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News Article
Deaths inquiry extended to last three years
Patient-Safety-Learning posted a news article in News
A statutory inquiry into deaths of mental health patients will now cover fatalities that took place as late as December 2023. The inquiry’s investigations are focused “on the trusts which provide NHS mental health inpatient care in Essex”. This includes: “Essex Partnership University Foundation Trust, and the North East London Foundation Trust and their predecessor organisations, where relevant.” NELFT was not specifically mentioned in the original terms of reference although the inquiry told HSJ it had been within the original scope. The inquiry will also now cover deaths of NHS patients from Essex who died when under the care of private sector providers. The inquiry’s previous terms of reference covered a period ending in 2020. However, the inquiry’s chair, Baroness Kate Lampard, proposed extending the inquiry’s scope last year due to “ongoing concerns” over services at EPUFT. Read full story (paywalled) Lampard Inquiry: Terms of reference Source: HSJ, 11 April 2024 -
Content Article
Lampard Inquiry: terms of reference (10 April 2024)
Mark Hughes posted an article in Other reports and inquiries
The Lampard Inquiry will seek to understand the events that led to the tragic deaths of mental health inpatients under the care of NHS trusts in Essex between 2000 and 2023. This document outlines the terms of reference set following consultation with the chair of the inquiry, Baroness Lampard. -
Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Joy talks to us about why we need to reduce the use of restrictive practices in healthcare, the role of research in identifying unsafe practices and how the Restraint Reduction Network shares and helps organisations implement safer approaches to care. -
Content ArticleThis report sets out the findings of an Independent Review into the care and treatment provided by Greater Manchester Mental Health NHS Foundation Trust. The review was commissioned following reports of failings within the Trust’s services at the Edenfield Centre and the failure within the organisation to escalate concerns and mitigate patient harm.
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Content Article
In this report the Parliamentary and Health Service Ombudsman (PHSO) looks at patient safety concerns relating to the care and discharge of mental health patients. Its findings are based on the analysis of more than 100 complaints that the Ombudsman has investigated between April 2020 and September 2023 where it found failings in care that involved mental health care. -
News Article
Patients at risk of suicide and harm over unsafe hospital discharges
Patient-Safety-Learning posted a news article in News
Mental health services are failing to keep patients safe from suicide and harm after leaving hospital, the Parliamentary and Health Service Ombudsman (PHSO) has warned. It also identified failings around planning and communication when patients are discharged, and has urged the Government to strengthen the Mental Health Act. The warning comes after the Department for Health and Social Care was forced to announce a Care Quality Commission (CQC) rapid review into mental health services in Nottingham following the killings of students Grace O’Malley-Kumar and Barnaby Webber, both 19, and school caretaker Ian Coates, 65, in June last year, by Valdo Calocane. Knifeman Calocane had paranoid schizophrenia and had been a regular patient of Highbury Hospital with mental health problems. In a report last week, The Independent revealed separate investigations into Highbury Hospital which have led to the suspension of more than 30 staff over allegations of falsifying records and harming patients. The latest report by the Parliamentary and Health Service Ombudsman (PHSO), following a report in 2018, looked at more than 100 complaints between 2020 and 2023 where it had identified failings in mental health care. Lucy Schonegevel, director of policy and practice at the charity Rethink Mental Illness, said: “Someone being discharged from a mental health service, potentially into unsafe housing, financial insecurity or distanced from family and friends, is likely to face the prospect with anxiety and a sense of dread rather than positivity. Mistakes or oversights during this process can have devastating consequences. This report puts a welcome spotlight on how services can improve the support they offer people going through the transition back into the community, by improving communication and the ways in which different teams work together to provide essential care.” Read full story Read PHSO report Discharge from mental health care: making it safe and patient-centred (PHSO, 1 February 2024) Source: Independent (1 February 2024) -
News Article
‘Insufficient curiosity’ of trust’s leaders enabled abuse
Patient-Safety-Learning posted a news article in News
A major review into a mental health unit abuse scandal has found a catalogue of failings, including repeated missed opportunities to act on concerns, and a board “disconnected” from the realities faced by patients and staff. The independent review into failings at Greater Manchester Mental Health Foundation Trust was published today, commissioned after BBC Panorama revealed a “toxic culture of humiliation, verbal abuse and bullying” at Edenfield Centre in Prestwich in September 2022. The trust’s then chair, Rupert Nichols, resigned in November 2022, and CEO Neil Thwaite stepped down in spring last year. Review chair Professor Oliver Shanley, a former mental health trust CEO and chief nurse, describes in his report how the trust’s culture and leaders’ “insufficient curiosity” contributed to the “invisibility” of the deterioration in care quality. He says its board was focused on “expansion, reputation and meeting operational targets”. Read full story (paywalled) Read the report of the Independent Review into Greater Manchester Mental Health NHS Foundation Trust Source: HSJ, 31 January 2024 -
News ArticleUnregulated healthcare workers are a risk to the most vulnerable patients, a former victim’s commissioner has warned after The Independent and Sky News uncovered a “horrifying” sexual abuse scandal within NHS mental health services. Dame Vera Baird called for a formal framework for healthcare assistants and support workers, who do not have a mandatory professional register like doctors and nurses and can “come in and go out from one hospital to another” without the same thorough checks. Dame Vera told The Independent that the setup did not lead to a “very safe way of working” because healthcare assistants are “in an environment where they are responsible for vulnerable people”. “If there has been abuse from mental health care assistants who are also agency staff who are coming in and going out from one hospital to another, that needs to be looked at,” she said. “This is not a very safe way of working. Some kind of framework around agency staff seems to be very important [to have].” She warned that sexual predators may go into mental health services and work in units where patients can be “highly sexualised”, prompting a “dreadful combination”. Read full story Source: The Independent, 30 January 2024
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Content Article
Patient 11: Sky News podcast series (28 January 2024)
Patient Safety Learning posted an article in Mental health
Young mother and former GB youth swimmer, Alexis, agrees to enter NHS England psychiatric care following a family tragedy. She could never imagine that her three-day admission will turn into a three-year ordeal. Then undiagnosed with autism, and often the subject of 24-hour surveillance as well as long periods in solitary confinement, Alexis descends to the darkest reaches of locked-in, psychiatric care. There, she encounters the kind of threat she never could have imagined in a secure mental health hospital. In a bid to break free, Alexis plots a daring escape. This series discusses rape and sexual assault. -
News ArticleTens of thousands of sexual assaults and incidents have been reported in NHS-run mental health hospitals as a “national scandal” of sexual abuse of patients on psychiatric wards can be revealed. Almost 20,000 reports of sexual incidents in the last five years have been made in more than half of NHS mental health trusts, according to exclusive data uncovered in a joint investigation and podcast by The Independent and Sky News. The shocking findings, triggered by one woman’s dramatic story of escape following a sexual assault in hospital revealed in a podcast, Patient 11, show NHS trusts are failing to report the majority of incidents to the police and are not meeting vital standards designed to protect the UK’s most vulnerable patients from sexual harm. Throughout the 18-month investigation, multiple patients and their families spoke to The Independent about their stories of sexual assault and abuse while locked in mental health units. Dr Lade Smith, president of the Royal College of Psychiatrists, called the findings “horrendous”, while shadow health secretary Wes Streeting said it was a “wake-up call” for the government. Dr Smith told The Independent: “There is no place for sexual violence in society, which has a profound and long-lasting negative impact on people’s lives. Today’s horrendous findings show that there is still much to do to make sure that patients and staff in mental health trusts are protected from sexual harms at all times. “It is deeply troubling to see that so many incidents in mental health settings go unreported.” Read full story Source: The Independent, 29 January 2024
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News ArticleThe NHS and a local council have been told to urgently find a home for a 28-year-old autistic man who is facing psychological and physical abuse within a mental health hospital, after an independent review of his care. Nicholas Thornton has autism and learning disabilities and is currently being held in the Rochford mental health unit, in Essex, after a decade of being locked away in places not able to care for him adequately. Now an independent safeguarding review into his care provided at the Essex hospital has ordered the local authority and NHS to find him a home in the community because his relationship with hospital staff has become so bad he is facing psychological and physical harm. He is one of the 2,045 people with learning disabilities and autism trapped within inpatient units across England. Mr Thornton has been in the unit, run by the Essex Partnership University NHS Foundation Trust (EPUT), since May this year. He is not under a mental health section, nor does he need mental health treatment, but he is unable to leave because the local authority has not agreed on a place into which he can be discharged. EPUT is currently facing a public inquiry probing the deaths of 2,000 patients following multiple reviews since 2016 from coroners, the police and health ombudsman criticising the care within the hospital. A safeguarding report into Mr Thornton’s situation, seen by The Independent and Channel Four News, revealed staff working in the Rochford hospital told investigators they cannot adequately care for Mr Thornton themselves as they are not trained in supporting patients with autism. Read full story Source: The Independent, 13 December 2023
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News Article
Two trusts to miss deadline for eliminating ‘distressing’ wards
Patient Safety Learning posted a news article in News
At least two trusts are set to fall short on a high-profile pledge to eradicate ‘dormitory’ style wards in mental health facilities, with delays caused by cost pressures and shortage of materials and labour. In 2020, ministers said more than 1,200 beds in mental health dormitories across more than 50 sites would be replaced with single, en-suite accommodation by March 2025. Around £400m was allocated to achieve this. However, information gathered by HSJ via freedom of information requests suggests there will be at least 37 dormitory beds still in use beyond that date. In 2018, the Care Quality Commission said: “In the 21st century, patients, many of whom have not agreed to admission, should not be expected to share sleeping accommodation with strangers, some of whom may be agitated”. Patients have told HSJ they felt “distressed”, “unsafe” and “intimidated” on dormitory style wards. Leaders of trusts impacted by delays told HSJ of rising cost pressures, shortages of construction materials and availability of labour. Read full story (paywalled) Source: HSJ, 17 October 2023 -
News Article
‘High use of agency staff’ contributed to care failings exposed by hidden cameras
Patient Safety Learning posted a news article in News
High use of agency staff contributed to the care failings exposed at a mental health trust by undercover reporters, an internal inquiry has found. Essex Partnership University Trust was at the centre of a Channel 4 documentary last year which raised concerns over care, including the use of restraints and patient observations. The trust initially refused to release the final report after a freedom of information request by HSJ, but has now released a redacted version on appeal. The report identified a number of concerns in relation to patient and staff safety, saying factors that contributed to these concerns included high usage of temporary staff and high patient acuity on the two acute mental health wards recorded. The internal inquiry looked into allegations of the inappropriate use of restraints raised in the documentary. This section, which contained redactions, found restraint was taught to be used as a last resort, but suggested high temporary staffing levels and a “lack of confident and adequately skilled staff” contributed to guidance not being followed. Another concern was around staff sleeping on duty and the use of mobile phones during patient observations. The internal inquiry found there was an “absence of visible leadership and role modelling” to ensure this did not happen during clinical practice. Read full story (paywalled) Source: HSJ, 17 October 2023 -
News Article
NHS psych ward period provision criticised by patients
Patient Safety Learning posted a news article in News
Imagine being on your period and "forced to beg for pads and tampons". According to 24-year-old Lara, that's common for her and others on mental health hospital wards in the UK. When she posted about her experience online, people from across the country responded with their own similar stories. Mental health hospitals have various rules in place for safety reasons, including access to certain items. However, NHS guidance states that period products should be available to anyone who needs them. Lara says this hasn't always been the case for her. "I've had a number of hospital admissions to psychiatric units and on one of my first they confiscated my period products," she says. Lara's currently on one-to-one observations for her own safety, which means someone has to escort her to the toilet and watch her change a pad or tampon. But she says her worst experience was when she's had to wear anti-ligature clothing - again for safety reasons. "I was forced to remove my pants and sanitary pad - which meant I just had to bleed into the clothing," she says. "I understand the need for safety to come first, but this experience was unhygienic, traumatising and embarrassing for people to see." Eleanor is 20 years old and recently spent time in a mental health hospital. At her "most unwell", she says she didn't have access to her own clothing and had to wear the same special clothing Lara spoke about. "I'd have two or three people watching me changing and even though I know it's for my own safety, it's dehumanising," she says. Newsbeat asked a number of unions, organisations and charities to comment on the experiences described but none wanted to provide one. But one mental health professional, Kasper, did agree to discuss it. Kasper agrees that safety is always a top priority but adequate period provision is often overlooked."I'm sure all trusts have a policy, but don't think it's always applied - and my observation is that it very much depends on what staff are on shift, especially when there can be lots of agency workers," Kasper says."We do keep products on my ward, but there's not much of a range. "Patients can't access them and some staff don't know where they are either - so the onus is very much on patients, which can be tricky when they're unwell." Read full story Source: BBC News, 16 October 2023 -
News Article
Over 17 000 serious incidents reported in mental healthcare last year
Patient Safety Learning posted a news article in News
The UK’s largest mental health charity, Mind, has published previously unseen data laying bare the full scale of the emergency in mental healthcare, with staff reporting 17,340 serious incidents in 12 months. The Care Quality Commission (CQC) figures shows mental healthcare staff across England reported an incident two times every hour in the last year, where people are treated for issues including self-harm, eating disorders and psychosis. Incidents included: injuries to patients that caused likely long term sensory, movement or brain damage, or physically damaged their body prolonged physical pain or psychological harm, or shortened life expectancy cases of abuse, including those involving the police injuries for which the patient needed treatment to prevent them dying. All of these incidents involved care providers raising concerns with the CQC under their statutory duty under Regulation 18. Dr Sarah Hughes, Chief Executive of Mind, says: “It is deeply worrying that healthcare staff across the country are so concerned about the situation in mental health settings that they are reporting a serious incident once every half an hour. We knew this was a crisis – now we know the scale of this crisis. People seek mental healthcare to get well, not to endure harm. Families are being let down by a system that’s supposed to protect their loved ones when they are most sick. The consequences can be and have been fatal". Read full story Source: Mind, 10 October 2023 -
News Article
Patient's water drinking death was preventable
Patient Safety Learning posted a news article in News
The death of a mentally ill teenager who died after drinking an excessive amount of water was preventable, an investigation has found. The 18-year-old, known at Mr D, was being detained under the Mental Health Act at the time of his death. An inquiry by the Mental Welfare Commission said he had previously been treated for drinking too much water. It found several areas where a different course of action could have prevented his death. The teenager was admitted out-of-hours to an adult mental health service (AMHS) inpatient unit in a health board neighbouring his own on 5 December 2018 as there were no local beds available. This move was described in the report as a "high-risk action". On the evening of 7 December he suffered a seizure after drinking too much water and was transferred to intensive care. He died three days later from the consequences of water intoxication. Suzanne McGuinness, executive director (social work) at the Mental Welfare Commission, said: "This was a tragic death of a young man while he was being cared for in hospital. "We found that a more assertive approach to the treatment of Mr D's psychotic illness in the two years before his death was warranted. The risks associated with psychotic illness were not coherently managed." Read full story Source: BBC News, 21 September 2023 -
Content ArticlePatients in seclusion in mental health services require regular physical health assessments to identify, prevent and manage clinical deterioration. Sometimes it may be unsafe or counter-therapeutic for clinical staff to enter the seclusion room, making it challenging to meet local seclusion standards for physical assessments. Alternatives to standard clinical assessment models are required in such circumstances to assure high quality and safe care. The primary aim of this study was to improve the quality of physical health monitoring by making accurate vital sign measurements more frequently available. It also aimed to explore the clinical experience of integrating a technological innovation with routine clinical care. The results showed that the non-contact monitoring device enabled a 12 fold increase overall in the monitoring of physical health observations when compared to a real-world baseline rate of checks. Enhancement to standard clinical care varied according to patient movement levels. Patients, carers and staff expressed positive views towards the integration of the technological intervention.
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Content ArticlePreventing patients from self-harming is an ongoing challenge in acute inpatient mental health settings. New technologies that do not require continuous human visual monitoring and that maintain patient privacy may support staff in managing patient safety and intervening proactively to prevent self-harm incidents. This study in the Journal of Mental Health aimed to assess the effect of implementing a contact-free vision-based patient monitoring and management (VBPMM) system on the rate of bedroom self-harm incidents. The results showed a 44% reduction in bedroom self-harm incidents and a 48% reduction in bedroom ligatures incidents, suggesting that that the VBPMM system helped staff to reduce self-harm incidents, including ligatures, in bedrooms.
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Content ArticleDespite the prevalence of diabetes amongst individuals with Serious Mental Illness (SMI), diabetes care is not currently audited within mental health inpatient settings as it audited in physical health settings. This project piloted an audit to assess the diabetes care within London NHS Mental Health Trusts. The Health Innovation Network in partnership with South London and Maudsley NHS Foundation Trust (SLaM) developed and piloted a diabetes audit. Following the SLaM pilot, the audit was completed by all nine London Mental Health Trusts. A diverse approach was taken to spread and adoption. This included piloting the audit within one MH Trust, refining, and then rolling out the audit to eight London Mental Health Trusts.
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Content Article
Video: Living with schizophrenia (6 July 2023)
Patient-Safety-Learning posted an article in Mental health
In this video, Chris tells his story of how he dealt with a traumatic childhood and subsequent diagnosis of schizophrenia. He talks about the medication and therapy that have helped him. Warning: The film does contain references to distressing themes. -
EventThis national conference looks at the practicalities of Serious Incident Investigation and Learning from Deaths in Mental Health Services and implementation of the New Patient Safety Incident Response Framework (PSIRF previously known as the Serious Incident Framework). The Patient Safety Incident Response Framework (PSIRF) was published on 16th August 2022 and replaces the Serious incident Framework. The conference will also update delegates on best current practice in serious incident investigation and learning, including mortality governance and learning from deaths. There will be an extended focus on ensuring serious investigation findings lead to change and improvement, and updates from PSIRF early adopter sites in mental health. The conference will also examine how the new framework will fit with the Royal College of Psychiatrists Care Review Tool for mortality review. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/investigation-of-deaths-serious-incidents-in-mental-health-services or email kate@hc-uk.org.uk hub members receive 20% off. Email info@pslhub.org for discount code. Follow this conference on Twitter @HCUK_Clare #SIMental
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News ArticleThe government’s national review of mental health hospitals must urgently address the “lack of sympathy and compassion” towards patients if safety is to improve, the health ombudsman has said. Rob Berhens said the investigation, prompted by The Independent’s reporting on deaths and abuse of vulnerable patients, must look at three key issues, including a lack of empathy for those with mental health challenges, a lack of resources and poor working conditions for staff. Health Secretary Steve Barclay announced last week that a new safety body, the Health Services Safety Investigations Body (HSIB), would look into the care of young people, examine staffing levels and scrutinise the quality of care within mental health units. Mr Berhens said: “I trust [HSIB] to be able to understand what are the key issues, they’re about the lack of sympathy and compassion for people who have mental health challenges, which to me is a human rights issue." Read full story Source: The Independent, 1 July 2023
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Content ArticleOn the 23 January 2023 the Minister for Mental Health and Women’s Health Strategy, Maria Caulfield MP, announced the commencement of a rapid review into patient safety in mental health inpatient settings in England. The review Chair, Dr Geraldine Strathdee, was asked to consider how improvements could be made to the way that data and information is used in relation to patient safety in mental health inpatient care settings and pathways, including for people with a learning disability and autistic people. This report contains the findings of this review and an associated set of recommendations.
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Content ArticleThis is the transcript of an oral statement to the House of Commons by Steve Barclay MP, Secretary of State for Health and Social Care, on improving safety in mental health in-patient services across England.
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News ArticleToday it was announced by the Secretary of State for Health and Social Care that the future Health Services Safety Investigations Body (HSSIB) will undertake a series of investigations focused on mental health inpatient settings. The investigations will commence when HSSIB is formally established on 1 October 2023. The HSSIB will conduct investigations around: How providers learn from deaths in their care and use that learning to improve their services, including post-discharge. How young people with mental health needs are cared for in inpatient services and how their care could be improved. How out-of-area placements are handled. How to develop a safe, therapeutic staffing model for all mental health inpatient services. Rosie Benneyworth, Chief Investigator at HSIB, says: “We welcome the announcement by the Secretary of State and see this as a significant opportunity to use our expertise, and the wider remit that HSSIB will have, to improve safety for those being cared for in mental health inpatient settings across England. The evidence we have gathered through HSIB investigations has helped shed light on some of the wider challenges faced by patients with mental health needs, and the expertise we will carry through from HSIB to HSSIB will help us to further understand these concerns in inpatient settings, and contribute to a system level understanding of the challenges in providing care in mental health hospitals. “HSSIB will be able to look at inpatient mental health care in both the NHS and the independent sector and any evidence we gather during the investigations is given full protection from disclosure. It is crucial that those impacted by poor care and those working on the frontlines of the inpatient settings can share their experiences, reassured that HSSIB will use this information to improve care and not apportion blame or liability. “At HSIB we will begin conversations with our national partners across the system, as well as talking to staff, patients and families. This will ensure that when investigations are launched in October, we have identified and will address the most serious risks to mental health inpatients within these areas and will identify recommendations and other safety learning that will lead to changes in the safety culture and how safety is managed within mental health services.” Read full story Source: HSIB, 28 June 2023
