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Found 153 results
  1. Content Article
    This is a brief summary of a Westminster Hall debate in the House of Commons on the 31 January 2023 concerning the Essex Mental Health Independent Inquiry.
  2. Content Article
    This prevention of future deaths report looks at the death of Ben King, who died of acute respiratory failure, obesity hypoventilation syndrome and use of sedative medication. Ben had Down's Syndrome and obstructive sleep apnoea and had been detained under the Mental Health Act at Jeesal Cawston Park (JCP) from 2018. Ben’s weight as at June 2019 was recorded at 85.2 kg which had risen to 106 kg by June 2020. He was given the sedative Promethazine after becoming agitated and found unresponsive on 29 July 2020. He died later that day at  Norfolk and Norwich University Hospital.
  3. Content Article
    This report from Simon Milburn, Area Coroner for the area of Cambridgeshire and Peterborough, looks at the death of Jonathan Kingsman, who died of pulmonary thromboembolism and deep vein thrombosis on 1 February 2021. Mr Kingsman had been admitted to Fulbourn Hospital, Cambridge under section 2 of the Mental Health Act 1983 on 26 January. It was noted that on admission, Mr Kingsman had not consumed any fluids for several hours. The doctor on call carried out an initial risk assessment for venous thromboembolism (VTE), but as Mr Kingsman's mobility was deemed to 'not have significantly reduced ability', the assessor was directed by the guidance to stop the assessment. It was agreed at the Inquest that Mr Kingsman fell into this category and likewise agreed that throughout his time in hospital that there were no changes to his mobility which would have prompted a renewed risk assessment. However, Mr Kingsman did have other risk factors for VTE, and the coroner raised matters of concern about the risk assessment process as follows: That the risk assessment requires no consideration of risk factors other than mobility unless ‘Step 1’ is passed regardless of the number of other risk factors which may be present and their severity – Mr Kingsman was not obviously at risk of ‘significantly increased immobility compared to his normal state’ but died as a result of a DVT/VTE nonetheless. It is reasonable to expect that others may be in the same position in the future. The risk assessment form contains no guidance on its completion and no definition of certain terms. A copy of the report was sent to The Secretary of State for the Department of Health.
  4. Content Article
    On 4 March 2020 an investigation into the death of Yvonne Eaves was opened. The inquest came to a narrative conclusion that "The Deceased suffered from a chronic mental disorder and serious self-neglect. After compulsory admission to hospital under the Mental Health Act there was a gross failure to provide her with basic medical care which contributed to her death and it was possible that if she had received that care and VTE prophylaxis treatment she would not have developed a pulmonary thromboembolism and died."
  5. News Article
    A growing number of children with mental health problems are being treated on adult psychiatric wards as services struggle to cope with a surge in demand following the pandemic, the NHS watchdog has warned. There were 249 admissions of under-18s to adult psychiatric wards in England in 2021-22, according to data provided by NHS trusts to the Care Quality Commission (CQC), up 30% on the year before. Of the children admitted to adult wards, 58% of cases were because the child needed to be admitted immediately for their safety. But in more than a quarter of cases, 27%, the child was admitted to the adult ward because there was no alternative child inpatient or community outreach service available. The findings come more than 15 years after the government set a target to end inappropriate admissions of children to adult psychiatric wards. The number of admissions gradually reduced but has now risen again, the CQC figures suggest. Dr Elaine Lockhart, chair of the Child and Adolescent Faculty at the Royal College of Psychiatrists, said the figures were “a concern but not a surprise. We’ve got a lot of children and young people who have become more unwell. Services are really struggling to meet their needs,” she said. Read full story Source: The Guardian, 30 October 2022
  6. News Article
    Results from the recently published Community Mental Health Survey highlight that issues with access to services and support, as evidenced in the 2020 and 2021 surveys, continue to persist. The 2022 Community Mental Health Survey – coordinated by Picker for the Care Quality Commission – collected feedback from more than 13,400 people in contact with services between September and November 2021. The survey is an important source of information to help us understand the quality of person-centred care provided to mental health service users. A key feature of a high-quality person centred mental health service is timely access to care. The survey shows that there is more to be done here to ensure that service users have a good experience as nearly a third (31%) reported not being told who was in charge of organising their care and services – up from 28% in 2021. In parallel with this, 30% of service users said that they had not seen NHS mental health services enough in the last 12 months (compared to 27% in 2021 and 24% in 2020) and only 55% said they were given enough time to discuss their needs and treatment. Just over half of service users (51%) said that they did not receive any help or advice with finding support for financial advice or benefits – a 3% point increase from last year’s survey. When asked a similar question regarding support for finding or keeping work, 50% said they did not receive help or advice but would have liked it. With the financial worries that the increased cost of living is causing for many people, signposting support and advice for employment, managing money, and claiming benefits are vital for helping people maintain good mental health. Commenting on the results, Jenny King, Picker’s Chief Research Officer, said: “On the 22nd September 2022, the Secretary of State for Health and Social Care and Deputy Prime Minister at the time, Thérèse Coffey, announced the UK government’s Our plan for patients. Whilst it notes that work will continue to improve the availability of mental health support through expansion of services, there was little detail on how this would be achieved and how backlogs of care in mental health services would be resolved. With the backdrop of the cost of living crisis and its impact on people’s mental health, the findings from this survey highlight the urgent need for more to be done to address accessibility issues. And not just in mental health services but across health and social care where, as highlighted by CQC’s 2021/22 State of Care report, people are waiting too long for appointments, assessments, and treatment. Without a plan for tackling the NHS’s workforce crisis, the ability to make sustainable service improvements to address the unmet need is severely restricted.” Read full story Source: Picker, 27 October 2022
  7. News Article
    Ministers have been urged to launch a public inquiry into the care of mental health patients after The Independent revealed allegations that patients had suffered “systemic abuse” in inpatient units. A joint investigation with Sky News found that teenagers at facilities run by The Huntercombe Group had been left with post-traumatic stress disorder by their treatment despite hundreds of warnings to regulators and the NHS. Now the government is facing calls to review all mental health care services over fears that these cases are “the tip of the iceberg”. Labour’s shadow mental health minister Dr Rosena Allin-Khan has called for a “rapid review” by the government into inpatient mental health services, while Deborah Coles, the chief executive of charity Inquest, has called on the new health secretary Steve Barclay to launch a statutory public inquiry. Read full story Source: The Independent, 28 October 2022
  8. News Article
    Children say they were "treated like animals" and left traumatised as part of a decade of “systemic abuse” by a group of mental health hospitals, an investigation by The Independent and Sky News has found. The Department of Health and Social Care has now launched a probe into the allegations of 22 young women who were patients in units run by The Huntercombe Group, which has run at least six children’s mental health hospitals, between 2012 and this year. They say they suffered treatment including the use of “painful” restraints and being held down for hours by male nurses, being stopped from going outside for months and living in wards with blood-stained walls. They also allege they were given so much medication they had become “zombies” and were force-fed. But despite reports to police and regulators dating back seven years, and findings by the Care Quality Commission (CQC) that the units were inadequate, the NHS has still handed Huntercombe nearly £190m since 2015-16 to admit children to its mental health beds. Through witness testimony, documents obtained by Freedom of Information request and leaked reports, the investigation has uncovered: The CQC has received more than 700 whistleblowing and safeguarding reports, including “incidents of concern” and several “sexual safety” concerns. NHS England was notified of 195 safeguarding reports between 2020 and 2021. A 2018 internal report at Meadow Lodge hospital in Newton Abbot (now closed) found staff members using sexually inappropriate language in front of patients. 160 reports investigated by Staffordshire police about Huntercombe Staffordshire between 2015 and 2022. Between March 2021 and 2022, the CQC gave permission for 29 patients to be admitted to Maidenhead hospital after it was placed in special measures. Read full story Source: The Independent, 27 October 2022
  9. News Article
    A shocking undercover investigation has laid bare appalling failures in patient care on Britain’s mental health wards. Reporters from Channel 4’s Dispatches programme spent three months secretly filming at one of the UK’s biggest mental health trusts – Essex Partnership University NHS Foundation Trust. The footage reveals horrifying abuses of vulnerable residents on two acute mental health wards. It includes patients being dragged across the floor, pinned down by staff, mocked while they are in distress and humiliated. On one occasion, a patient who is at high risk of suicide and supposed to be under constant supervision is left unattended and makes an attempt on their own life. Another chaotic scene involves staff trying to locate a crucial bag of specialist cutting devices to save the life of a female patient who got hold of a ligature, after a carer failed to keep watch. In one distressing example, a young woman being treated for anorexia – who is heard hyperventilating with fear – is dragged across the floor by her arms. When she is later discovered making a suicide attempt, she is pinned down by five carers for 40 minutes. As the woman lies sobbing on the floor, one of the staff members discusses the success of his latest diet. Another carer laughs as she marks the rhythm of the woman’s laboured breathing with her hands. The damning footage raises fresh concerns about the state of treatment for the most mentally unwell in this country. While the Essex Trust is just one of 54 across England, mental health professionals and families warn that such failures are widespread. Former mental health nurse Julie Repper, director of imROC, an organisation that helps improve patients’ experiences in mental health services, describes events in the film as ‘literally abusive’. "I asked the peer support workers we train about their experiences of the system, and they described seeing repeated ligaturing, people being dragged by their feet and being restrained. It’s ubiquitous". "These units are supposed to keep people safe, but this film shows they’re not. Everybody has a stake in seeing this improve, because every single one of us may become overwhelmed at some point and find we hit a crisis." Read full story Source: MailOnline, 10 October 2022
  10. News Article
    An appeal to establish a dedicated Mother and Baby Perinatal Mental Health Unit will be delivered to the Nothern Ireland health minister later. Individual women, charities and other organisations will hand over a public letter urging Robin Swann to act. Northern Ireland is the only place in the UK which has no dedicated in-patient service for women with serious post-partum mental health issues. The units admit mothers with their babies so that they can be with them. About 70 women a year in Northern Ireland are admitted to hospital with post-partum psychosis. The health minister approved some funding for perinatal mental health last year. However, no decision has been made on in-patient services. Read full story Source: BBC, 10 October 2022
  11. News Article
    The NHS’ mental health director has branded abuse exposed at a city inpatient unit as “heartbreaking and shameful” and ordered a national review of safety across all providers. In a letter to all leaders of mental health, learning disability and autism providers, shared with HSJ, Claire Murdoch responded to BBC Panorama’s exposure of patient abuse at the Edenfield Centre run by Greater Manchester Mental Health FT by warning trusts they should leave “no stone unturned” in seeking to eradicate and prevent poor care. An investigation by the programme found a “toxic culture of humiliation, verbal abuse and bullying” at the medium-secure inpatient unit in Prestwich near Manchester. In response, Ms Murdoch said the mindset that “it could happen here” must be at the front and centre of national and local approaches, adding that trusts which already adopt this outlook are most likely to identify and prevent toxic and closed cultures. She also urged all boards to urgently review safeguarding of care in their organisations and identify any immediate issues requiring action now, such as freedom to speak up arrangements, complaints, and care and treatment reviews. A separate national probe into the quality of inpatient care is due to launch imminently. Read full story (paywalled) Source: HSJ, 30 September 2022
  12. News Article
    Greater Manchester Mental Health NHS Foundation Trust said a number of staff at its Edenfield Centre had been suspended after an undercover investigation found what was described as a "toxic culture" of humiliation, verbal abuse, and bullying of patients. BBC Panorama reporter, Alan Haslam, spent 3 months as a support worker at the Centre in Prestwich. Wearing a hidden camera, he said he observed staff swearing at patients, mocking them, and falsifying observation records. A consultant psychiatrist, Dr Cleo Van Velsen, who was asked by the BBC to review its footage, said it showed a "toxic culture" among staff at the Centre with "corruption, perversion, aggression, hostility, [and a] lack of boundaries". Dr Van Velsen told the BBC that staff members at the Edenfield Centre acted "like a gang, not a group of healthcare professionals". Patients at the Centre told the undercover reporter that they felt "bullied and dehumanised". Greater Manchester Police said it was working with the Crown Prosecution Service with a view to prosecuting anyone who had committed a crime. In a statement, Greater Manchester Mental Health NHS Foundation Trust said: "We are taking the allegations raised by Panorama very seriously since the BBC sent them to us earlier this month. We have put in place immediate actions to protect patient safety, which is our utmost priority. "Since then, senior doctors at the Trust have undertaken clinical reviews of the patients affected, we have suspended a number of staff pending further investigations, and we have also commissioned an independent clinical review of the services provided at the Edenfield Centre. " Read full story Source: Medscape. 29 September 2022
  13. News Article
    Evidence of abusive and inappropriate treatment of vulnerable patients at a secure mental health hospital has been uncovered by BBC Panorama. One young woman was locked in a seclusion room for 17 days, was then allowed out for a day, only to be hauled back in for another 10 days. Harley was sitting on the floor wearing pink pyjamas, with her hair tied up in neat braids, when hospital staff piled through the door one after another. Two male nurses grabbed her by the arms. "You're not giving me a chance to work with you," she screamed. "Let me get up." But it was no use. Managers at the secure mental health hospital had decided there would be - in their words - "no negotiation". As she struggled, other nurses and support staff joined in. With her arms, legs and head restrained, she was pinned to the floor, face down. Secret filming by BBC Panorama captured the moment the 23-year-old was forced into a seclusion room at the Edenfield Centre in Prestwich, near Manchester. The hidden camera had already recorded staff justifying their actions and agreeing they would not try to reason with her this time. Panorama's undercover reporter was told that Harley had previously been aggressive towards staff - but, this time they said she was being isolated for screaming and being verbally abusive. Seclusion should only be used when it is of "immediate necessity" to contain behaviour that is likely to harm others, with patients locked away for the shortest time necessary, guidelines say. England's independent healthcare regulator, the Care Quality Commission, says it should only be used in extreme cases - while the government has said the use of restrictive methods in hospitals should be reduced. But research by BBC News has found the numbers are steadily increasing. Read full story Source: BBC News, 28 September 2022
  14. News Article
    Police are preparing to investigate alleged mistreatment of patients at a mental health unit. The Edenfield Centre based in the grounds of the former Prestwich Hospital in Bury is at the centre of the claims. The unit cares for adult patients. The Manchester Evening News understands that action was taken after the BBC Panorama programme embedded a reporter undercover in the unit and then presented the NHS Trust which runs it with their evidence. A spokesperson for Greater Manchester Police said: "We are aware of the allegations and are liaising with partner agencies to safeguard vulnerable individuals and obtain all information required to open an investigation." A spokesperson for Greater Manchester Mental Health NHS Foundation Trust said: "We can confirm that BBC Panorama has contacted the Trust, following research it conducted into the Edenfield Centre. We would like to reassure patients, carers, staff, and the public that we are taking the matters raised by the BBC very seriously". "Immediate action has been taken to address the issues raised and to ensure patient safety, which is our utmost priority. We are liaising with partner agencies and stakeholders, including Greater Manchester Police. We are not able to comment any further on these matters at this stage." Read full story Source: Manchester Evening News, 14 September 2022
  15. Content Article
    This is an annual report by the Children’s Commissioner review in children’s mental health services in England during 2021-22. It considers key trends in children’s access to mental health services and considers the current state of care provided to children who are admitted to inpatient mental health settings.
  16. 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.
  17. News Article
    Ministers are considering the use of body cameras within mental health units as part of the government’s response to NHS abuse scandals, The Independent has learned. Senior sources with knowledge of the conversation between the Department for Health and Social Care and the NHS have raised concerns about the plans. There are fears that using the technology in mental health units could have implications for human rights and patient confidentiality. One senior figure criticised the proposals and said: “The DHSC are all talking about body-worn cameras, closed circuit TV, etc... The whole thing is fraught with huge difficulties regarding human rights, about confidentiality. They are thinking about it [cameras] and it is ridiculous.” The DHSC’s mental health minister Maria Caulfield said in parliament earlier this month that she and health secretary Steve Barclay were due to meet with NHS officials to discuss what response was needed to recent exposes of abuse within mental health services. It comes after a string of reports from The Independent, BBC Panorama and Dispatches revealing abuse of inpatients. The Panorama and Dispatches reports included video evidence of abuse captured by hidden cameras. Following a scathing independent review into the deaths of three young women, Tees, Esk and Wear Valleys NHS Trust said it is piloting the use of body-worn cameras across 10 inpatient wards “to support post incident reviews for staff and patients.” Read full story Source: The Independent, 23 November 2022
  18. News Article
    Children say they were “treated like animals” and left traumatised as part of a decade of “systemic abuse” by a group of mental health hospitals, an investigation by The Independent and Sky News has found. The Department of Health and Social Care has now launched a probe into the allegations of 22 young women who were patients in units run by The Huntercombe Group, which has run at least six children’s mental health hospitals, between 2012 and this year. They say they suffered treatment including the use of “painful” restraints and being held down for hours by male nurses, being stopped from going outside for months and living in wards with blood-stained walls. They also allege they were given so much medication they had become “zombies” and were force-fed. Through witness testimony, documents obtained by Freedom of Information request and leaked reports, the investigation has uncovered: The CQC has received more than 700 whistleblowing and safeguarding reports, including “incidents of concern” and several “sexual safety” concerns. NHS England was notified of 195 safeguarding reports between 2020 and 2021. A 2018 internal report at Meadow Lodge hospital in Newton Abbot (now closed) found staff members using sexually inappropriate language in front of patients. 160 reports investigated by Staffordshire police about Huntercombe Staffordshire between 2015 and 2022. Between March 2021 and 2022, the CQC gave permission for 29 patients to be admitted to Maidenhead hospital after it was placed in special measures. Read full story Source: The Independent, 17 November 2022
  19. News Article
    Hundreds of mental health patients in England are sent to hospitals miles from home each month because of local bed shortages - more than a year after the NHS aimed to end the practice. NHS data shows that 630 patients were in inappropriate out of area placements (OAPs) at the end of August 2022. An inappropriate OAP is when someone is sent to a hospital in a different area because no beds are free locally. Of the 630 patients in inappropriate OAPs in August 2022, more than half were sent away that month. In 2019, Kelly was sectioned and - because no local bed was free - sent to a hospital 23 miles from her home. "I didn't have anything on me", she says, "I only had my phone and the clothes that I was in." With family members too far away to bring her possessions, the hospital provided basics: pyjamas, trousers, a T-shirt, one pair of socks and two pieces of underwear. "All I could wear were the pyjamas and the same top and trousers every day for three weeks," says Kelly. "It was just awful. When you're stuck in a strange place as it is... It's even more distressing not having your own familiar things to take comfort in." Shortly after her discharge, Kelly was sectioned again - this time closer to home. She says this made a "massive difference", adding: "When you're closer to home you've got your friends and your family coming to visit you and take you out for a walk." Paul Spencer, the charity Mind's head of health, policy & campaigns, describes OAPs as traumatic, isolating and costly to the NHS. He says that "people are cut off from their support networks right at the very moment they need them most". Read full story Source: BBC News, 16 November 2022
  20. News Article
    Whistle-blowers have described neglect, patient-on-patient assault and staff who bully colleagues and sleep on the job at a troubled mental health ward. Sources told a BBC investigation that a patient of 25-bed, mixed-gender Hill Crest Ward in Redditch, Worcestershire, suffered a broken jaw during one clash. They also claimed three nurses were "forced out" amid bullying behaviour. The NHS trust that runs Hill Crest said it believed changes there were having a positive impact. Accounts have been corroborated via five independent sources to whom the BBC spoke. They follow reports earlier this year of a fire and an incident in which staff locked themselves in an office when a patient ran around armed with boiling water and sugar. Additionally, one patient has provided the BBC with images alleged to show the effects of her battering herself out of desperation - without staff intervening. Sources also described staff being bullied, with one saying a nurse who particularly suffered had her resignation letter read out and mocked by tormentors. Sources independently complained of the workplace culture, with the BBC aware of explicit images bearing lewd comments about colleagues. Read full story Source: BBC News, 15 November 2022
  21. News Article
    A whistleblower at a mental health trust criticised over the deaths of three teenagers has said bosses ignored workers when they raised concerns. Christie Harnett and Nadia Sharif, both 17, and Emily Moore, 18, who were friends, all took their own lives within eight months of each other. The whistleblower said agency workers fell asleep on duty at Middlesbrough's West Lane Hospital and staff struggled "to keep children alive". The trust has apologised for failings. Reports into the women's care found 120 failings at Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV), which ran the hospital, and other agencies. Speaking after the reports were published, the health trust worker, who did not wish to be identified, told the BBC staff were "ignored" when they tried to warn bosses about conditions in the hospital. "Staff repeatedly raised concerns with managers, some of the time we just didn't have enough staff to keep the children safe," the worker said. "We warned them something serious was going to happen, but they just ignored us. "Senior managers looked at numbers, rather than the skillset that staff actually had. "The agency staff would sometimes fall asleep on duty or watch the telly rather than engage with patients." Read full story Source: BBC News, 4 November 2022
  22. News Article
    Ministers may order a public inquiry into mental health care and patient deaths across England because of the number of scandals that are emerging involving poor treatment. Maria Caulfield, the minister for mental health, told MPs on Thursday that she and the health secretary, Steve Barclay, were considering whether to launch an inquiry because the same failings were occurring so often in so many different parts of the country. They would make a final decision “in the coming days”, she said in the House of Commons, responding to an urgent question tabled by her Labour shadow, Dr Rosena Allin-Khan. An independent investigation found this week that that three teenage girls – Christie Harnett, 17, Nadia Sharif, 17, and Emily Moore, 18 – took their own lives within the space of eight months after receiving inadequate care from the Tees, Esk and Wear Valleys (TEWV) NHS mental health trust in north-east England. They died after “multifaceted and systemic failings” by the trust, especially at its West Lane hospital in Middlesbrough, the inquiry found. Allin-Khan pointed to a series of scandals that have come to light, often through media investigations, about dangerously substandard mental health care being provided by NHS services and also private firms in England, including in Essex and in Greater Manchester. “Patients are dying, being bullied, dehumanised, abused and their medical records are being falsified, a scandalous breach of patient safety,” Allin-Khan said. “The government has failed to learn from past failings.” Read full story Source: The Guardian, 3 November 2022
  23. 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
  24. 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
  25. 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
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