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Found 151 results
  1. 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
  2. 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
  3. 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.
  4. 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.
  5. Content Article
    The Essex Mental Health Independent Inquiry has been established to review the care and treatment pathways and the circumstances and practices surrounding the deaths of mental health inpatients. The Inquiry will investigate the deaths which took place in mental health inpatient facilities across NHS Trusts in Essex between 1 January 2000 and 31 December 2020. It will draw conclusions in relation to the safety and quality of care provided locally and nationally to mental health inpatients. The Inquiry intends to publish a report in spring 2023.
  6. Content Article
    Benjamin Lee Stroud died on the 19 March 2021 at home. He lived alone but had a partner who saw him regularly. He had a previous medical history of recreational drugs, including steroids and cannabis; he was recently diagnosed as insulin dependent diabetic and had undergone a kidney transplant. He fell and injured his back at work, and developed a dependence on pain medication, some of which were purchased on the internet. His mental health issues increased as a result of his psychical health problems. A post mortem was undertaken and the cause of death was multiple drug toxicity.
  7. Content Article
    In this study, 156 participants were recruited and randomised to placebo (n=83) or ketamine (n=73), stratified by centre and diagnosis: bipolar, depressive, or other disorders. Two 40-minute intravenous infusions of ketamine (0.5 mg/kg) or placebo (saline) were administered at baseline and 24 hours, in addition to usual treatment. The primary outcome was the rate of patients in full suicidal remission at day 3, according to the scale for suicidal ideation total score ≤3. Analyses were conducted on an intention-to-treat basis. The findings indicate that ketamine is rapid, safe in the short term, and has persistent benefits for acute care in suicidal patients. Comorbid mental disorders appear to be important moderators. An analgesic effect on mental pain might explain the anti-suicidal effects of ketamine. There are also some useful and thought-provoking comments on this research, and a helpful visual aid.
  8. Event
    This 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
  9. Content Article
    On 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.
  10. News Article
    Three mothers whose sons have been locked in hospital psychiatric units in Scotland for years have spoken to the BBC because they’re desperate to get them out. The three young men did not break the law but have autism and learning disabilities. Jamie has autism and was sectioned after becoming distressed at 19. Although he was free to go after 3 months there was no where for him to go so he has lived in hospital units since then. He is now 24. The Scottish government said it was unacceptable to hold people with complex needs in hospital when they could be cared for in the community. "He's left to rot", says his mother. Watch video Source: BBC News, 9 February 2022
  11. News Article
    The Healthcare Safety Investigation Branch (HSIB) has launched an investigation into community mental health care following the death of a 56-year-old woman. HSIB has begun examining how patients in crisis with severe mental health needs are assessed by NHS services. The investigation came after warnings from multiple coroners over the poor assessment of suicide risk in people in mental health crisis in the last year and followed the death of Frances Wellburn, who took her own life in August 2020 while under the care of Tees, Esk and Wear Valleys Foundation NHS Trust (TEWV). Wellburn had long-term mental health problems but suffered a crisis and was admitted to hospital in September 2019. Following discharge, she was not referred to a specialist NHS service for people experiencing psychosis because clinicians incorrectly believed she was too old for the service, according to a TEWV investigation report seen by The Independent. Despite being assessed as a “medium risk”, Wellburn was not contacted by mental health teams for three months. In June 2020, she was admitted to an inpatient unit for three weeks, but her health deteriorated, and she later took her own life. Separately, coroner warnings in three prevention of future deaths reports published last year found mental health staff failing to risk assess people who later took their own lives. HSIB’s investigation will look into how patients’ risk is assessed when receiving care in the community and how services interact with families and other health services. It will also examine how mental health services consider menopause when assessing women’s mental health and referrals to early intervention psychosis services. Read full story Source: The Independent, 27 January 2022
  12. News Article
    There are serious concerns over the standards of specialist care being provided to patients with the most complex mental health needs, a BBC investigation has found. Patients sent by the NHS to stay in mental health rehabilitation units say they have been placed in unsafe environments, often far from home, with untrained staff. Experts say not enough is being done to regulate the sector, which costs the NHS half a billion pounds a year. Lissa had spent years struggling with her mental health, having experienced traumatic life events. She was diagnosed with mixed personality disorder, depression and high-functioning Asperger's. So when the NHS sent her to a unit in Coventry run by Cygnet Health Care for a specialist talking therapy, she agreed. The hospital, however, was in special measures. There had been two deaths in the previous 20 months. In both cases there was found to be a failure to follow the patient's care plan and carry out observations correctly. Lissa says staff failed to treat her with dignity and respect. The system in England is regulated by the Care Quality Commission, (CQC). Some rehabilitation wards haven't been inspected for four or more years. John Chacksfield, who was a CQC inspector until late 2020, says greater scrutiny is needed. "Sometimes the private sector provides really excellent service, but there are certain units that really do need regular inspections just to make sure staff are being trained enough, or are having enough clinical supervision. It does worry me," he says. Read full story Source: BBC News, 18 January 2022
  13. News Article
    “Unacceptable” failures by a mental health hospital to manage the physical healthcare of a woman detained under the mental health act contributed to her starving to death, The Independent has learned. A second inquest into the death of a 45-year-old woman, Jennifer Lewis, has found that the mental health hospital to which she was admitted “failed to manage her declining physical health” as she suffered from the effects of malnutrition. Ms Lewis had a long-term diagnosis of schizophrenia. Her family described how she had lived a full life, completed a degree, and given lectures about living with mental illness. However, after undergoing bariatric surgery, against the wishes of her family, her mental state declined and she was admitted to the Bracton Centre, run by Oxleas, in 2014. In an interview with The independent, her sister, Angela, described how, in the year before her death, Ms Lewis lost her hair, suffered from diarrhoea, and developed sores on her legs as she effectively “starved to death” from malnutrition. Ms Lewis’s sister told The Independent that in the year leading up to her death, when the family warned doctors she was “starving to death”, their concerns were dismissed and they were told that the hospital “will not let it come to that”. Mental health charity Rethink has called for improvements to physical healthcare for patients with severe mental illness, whose physical needs they say are “all too often ignored”, while experts at think tank the Centre for Mental Health have warned that patients with mental illness are dying too young as the system “still separates mental and physical health”. Read full story Source: The Independent, January 2022
  14. 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
  15. 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
  16. 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
  17. 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
  18. 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
  19. 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
  20. 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
  21. 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
  22. 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
  23. 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
  24. 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
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