Psychiatrists Non - Specialist (PNMH) Services Admittance to general psychiatric ward Crisis Home Resolution Teams – “gatekeepers” NHS Integrated Care Networks (Examples) Nottingham, Southampton, Birmingham, Glasgow, etc. Non-specialist services - lead by PNMH Champions with support of GP’s, Midwives, Health Visitors, Care Workers, volunteers, etc. 3 rd Sector Support (Examples) Family Action - support program & befrienders Net Mums - online CBT & chat rooms House of Light - call-line and drop in groups Joanne Bingley Memorial Foundation - raising awareness, training & education Peurperal Pscyhosis 1 in 500 Mums Numbers based on 706,248 live births in 2009 and the agreed rates of occurence National Perinatal Mental Health Project Report – A Review of Current Provision (2011)

22 Dads and “ Significant Others” Whilst Health Visitors and Midwives are the primary contact for Mums during pregnancy latest research shows mums are far more likely to turn to their partners for help and support than to Health Care professionals. A survey by Netmums and the Royal College of Midwives (Nov 2012) found: Mums mainly (42%) turned to their husband or partner when they first talked about how they felt with only a third (30%) first mentioned it to a health professional. Only a third of mums (30%) were told about the possibility of depression by their midwife and only a quarter ((27%) reported being asked how they felt emotionally during their pregnancy. Nearly three-quarters (74%) of those surveyed said it often took a few weeks or more likely a few months before they recognised they had a problem. Over a third of women who suffer depression during pregnancy have suicidal thoughts. The NHS currently does not commission or provide any support for Dads, family members or Significant Others who are expected to provide the support to those suffering from postnatal depression … as insufficient research has been done!

23 Dads as “Carers” The NHS Choices Website gives as an example a “a Carer” is “someone looking after a person between mental health crisis”. "As a new father, it was very difficult. It was time for me to learn everything. It's expected that 'you are the man' so you can manage. It's never about how you are feeling, it was all about her. It didn't matter what you did, nothing was good enough. There was the new baby, we had a new house and all the added other pressures that Michelle use to deal with and, most importantly, my wife's illness. I had to give up work for six months. The isolation was the biggest thing I felt hard to cope with. How was I going to tell my friends if I didn't understand myself? I was exactly like the people who still say "how can you be depressed" - with mental illness, you can't just snap out of it.”Mark Williams Fathers Reaching Out aims to help men who suffer from perinatal mental illness and who are left responsible for caring for mums suffering from perinatal mental illness The crucial role “Carers” play, whether dads, partners, family members or friends, must be recognized by service providers…… even though NICE fails to mention “DADS”

24 Why things remain unchanged According to The Confidential Enquiries into Maternal Death the highest cause of maternal death is suicide as a result of suffering depression. 86% of deaths are “avoidable deaths” based upon findings that it was possible to have identified the illness and provided treatment for the Mums to have made a full recovery. The sad facts are: The stigma associated with suffering mental illness has not gone away Mental illness does not get “parity of care” with physical illness NHS Primary Care Trusts failed to commission perinatal mental health services across more than 50% of the country (1) Huge gaps and discrepancies in provision of services across the UK (3) Currently 97% of Health and Well Being Boards in England have failed to include any strategy on Perinatal (Maternal) Mental Health. This is WHY – outcomes for most patients have remained unchanged for 10 yrs

25 Why I am here …. Why ? Joe was a dedicated and caring nursing professional In 20 years working at Huddersfield Royal Infirmary she enjoyed caring and treating those who were ill but also cherished her time mentoring and supporting others Whilst there is a stepped change underway, back to the core values of “caring” and “putting the patient first” It will take at least 10 years before significant improvements are seen in the provision of Specialist Perinatal Mental Health Services The 3 rd Sector, Family and Mental Health Services must work together to create the Integrated Care Networks required to fill the gaps in mental health care, “provide support for those suffering in silence” and “eliminate the unnecessary suffering” and “prevent the avoidable deaths” that devastate the whole family.

26 The Joanne (Joe) Bingley Memorial Foundation  Founders Statement  How we help  Parliamentary Commission into PNMH  Why I am here……

27 JBMF – Founders Statement “The Joanne Bingley Memorial Foundation is a charity that exists to ensure future generations such as my daughter have access to the appropriate care and support, that services adhere to care quality standards and to inspire sustainable change in the perception and provision of maternal mental health services in the UK” Joanne, or Joe as she preferred to be called, was a nurse with over 20 years experience. She was dedicated, caring and diligent as are most health care professionals I have met. But Joanne was let down by the very NHS organisation that she gave everything to and just 10 short weeks after giving birth to her much longed for daughter Emily, whilst being treated at home for severe postnatal depression she took her own life.

28 JBMF – How we help How the foundation delivers it’s aims: Website and information leaflets - we provide information on what you need to know so dads, grandparents and friends can help. We publish stories in national media, Twitter, Facebook and our website to encourage open discussion and raise awareness Knowledge of ‘Best practice’ – legislation, care quality protocols, befriender and peer support groups, self help, supervision, etc; presenting at seminars and workshops to inform commissioners, dept health, parliament, etc. on patient and service issues. We provide training & education workshops for professional health care workers and volunteers We have supported research including: The Patients Association survey of Primary Care Trusts Kings College User Group Through links with MP’s and other organisations we inform NHS policy makers and parliament of service user issues and expectations Supporting the Maternal Mental Health Alliance we work with other organisations to deliver improvements in PNMH services.

29 Parliamentary Commission Into Perinatal Mental Health Proposed Scope and Terms of Reference: The inquiry will provide an independent review and detailed investigation to understand and highlight the issues and policy areas Why? has there been a failure to implement Specialist Perinatal Mental Health Care Services across the UK despite Parliamentary and Department of Health promises after the death of Daksha Emson. Why? has there been a failure to implement “lessons learned” from Independent Investigations and Confidential Enquiries and a failure to implement and follow Care Standards. Why? Dads are not being recognised as Carers by NICE even though “Home Care” is the primary treatment offered by Mental Health Crisis Teams (Note use of the term …. “Significant Others”) What? are the implications and costs to society and the economy: Mums - unnecessary “Suffering in Silence” and “Avoidable Deaths” Dads – “Caring for Partners” and “suffering from PND” Early Years Child Development – issues in the 1001 Critical Days The breakdown of Family Finances, Family Relationships and Resulting Deprivation Businesses Productivity and Employer Costs The “Consequences of Failure” on the wider community and general public What? are the required actions to enforce the implementation of Care Standards and Lessons Learned, and to ensure promises made are delivered. What? are the recommendations to reduce the “unnecessary suffering” and “avoidable deaths”

30 Why I am here ……

31


Download ppt "Joanne’s Story: A Reason to Act What’s Going Wrong ? Presented by Chris Bingley Charity Registration Number: 1141638."

Similar presentations


Ads by Google