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Found 153 results
  1. News Article
    A nurse who was struck off for refusing to admit a woman to a mental health unit before she killed herself said 'leave her, she will faint before she dies' before he kicked her out of the facility. Paddy McKee allegedly made the comment as Sally Mays, 22 - who had mental health issues - tried to strangle herself when she was refused admission. Ms Mays killed herself at home in Hull in July 2014 after being refused a place at Miranda House in Hull by McKee and another nurse. Despite her being a suicide risk, they would not give her a place at the hospital after a 14-minute assessment. Her parents Angela and Andy have fought for several years for improvements to be made and lessons to be learnt from her death. McKee was this month struck off following a Fitness to Practice hearing conducted by the Nursing and Midwifery Council. The report by the NMC was this week published and condemned McKee, saying 'he treated her in a way that lacked basic kindness and compassion'. The NMC found his actions to refuse Ms Mays' admission had contributed to her death. Read full story Source: Mail Online, 12 January 2022
  2. Content Article
    In this blog, Debbie Ivanova, Deputy Chief Inspector — People with a learning disability and autistic people, and Jemima Burnage, Deputy Chief Inspector and Mental Health Lead, update on progress since the Care Quality Commission’s (CQC) 'Out of Sight' report published in October 2020. Their blog discusses the findings of the authors' 'Restraint, segregation and seclusion review: Progress report' published in December 2021.
  3. Content Article
    In this report, the Care Quality Commission (CQC) comments on progress following publication of its 'Out of sight – who cares?' report in October 2020, and highlights the main areas where further work is still needed.
  4. News Article
    NHS mental health services are facing a “desperate” situation as all hospitals across the country are dangerously full and leaked data shows hundreds of patients waiting over 12 hours in A&E, The Independent can reveal. The news comes as the spread of Omicron risks outbreaks in mental health hospitals, with a large hospital in London forced to close its doors to new admissions on three wards. In response to the growing bed pressures in the capital over the past month the NHS has commissioned 40 beds from private sector hospitals run by The Priory Group, The Independent understands. NHS data, seen by The Independent, has revealed that almost all mental health hospitals in London have been at “black alert” levels of bed availability during October and November, meaning their beds were nearly 100 per cent full. A senior national source has warned the situation is similar across the country, with nearly all mental health trusts 94 per cent full and services at their most stressed ever. Read full story Source: The Independent, 23 December 2021
  5. News Article
    People needing acute mental health treatment are being left in prison for extended periods, HSJ can reveal. Figures HSJ obtained under the Freedom of Information Act show that 3,111 patients were transferred from prisons to mental health facilities between 2018-19 and 2020-21. A total of 481 (15%) of the transfer took more than 14 days from the date the mental health casework section received an application for transfer to the date the transfer took place. Across these three years, 167 transfers (5%) took more than 28 days. The longest wait for transfer was 161 days, which happened in 2018-19. However, the average number of days taken to transfer a patient has remained consistent at between 10 and 11 days. Until the summer, NHS England’s guidance recommended a 14-day time limit for transfers of patients from prisons to mental health facilities. In June 2021, NHSE published new guidance which recommended a 28-day time limit between a person first being referred for inpatient assessment and being admitted to a mental health facility. The timeline, which consists of two sequential 14-day periods, says medical reports should be “completed to be sent to the [MHCS]” between days 15 and 25, while the MCHS should approve and issue a warrant and admission should take place before day 28. Sophie Corlett, of mental health charity Mind, said: “Nobody who has been assessed as needing specialist inpatient care should be left for extended periods of time in prison, as it’s a completely inappropriate setting for anyone in crisis… When people are a risk to themselves, it’s crucial there are enough staff and beds available to make sure they are cared for in a safe and therapeutic environment.” Bethan Roberts, British Medical Association forensic and secure environments committee interim chair, said: “A prisoner who is mentally unwell and cannot be adequately cared for in a prison should… be transferred to a forensic mental health unit as soon as possible." Read full story (paywalled) Source: HSJ, 1 December 2021
  6. News Article
    A woman took her own life on a ward after her move to a mental health hospital was not facilitated. Anne Clelland was found unconscious in the toilet of her room in Glasgow's Queen Elizabeth University Hospital and later died of a brain injury. Anne - who had a history of self-harm - was admitted following an overdose. She was due to be moved to a psychiatric hospital three days before her death but this did not take place because of a "failure of communication." NHS Greater Glasgow and Clyde pled guilty today to failing to conduct their undertaking in a way that a person would not be exposed to risks to their health and safety. Glasgow Sheriff Court heard Anne was admitted to Ward 5A at the hospital after overdosing on 7 May 2015. A specialist met with Ann on 11 and 12 May with a plan put in place for her to be transferred to Leverndale hospital once she was medically fit. A psychiatry team was to be contacted at that time for a further review to facilitate the transfer. Prosecutor Catriona Dow said: “There was no suggestion at this time that despite her ongoing treatment following her suicide attempt, that she was at risk of suicide and required special requirements such as the removal of her possessions and enhanced observations such as constant observations.” “There appears there was a breakdown in communication regarding the intention of the psychiatrist that Anne would be transferred that evening due to her assessed risk of self-harm.” Other witnesses recalled a plan for a transfer to Leverndale but it was understood that until a bed was to become available, she would be able to remain at Ward 5A. Other staff appeared not to have been aware of the assessed risk of self-harm and her transfer to Leverndale that evening. Read full story Source: Glasgow Live, 8 November 2021
  7. News Article
    A new community-based mental health facility is under construction in South West London. Set to open during 2022, the new facilities will provide high quality inpatient services that are designed to deliver the most modern mental health care in the country. The service will give people the best chance to recover in the best environment and will support Trust staff to deliver outstanding care. The new buildings will form part of the new ‘Springfield Village’, which will include a new 32-acre park at Springfield Hospital, as well as hundreds of new homes. Ian Garlington, Director for South West London and St George’s Mental Health NHS Trust’s Integrated Programme, which is delivering investments in NHS mental health services in South West London, said: “We are proud to be leading the way in breaking stigma by developing facilities that will sit at the heart of our Springfield Village, alongside a fantastic new 32-acre park, supporting the health and wellbeing of our whole community.” hub topic lead, Steve Turner, said: As a nurse who completed my registered nurse training at St George's Hospital and mental health nurse training at Springfield Hospital in the 1980s, I am very pleased to see this development on the site where I once worked and will be following progress with interest." Read full story Source: NHS South West London and St George's Mental Health NHS Trust
  8. Content Article
    This report looks into the circumstances surrounding the deaths of three young adults; Joanna, Jon and Ben. They each had learning disabilities, were patients at Cawston Park Hospital and died within a 27 month period (April 2018 to July 2020). It highlights multiple significant failures in care, including excessive use of restraint and seclusion, overmedication of patients, lack of record keeping and the physical assault of patients. The report also makes a series of recommendations for critical system and strategic change, both at a local and national level.
  9. News Article
    A coroner has raised concerns about how a family was allowed to bring a restricted item that contributed to a man's death into a mental health unit. Joshua Sahota, 25, died as a result of asphyxia and psychosis in Bury St Edmunds, Suffolk, on 9 September 2019. Suffolk coroner Nigel Parsley said Mr Sahota's relatives were not told the item they brought in when visiting was on a restricted list. The NHS trust which runs the unit said it had improved its internal processes. Mr Sahota, from Kennett in Cambridgeshire, was taken to the Wedgewood Unit on the West Suffolk Hospital site three weeks before his death as his mental health had declined. Insufficient staffing levels contributed to his death, an inquest jury at Suffolk Coroner's Court concluded. Other factors included insufficient observations and one-to-one processes, no clear and concise risk assessments, being slow to develop a care plan and the absence of a documented crisis plan. Read full story Source: BBC News, 21 September 2021
  10. News Article
    Young people cared for by an NHS mental health service "came to harm" because of its failings, inspectors said. The care provided by Essex Partnership University NHS Foundation Trust (EPUT) has been rated "inadequate" by the Care Quality Commission (CQC). It has now been stopped from admitting new patients after inspectors found "serious concerns" in the children and adolescent mental health services. EPUT said it had increased staffing levels and had been coaching staff. The inspection was prompted by a serious incident and concerning information received about safety and quality, the CQC said. Inspectors visited, unannounced, in May and June and looked at the Larkwood and Longview wards at the St Aubyn Centre in Colchester and the Poplar Adolescent Unit at Rochford Hospital. The CQC found observations were not always carried out safely and patients "had been harmed as a result of the poor practices", which included patients self-harming. It said these incidents were not always reported or dealt with appropriately. Read full story Source: BBC News, 15 September 2021
  11. News Article
    The father of a man who took his own life said the mental health unit where he was staying "failed him completely". Joshua Sahota, 25, died as a result of asphyxia and psychosis at the Wedgewood Unit in Bury St Edmunds, Suffolk, on 9 September 2019. Insufficient staffing levels at the unit contributed to his death, an inquest jury found. Mr Sahota, from Kennett in Cambridgeshire, was taken to the unit three weeks before his death as his mental health had declined. There was no psychologist in post and the jury at Suffolk Coroner's Court recorded this as having contributed to his death. It also found that a plastic bag which contributed to his death was on a restricted items list, but this was "unclear" and there were "inconsistencies of understanding this" by staff and visitors. Other factors that the jury said contributed to his death included insufficient observations and one-to-one processes, no clear and concise risk assessments, being slow to develop a care plan and the absence of a documented crisis plan. Read full story Source: BBC News, 10 September 2021
  12. Content Article
    The Lampard Inquiry is a statutory inquiry investigating mental health inpatient deaths in Essex, focused on services provided by the Essex Partnership University Foundation NHS Trust (EPUT) and the North East London Foundation Trust (NELFT) and their predecessor organisations. This Inquiry continues the work of the Essex Mental Health Independent Inquiry. This website provides information about the inquiry team, terms of reference and publications relating to this.
  13. Content Article
    In this blog Alice Fletcher, Programme Manager for Patient Safety (Mental Health) at the Innovation Agency, talks about the first phrase of the Mental Health Safety Improvement Programme being delivered by the 15 Academic Health and Science Networks in England. Its initial focus is on reducing restrictive practice in mental health wards, considering where this can be dealt with differently if staff have adequate training and knowledge of other methods.
  14. Content Article
    The Suicide Prevention National Transformation Programme aims to reduce the number of deaths by suicide in England by 10% by 2020/21.  NHS England are investing funding in 37 local areas to establish or develop their multi-agency suicide prevention action plans to reduce suicide and self-harm. These plans cover three of the main priority areas identified in the National Suicide Prevention Strategy: Reducing risk in men. Prevention and response to self-harm. Improving acute mental health care. Find out more about the programme and useful resources from the link below.
  15. News Article
    The Department of Health and Social Care (DHSC) is facing being taken to court over an inquiry it launched into the deaths of dozens of mental health patients in Essex. Last year, the government said it would commission an independent inquiry into at least 36 inpatient deaths in Essex, which had taken place over the last two decades. However, more than 70 families are calling for a full statutory public inquiry, which can compel witnesses to give evidence. They have lodged judicial review proceedings at the High Court against the government to that effect. The DHSC said it could not comment on ongoing legal proceedings. The current inquiry was launched in response to a highly critical report from the Parliamentary Health Service Ombudsman, published in June 2019, into the deaths of two patients at North Essex Partnership University Foundation Trust, which has since merged to form Essex Partnership University FT. There has also been an investigation by Essex Police into 25 of the deaths. This concluded in 2018, when the force said there had been “clear and basic” care failings, but there was not enough evidence to prosecute the trust for corporate manslaughter. Read full story (paywalled) Source: HSJ, 11 May 2021
  16. News Article
    Police are investigating allegations around the death of a patient who was under the care of Hertfordshire Partnership University Foundation Trust. The probe by Hertfordshire Constabulary relates to the case of Margaret Molyneux, 69, who according to a review by the trust’s commissioners, was prescribed doses of anti-psychotic medication which were significantly higher than recommended limits. Police said the investigation is ongoing and no arrests have been made. Ms Molyneux had been admitted to the trust’s mental health unit in Radlett in 2017, after which her physical health declined and she was admitted to Watford General Hospital with pneumonia and dysphagia, which relates to difficulties swallowing. She was discharged back to the Radlett unit, but died several weeks later at Watford General Hospital, after choking on her food and developing aspiration pneumonia. An inquest in February 2018 ruled she died from natural causes, but an investigation into her case commissioned by East and North Hertfordshire Clinical Commissioning Group, seen by HSJ, subsequently suggested high doses of Olanzapine, an anti-psychotic drug, were “likely to have at least contributed to some of the physical problems she experienced… including low blood pressure, falls and dysphagia”. Read full story (paywalled) Source: HSJ, 6 May 2021
  17. Content Article
    The Serenity Integrated Mentoring (SIM) model is described as "an innovative mental health workforce transformation model that brings together the police and community mental health services, in order to better support 'high intensity users' of Section 136 of the Mental Health Act (MHA) and public services." The SIM model is part of a 'High Intensity Network' (HIN) approach, which is now live in all south London boroughs. In this hub post, Steve Turner highlights the benefits and risks of this approach and seek your views on it.
  18. Content Article
    Variation in healthcare processes is widespread in mental health care and can lead to inefficient processes and unnecessarily long inpatient stays. This study in The British Journal of Healthcare Management aimed to identify sources of variation and introduce a huddle intervention to increase system efficiency on a psychiatric inpatient ward in London. The study found that huddles are a useful way to improve staff communication and increase ward efficiency without taking up a significant amount of clinicians' time.
  19. Content Article
    For some time now I've been looking to find out more about mental health services in Trieste, Italy. Then I met Vincenzo Passante Spaccapietra, co-host of the Place of Safety? podcast series. This has enabled me to learn more about the closure of the mental institutions in Trieste, Italy, and the work of Franco Basaglia.  I was keen to find out what really took place, what this really means in practice and how we can adopt this model in the UK. We were delighted to have become involved and to have recorded a couple of podcasts. I recommend this resource to everyone interested in safe, compassionate, patient led mental health care.
  20. News Article
    A mental health trust prosecuted for failings after 11 patients died must make further safety improvements, the Care Quality Commission (CQC) said. Inspectors found safety issues on male wards and psychiatric intensive care units run by Essex Partnership University NHS Foundation Trust (EPUT). The Trust said it had taken "immediate action" to remedy the concerns. In November, EPUT pleaded guilty to safety failings related to patient deaths between 2004 and 2015. The CQC's report followed inspections in October and November last year at the Finchingfield Ward - a 17-bed unit in the Linden Centre in Chelmsford which provides treatment for men experiencing acute mental health difficulties. The CQC said the visit was prompted "due to concerning information raised to the commission regarding safety incidents leading to concerns around risk of harm". The inspection, which looked at safety only, found the following concerns: Some staff did not follow the required actions to maintain patient safety. Closed-circuit television showed staff who were meant to be observing were not present, and this contributed to an incident of patient absconding. Staff did not keep accurate records of patient care and managers did not check the quality and accuracy. of notes. Shifts were not always covered by staff with appropriate experience and competency Stuart Dunn, head of hospital inspection at the CQC, said EPUT had "responded quickly to concerns raised" including improving security measures. Read full story Source: BBC News, 14 January 2021
  21. News Article
    An independent children’s and adolescents’ mental health service has been taken out of special measures after cutting beds by two-thirds. The Care Quality Commission has rated St Andrew’s Healthcare’s CAMHS unit in Northamptonshire “requires improvement” but removed it from special measures. Among improvements noticed were a major change in the service’s leadership and staff raising concerns openly and honestly. The unit was rated “inadequate” and served with a section 31 notice following inspections in June and December last year. After its December inspection, the charity reduced the number of beds within its CAMHS offering from 90 to 30. Around the same time, St Andrew’s Healthcare chief executive Katie Fisher also revealed plans to shrink its services by half to address the serious quality issues. Speaking to HSJ, St Andrew’s Healthcare chief executive, Kate Fisher, who was appointed in 2018, said: “this isn’t just words, we are absolutely walking the walk and seeing through the strategy we set ourselves.” Read full story (paywalled) Source: HSJ, 18 December 2020
  22. Content Article
    This study in the International Journal of Mental Health Nursing presents a qualitative evaluation of staff perspectives of the impact and value of the REsTRAIN Yourself initiative. REsTRAIN Yourself aimed to reduce the use of physical restraint in mental health inpatient wards through training and practice development with whole teams within ward settings. Thirty-six staff participated in semi-structured interviews for this study.
  23. Content Article
    This document by the Restraint Reduction Network offers a framework to support care providers in reducing the use of restrictive practices. Restrictive practices are often a response to behaviours seen by care providers and wider society as ‘behaviours of concern’ or ‘challenging behaviour’. These behaviours can occasionally include wilful acts that have the potential to cause harm, but more often than not, these behaviours are symptoms of distress or frustration and a response to the environment or situation that a person finds themselves in. This document outlines the National Minimum Standards for the content of Restrictive Interventions Reduction Plans in mental health and learning disability settings.
  24. News Article
    Women in a newly opened psychiatric intensive care unit (PICU) had concerns for their sexual safety, a Care Quality Commission (CQC) report has revealed. Inspectors found women in the PICU at Cygnet Health Care’s Godden Green Hospital, in Kent, were afraid to shower because male staff did not always knock before entering bedrooms and staff entered bathrooms without permission. Patients were often looked after by male staff despite having asked for a female staff member and, in some cases, had an all-male care team. Most patients the inspectors spoke to had concerns about their sexual safety. The CQC carried out an unannounced inspection of the PICU in October, following concerns raised by members of the public and to check concerns identified in an earlier inspection of the hospital’s child and adolescent mental health services were not organisational. The PICU opened in November 2019. Since the summer, Kent and Medway NHS and Social Care Partnership Trust has commissioned some of the beds, but HSJ understands it stopped admissions for a time to review the care being provided. Inspectors found records referred to PICU patients as “difficult” and “troublemakers” and warned a ”culture of negativity towards patients had developed among some staff”. Read full story (paywalled) Source: HSJ, 4 December 2020
  25. News Article
    Staff at a mental health unit missed "multiple opportunities" to realise a woman had become unwell before she died, a coroner has said. Sian Hewitt, 25, died at Milton Keynes Hospital last year after collapsing at the nearby Campbell Centre. Coroner Tom Osborne said there was "a failure to start effective CPR". A spokesman for the centre said changes have been made to how care is delivered. Ms Hewitt, who had Asperger's syndrome and bipolar disorder, was admitted to the inpatient unit on 13 March 2019. She died less than a month later on 6 April 2019 at Milton Keynes Hospital, where she was taken after collapsing on Willow Ward at the centre. An inquest concluded she died of a pulmonary embolism, caused when a blood clot travels to the lungs. In a Prevention of Future Deaths Report, Mr Osborne said the centre failed to carry out a risk assessment and there was a delay in administering a drug resulting in "her mania not being brought under control". His report said the "failure to recognise how seriously ill she had become" had "resulted in lost opportunities to treat her appropriately that may have prevented her death". He said her death suggested the NHS was "unable to provide a place of safety for those who are suffering from Asperger's syndrome" or other forms of autism "when they are also suffering additional mental health problems such as bipolar". Read full story Source: BBC News, 4 December 2020
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