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Found 153 results
  1. News Article
    A mother fighting for a public inquiry into the death of her son and more than 20 other patients at an NHS mental health hospital in Essex has won a debate in parliament after more than 100,000 people backed her campaign. On Monday, MPs in the House of Commons will debate Melanie Leahy’s petition calling for a public inquiry into the death of her son Matthew in 2012, as well as 24 other patients who died at The Linden Centre, a secure mental health unit in Chelmsford, Essex, since 2000. The centre is run by Essex Partnership University NHS Trust which has been heavily criticised by regulators over the case. A review by the health service ombudsman found 19 serious failings in his care and the NHS response to his mother’s concerns. This included staff changing records after his death to suggest he had a full care plan in place when he didn’t. Matthew was detained under the Mental Health Act but was found hanged in his room seven days later. He had made allegations of being raped at the centre, but this was not taken seriously by staff nor properly investigated by the NHS. The trust has admitted Matthew’s care fell below acceptable standards. In November, it pleaded guilty to health and safety failings linked to 11 deaths of patients in 11 years. Read full story Source: The Independent, 29 November 2020
  2. News Article
    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
  3. News Article
    A privately run child and adolescent mental health unit has been closed permanently, with its residents moved elsewhere, after concerns were raised about their safety. The Care Quality Commission (CQC) said it had taken “urgent action to ensure the provider makes immediate and significant improvements” at the Cygnet Hospital in Godden Green, outside Sevenoaks in Kent, after a series of unannounced inspections last month and this month. The hospital had a CAMHs unit with up to 23 beds – details of which have been removed from the company’s website. However, only a small number of beds were occupied and these patients were either discharged or transferred to other hospitals before the unit closed on Monday. Last year Cygnet Health Care also launched a 12 bed female psychiatric intensive care unit on the site. Some of these beds have been commissioned by Kent and Medway NHS and Social Care Partnership Trust since early this year, as there are no NHS female PICU sites in the county. This unit remains open, although the CQC said the concerns raised with it related to the safety of both PICU and CAMHs patients. Karen Bennett-Wilson, the CQC’s head of hospital inspection and lead for mental health in the south, said: “CQC has also worked closely with NHSE/I, Cygnet Healthcare and other local partners who have taken the decision to close the CAMHS unit and move the young people in the service to other care appropriate to their needs." Read full story (paywalled) Source: HSJ, 20 October 2020
  4. News Article
    A mental health unit where a patient was found dead has been placed into special measures over concerns about safety and cleanliness. Field House, in Alfreton, Derbyshire, was rated "inadequate" by the Care Quality Commission (CQC) following a visit in August. A patient died "following use of a ligature" shortly after its inspection, the CQC said. Elysium, which runs the unit for women, said it was "swiftly" making changes. The inspectors' verdict comes after the unit was ordered to make improvements, in January 2019. Dr Kevin Cleary, the CQC's mental health lead, said: "There were issues with observation of patients, a lack of cleanliness at the service and with staffing. "There were insufficient nursing staff and they did not have the skills and experience to keep patients safe from avoidable harm. Bank and agency staff were not always familiar with the observation policy." "It was also worrying that not all staff received a COVID-19 risk assessment, infection control standards were poor, and hand sanitiser was not available in the service's apartments." The CQC said a follow-up inspection on Monday had showed "areas of improvement" but it would continue to monitor the service. Read full story Source: BBC News, 22 October 2020
  5. Content Article
    Loneliness and social networks may influence onset of Alzheimer's disease, but little is known about this relationship in people with Alzheimer's disease. This study, published in Geriatric Psychology, aimed to explore the relationship between loneliness and social networks (social measures) and cognitive and psychopathology decline in people with Alzheimer's disease. The authors concluded that maintaining or developing a close friendship network could be beneficial for cognition in people with Alzheimer's disease.
  6. News Article
    The care model run by independent sector mental health and learning disability hospitals is ‘inherently risky’, a Care Quality Commission (CQC) chief inspector has warned. Speaking at the NHS Providers conference, Ted Baker, chief inspector of hospitals for the Care Quality Commission, unveiled the regulator’s plans to change how it inspects health and care services. When asked by HSJ how its new “streamlined” approach would be applied to inpatient units run by the independent sector for people with mental health and learning disability, Professor Baker said: ”One of the things we’ve been doing during the pandemic, and will continue in our transitional approach, is target risk. And one of the risks we have been targeting is exactly this, patients with learning disability and/or autism in some of these small units that have got closed cultures." “I think we do recognise that model of care is an inherently risky model of care and so we have been inspecting many of those under this risk driven model and taking action against many of them. But there is ongoing concern about that model of care and in a few weeks’ time we will be publishing a report on our assessment of that model of care and the importance of it being changed for the benefit of the people being looked after. The model of care needs to be improved but we need to make sure we are tackling the risk.” The chief’s comments come ahead of the regulator’s state of care report, which is due to be published next week. In its report published last year the CQC highlighted a concern regarding the quality and safety of independent learning disability and autism units. In particular it warned these were at a higher risk of developing closed cultures. Read full story (paywalled) Source: HSJ, 7 October 2020)
  7. News Article
    Ten workers at a mental health unit have been suspended amid claims patients were "dragged, slapped and kicked". Inspectors said CCTV footage recorded at the Yew Trees hospital in Kirby-le-Soken, Essex, appeared to show episodes of "physical and emotional abuse". The details emerged in a Care Quality Commission (CQC) report after the unit was inspected in July and August. A spokeswoman for the care provider said footage had been passed to police. The unannounced inspections were prompted by managers at Cygnet Health Care, who monitored CCTV footage of an incident on 18 July. At the time, the 10-bed hospital held eight adult female patients with autism or learning difficulties. The CQC reviewed 21 separate pieces of footage, concluding that 40% "included examples of inappropriate staff behaviour". "People who lived there were subjected not only to poor care, but to abuse," a CQC spokesman said. Workers were captured "physically and emotionally abusing a patient", and failing to use "appropriate restraint techniques", the report said. It identified "negative interactions where staff visibly became angry with patients" and two cases where staff "dragged patients across the floor". "We witnessed abusive, disrespectful, intimidating, aggressive and inappropriate behaviour," the inspectors said. Read full story Source: BBC News, 23 September 2020
  8. News Article
    The mother of a former patient at a north Wales mental health unit has said she "couldn't let" her daughter "go back there" as new details about people being "neglected" there have emerged. ITV News has seen a leaked copy of the Robin Holden report from 2014. It was commissioned by Betsi Cadwaladr Health Board after staff on the Hergest mental health unit, which is situated within Ysbyty Gwynedd in Bangor, blew the whistle over management and patient safety concerns. It reveals details never before made public, about how staff struggled to care for patients. The document, which the health board has fought for six years to keep out of public view, gives an account of the death of a patient while no doctor was available because of rota gaps, another of a patient who tried to take their own life, again when no doctor was available, and inadequate staffing affecting patient care. Read full story Source: ITN News, 31 August 2020
  9. News Article
    The Care Quality Commission (CQC) staged an unannounced inspection after two deaths at a mental health unit which it had condemned as “not fit for purpose.” Two earlier CQC inspections – in 2017 and 2018 – had also been prompted by deaths on the same unit. The CQC visited the Abraham Cowley Unit, which is at St Peter’s Hospital in Chertsey and run by Surrey and Borders Partnership Foundation Trust, on 26 June. Two inpatients died in April and May on an inpatient ward for working age men. The deaths both involved “ligature harm” and have led to the trust reviewing its ligature minimisation strategy, according to board papers. Read full story (paywalled) Source: HSJ, 8 July 2020
  10. News Article
    Inspectors have placed a women’s mental health service into special measures after patients were said to have been subjected to “inappropriate” and “derogatory” treatment by staff. St Andrew’s Healthcare, which runs the women’s inpatient facility in Northampton, has received a series of damning reports among its services over the past two years. The inspectors noted during visits between February and March that staff reportedly used language to describe patients on a medium secure ward such as “self-harmers”, “attention seeking”, and “kicking off”. Patients said staff used “inappropriate restraint techniques that caused pain” with reports they “bent the patient’s wrist and arm behind their back.” They also said staff spoke to them in a “derogatory manner, for example telling them to sort themselves out when engaging in self harm behaviour.” Inspectors rated the service “inadequate” overall, noting concerns elsewhere including “forensic failure incidents due to staff shortages”, that staff were not reporting all safeguarding concerns and that “managers did not ensure safe and clean environments in the long stay rehabilitation service and learning disability service.” Read full story Source: HSJ, 10 June 2020
  11. News Article
    A dozen charities and voluntary organisations have now called on the Care Quality Commission (CQC) to re-start routine inspections of care homes and mental health units amid concerns about care of patients during the coronavirus pandemic. The watchdog suspended its routine inspections of care providers on 16 March, but said it would inspect providers in “a very small number of cases” where it had concerns for patients such as allegations of abuse. The CQC’s chief executive said the watchdog’s decision was designed in part to limit the spread of the disease but he added that since inspections were curtailed inspectors had maintained contact with providers and helped to source protective equipment for staff. The Relatives and Residents Association, a national charity for older people in care and their relatives, has written to the CQC’s chief executive Ian Trenholm asking him to “urgently reconsider” the decision to stop inspections. Edel Harris, chief executive of Mencap has also highlighted concerns for hundreds of children with learning disabilities who she said were detained in “modern-day asylums” adding: “Some families are rightly terrified about what might be happening to their loved ones behind closed doors. With family contact cut and CQC inspections reduced during lockdown, there is huge concern about who is making sure that some of the most vulnerable people in society are being kept safe and well during this national crisis.” Read full story Source: The Independent, 26 May 2020
  12. Content Article
    In this anonymous blog, published by the Guardian, the author describes their experience of working in an inpatient psychaitry unit during the current cornovirus outbreak. They raise concerns over the impossibility of physical distancing, lack of personal protective equipment (PPE), patients not being allowed to go out and a rise in violence and anxiety.
  13. Content Article
    After a year of attending lectures on pre-clinical medicine, Usama Ali found herself on the wards for the first time. Except for her, things were different. She was there as a patient in a psychiatric ward. In this BMJ article, Usama reflects on her experience and explains how the whole patient journey can influence recovery.
  14. News Article
    A mental health charity has branded as “irresponsible” the Government’s coronavirus bill which would grant single doctors the power to detain the mentally ill. The Government wants to relax legal safeguards in the Mental Health Act in order to free up medical staff to deal with the COVID-19 pandemic. If passed, the bill would reduce the number of doctors needed to approve detaining individuals from the current minimum of two, to just one. In addition, it would temporarily allow time limits in the Mental Health Act to be extended or removed altogether. This would mean patients currently detained in mental health facilities could be released into the community early, or be detained for longer. Akiko Hart, Chief of National Survivor User Network (NSUN), a UK mental health charity, said: “Whilst we understand that these are unprecedented times, any legislative change must be proportionate and thought through, and should protect all of us. Minimising some of the safeguards in the Mental Health Act and extending its powers, is a step in the wrong direction.” Read full story Source: The London Economic, 19 March 2020
  15. Content Article
    Patients in inpatient mental health settings face similar risks (e.g., medication errors) to those in other areas of healthcare. In addition, some unsafe behaviours associated with serious mental health problems (e.g., self-harm), and the measures taken to address these (e.g., restraint), may result in further risks to patient safety. The objective of this review from Thibaut et al., published in BMJ Open, was to identify and synthesise the literature on patient safety within inpatient mental health settings using robust systematic methodology. The authors found that patient safety in inpatient mental health settings is under-researched in comparison to other non-mental health inpatient settings. Findings demonstrate that inpatient mental health settings pose unique challenges for patient safety, which require investment in research, policy development, and translation into clinical practice.
  16. Content Article
    A Parliamentary and Health Service Ombudsman (PHSO) report of an investigation that found that Averil Hart's tragic death from anorexia would have been avoided if the NHS had cared for her appropriately. Ignoring the alarms: How NHS eating disorder services are failing patients highlights five areas of focus to improve eating disorder services.
  17. Content Article
    The Mental Health Optimal Staffing Tool (MHOST) was created, with the support of Health Education England, in recognition that there was no published, evidenced based mental health workforce tool which could be used in mental health hospitals. It has been developed alongside clinical leaders and workforce staff in mental health trusts and rigorously tested and validated.
  18. Content Article
    The National Institute for Health and Care Excellence (NICE) developed an evidence-based guideline on safe staffing for nursing in inpatient mental health settings. This guideline is primarily for NHS provider organisations or other organisations that provide or commission inpatient mental health services for the NHS. 
  19. Content Article
    A study of police wearing body worn cameras showed a reduction in complaints, and a decrease in occurrences and crimes. Mental health staff working in inpatient settings do not routinely wear cameras. The aim of this project, published in Mental Health in Family Medicine, was to examine the feasibility of using body worn cameras in an inpatient mental health setting. The results found that both staff and patients considered that their use in an inpatient mental health setting was beneficial. Compared to the same period the year before, there was a reduction in complaints and incidents during the duration of the pilot.
  20. News Article
    How many people die in California psychiatric facilities has been a difficult question to answer. No single agency keeps tabs on the number of deaths at psychiatric facilities in California, or elsewhere in the nation. In an effort to assess the scope of the problem, The Times submitted more than 100 public record requests to nearly 50 county and state agencies to obtain death certificates, coroner’s reports and hospital inspection records with information about these deaths. The Times review identified nearly 100 preventable deaths over the last decade at California psychiatric facilities. It marks the first public count of deaths at California’s mental health facilities and highlights breakdowns in care at these hospitals as well as the struggles of regulators to reduce the number of deaths. The total includes deaths for which state investigators determined that hospital negligence or malpractice was responsible, as well as all suicides and homicides, which experts say should not occur among patients on a psychiatric ward. It does not include people who died of natural causes or other health problems while admitted for a psychiatric illness. Read full story Source: Los Angeles Times, 1 December 2019
  21. Content Article
    I lead a team of multidisciplinary researchers who explore the power of routinely collected data for improving our understanding of patient safety. Our hope is that this insight will be translated into improvements in patient care. On this World Mental Health Day, there is an opportunity to reflect on the implications of harm to staff who deliver care to some of the most vulnerable patients in any healthcare system and what we might do to better protect them from harm. We recently published a study that focussed on staff safety in the mental healthcare setting and I'd like to discuss some of the findings in this blog.
  22. Content Article
    The Parliamentary and Health Service Ombudsman (PHSO) has published a report following investigations into the deaths of two vulnerable young men. They found a series of significant failings in their mental health care and treatment.  The PHSO are publishing the report and recommendations to alert parliament to systemic problems in care and treatment of patients with acute mental health problems at former North Essex Partnership University NHS Foundation Trust. NHS Improvement has agreed to establish a review in line with our recommendations and will share any learning it identifies across the NHS as needed. The North Essex Partnership University NHS Foundation Trust (now merged into the Essex Partnership University NHS Foundation Trust) has accepted the recommendations and are committed to continuing to work the PHSO to put things right. It is important the NHS understands why this happened and what lessons can be learned to prevent it happening again.
  23. Content Article
    The preventable death of Connor Sparrowhawk in July 2013 led to a number of investigations and enquiries into practice at Southern Health NHS Foundation Trust in whose care he died.
  24. Content Article
    Maintaining momentum highlights failings in specialist mental health services in England, and the devastating toll this takes on patients and their families.  The report's findings provide fresh impetus to deliver on the recommendations set out in the NHS Five Year Forward View for Mental Health.
  25. Content Article
    Powerful bog written by Alison Cameron about her experiences as a patient on a mental health unit.
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