CQC orders staffing and safety improvements at trust scrutinised over deaths

A mental health trust has been told to make ‘urgent improvements’ by regulators after a fourth inpatient death occurred with similar themes to three other patients dying within 12 months.

The warning, issued by the Care Quality Commission (CQC) to Devon Partnership Trust, was made after an unannounced inspection at the trust’s Langdon Hospital – following the death of a patient who died by suspected suicide in July.

Last week HSJ revealed how the death was the fourth inpatient death within the last 12 months at the trust, with each incident having recurring themes.

The latest death happened at Langdon Hospital in Dawlish, on one of the trust’s medium secure wards (Ashcombe), with the patient using a ligature point. It was a similar incident to another serious incident in May on a different ward (Holcombe) at the hospital, and it prompted the inspection from the CQC in mid-August.

While the death remains under investigation by the trust, early details shared with the CQC reveal that the incident happened in an area of the ward which had been changed to an “isolation area” under the trust’s COVID-19 infection prevention strategy. However, this meant there were not “good lines of sight” for staff monitoring patients – according to the CQC’s inspection report.

There were also “low staffing levels on the wards”, according to staff which spoke to the CQC. The staff also told inspectors they were “stressed, exhausted and burnt out following the demands of the pandemic”.

According to the CQC, some staff had concerns about areas on the ward where patients had “unrestricted access to items including sports equipment that could be used as weapons for self-harm”.

Although the ward’s ligature assessment claimed those areas were always supervised by staff, this was disputed by the staff themselves, the report said.

Read full story

Source: HSJ, 3 November 2020