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Found 153 results
  1. 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
  2. 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
  3. 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)
  4. 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
  5. News Article
    The Department of Health and Social Care (DHSC) is facing being taken to court over an inquiry it launched into the deaths of dozens of mental health patients in Essex. Last year, the government said it would commission an independent inquiry into at least 36 inpatient deaths in Essex, which had taken place over the last two decades. However, more than 70 families are calling for a full statutory public inquiry, which can compel witnesses to give evidence. They have lodged judicial review proceedings at the High Court against the government to that effect. The DHSC said it could not comment on ongoing legal proceedings. The current inquiry was launched in response to a highly critical report from the Parliamentary Health Service Ombudsman, published in June 2019, into the deaths of two patients at North Essex Partnership University Foundation Trust, which has since merged to form Essex Partnership University FT. There has also been an investigation by Essex Police into 25 of the deaths. This concluded in 2018, when the force said there had been “clear and basic” care failings, but there was not enough evidence to prosecute the trust for corporate manslaughter. Read full story (paywalled) Source: HSJ, 11 May 2021
  6. News Article
    Police are investigating allegations around the death of a patient who was under the care of Hertfordshire Partnership University Foundation Trust. The probe by Hertfordshire Constabulary relates to the case of Margaret Molyneux, 69, who according to a review by the trust’s commissioners, was prescribed doses of anti-psychotic medication which were significantly higher than recommended limits. Police said the investigation is ongoing and no arrests have been made. Ms Molyneux had been admitted to the trust’s mental health unit in Radlett in 2017, after which her physical health declined and she was admitted to Watford General Hospital with pneumonia and dysphagia, which relates to difficulties swallowing. She was discharged back to the Radlett unit, but died several weeks later at Watford General Hospital, after choking on her food and developing aspiration pneumonia. An inquest in February 2018 ruled she died from natural causes, but an investigation into her case commissioned by East and North Hertfordshire Clinical Commissioning Group, seen by HSJ, subsequently suggested high doses of Olanzapine, an anti-psychotic drug, were “likely to have at least contributed to some of the physical problems she experienced… including low blood pressure, falls and dysphagia”. Read full story (paywalled) Source: HSJ, 6 May 2021
  7. News Article
    A mental health trust prosecuted for failings after 11 patients died must make further safety improvements, the Care Quality Commission (CQC) said. Inspectors found safety issues on male wards and psychiatric intensive care units run by Essex Partnership University NHS Foundation Trust (EPUT). The Trust said it had taken "immediate action" to remedy the concerns. In November, EPUT pleaded guilty to safety failings related to patient deaths between 2004 and 2015. The CQC's report followed inspections in October and November last year at the Finchingfield Ward - a 17-bed unit in the Linden Centre in Chelmsford which provides treatment for men experiencing acute mental health difficulties. The CQC said the visit was prompted "due to concerning information raised to the commission regarding safety incidents leading to concerns around risk of harm". The inspection, which looked at safety only, found the following concerns: Some staff did not follow the required actions to maintain patient safety. Closed-circuit television showed staff who were meant to be observing were not present, and this contributed to an incident of patient absconding. Staff did not keep accurate records of patient care and managers did not check the quality and accuracy. of notes. Shifts were not always covered by staff with appropriate experience and competency Stuart Dunn, head of hospital inspection at the CQC, said EPUT had "responded quickly to concerns raised" including improving security measures. Read full story Source: BBC News, 14 January 2021
  8. News Article
    A coroner has raised concerns about how a family was allowed to bring a restricted item that contributed to a man's death into a mental health unit. Joshua Sahota, 25, died as a result of asphyxia and psychosis in Bury St Edmunds, Suffolk, on 9 September 2019. Suffolk coroner Nigel Parsley said Mr Sahota's relatives were not told the item they brought in when visiting was on a restricted list. The NHS trust which runs the unit said it had improved its internal processes. Mr Sahota, from Kennett in Cambridgeshire, was taken to the Wedgewood Unit on the West Suffolk Hospital site three weeks before his death as his mental health had declined. Insufficient staffing levels contributed to his death, an inquest jury at Suffolk Coroner's Court concluded. Other factors included insufficient observations and one-to-one processes, no clear and concise risk assessments, being slow to develop a care plan and the absence of a documented crisis plan. Read full story Source: BBC News, 21 September 2021
  9. News Article
    Young people cared for by an NHS mental health service "came to harm" because of its failings, inspectors said. The care provided by Essex Partnership University NHS Foundation Trust (EPUT) has been rated "inadequate" by the Care Quality Commission (CQC). It has now been stopped from admitting new patients after inspectors found "serious concerns" in the children and adolescent mental health services. EPUT said it had increased staffing levels and had been coaching staff. The inspection was prompted by a serious incident and concerning information received about safety and quality, the CQC said. Inspectors visited, unannounced, in May and June and looked at the Larkwood and Longview wards at the St Aubyn Centre in Colchester and the Poplar Adolescent Unit at Rochford Hospital. The CQC found observations were not always carried out safely and patients "had been harmed as a result of the poor practices", which included patients self-harming. It said these incidents were not always reported or dealt with appropriately. Read full story Source: BBC News, 15 September 2021
  10. News Article
    The father of a man who took his own life said the mental health unit where he was staying "failed him completely". Joshua Sahota, 25, died as a result of asphyxia and psychosis at the Wedgewood Unit in Bury St Edmunds, Suffolk, on 9 September 2019. Insufficient staffing levels at the unit contributed to his death, an inquest jury found. Mr Sahota, from Kennett in Cambridgeshire, was taken to the unit three weeks before his death as his mental health had declined. There was no psychologist in post and the jury at Suffolk Coroner's Court recorded this as having contributed to his death. It also found that a plastic bag which contributed to his death was on a restricted items list, but this was "unclear" and there were "inconsistencies of understanding this" by staff and visitors. Other factors that the jury said contributed to his death included insufficient observations and one-to-one processes, no clear and concise risk assessments, being slow to develop a care plan and the absence of a documented crisis plan. Read full story Source: BBC News, 10 September 2021
  11. Content Article
    The government has published a draft Mental Health Bill for pre-legislative scrutiny. The bill aims to modernise the Mental Health Act for the 21st century.
  12. Content Article
    The Quality Network for Inpatient Working Age Mental Health Services (QNWA) based within the Royal College of Psychiatrists' Centre for Quality Improvement are pleased to announce the publication of their 8th edition standards. Since the publication of the first edition standards in 2006, the Network has grown to include over 140 members from the NHS and private sector. This new edition of standards aims to reflect the changes in working practices and legislation over the last two years in addition to placing greater emphasis on equality, diversity and inclusion as well as sustainability in inpatient mental health services. The eighth edition standards have been drawn from key documents and expert consensus and have been subject to extensive consultation with professional groups involved in the provision of inpatient mental health services, and with people and carers who have used services in the past.
  13. Content Article
    This Healthcare Safety Investigation Branch (HSIB) investigation explores medicines omission among patients with learning disabilities who are cared for in medium and low secure wards in mental health hospitals. A medicine omission is when a patient doesn't receive medicines that have been prescribed to them, and the investigation focused on a number of factors that could contribute to omission: the environment in which medicines administration takes place the availability and use of learning disability nurses in these environments the skills required for nurses to help patients with learning disabilities be involved in choices about their medicines. For it's reference event, the investigation looked at the case of Luke, who was detained in a medium secure ward of a mental health hospital. He spent 21 months on the ward before moving into a low secure ward at the same hospital, where he stayed for a further 11 months. Both wards were specifically designated for patients with learning disabilities. While at the hospital, there were a number of periods when Luke was not given the physical health medication he had been prescribed for his diabetes and high cholesterol. Although Luke’s medication record regularly noted that Luke refused the medication, Luke and his Mother disagreed with this version of events, stating that other factors led to Luke’s medicine omissions.
  14. Content Article
    The Suicide Prevention National Transformation Programme aims to reduce the number of deaths by suicide in England by 10% by 2020/21.  NHS England are investing funding in 37 local areas to establish or develop their multi-agency suicide prevention action plans to reduce suicide and self-harm. These plans cover three of the main priority areas identified in the National Suicide Prevention Strategy: Reducing risk in men. Prevention and response to self-harm. Improving acute mental health care. Find out more about the programme and useful resources from the link below.
  15. Content Article
    An investigation started on 9 October 2020 into the death of Matthew Alexander Caseby. Following his admission and subsequent absconsion from the Priory Hospital in Edgbaston, Matthew stepped in front of a train on the 8 September 2020 and was fatally injured. At the time, Matthew was suffering from disorder thinking and did not have the capacity to form any intention to end his life. Matthew absconded from Beech ward over a fence in the courtyard area and at the time of his absconsion Matthew was unattended. It was inappropriate for Matthew to be left unattended in the courtyard. There were concerns regarding Matthew absconding but the recording processes on Beech ward were inadequate which resulted in the communication to staff involved in Matthew's care being lacking. As a result of risks not being fully recorded, Matthew's risk assessment was not adequate as it was not based on all of the available information. Overall, the inadequate risk assessment for Matthew, the inadequate documentation records, the lack of a risk assessment for the courtyard area and the absence of a policy regarding observations levels in the courtyard means that the courtyard was not safe for Matthew to use unattended. His death was contributed to by neglect on the part of the treating hospital.
  16. Content Article
    These Quality Standards have been developed by the Resuscitation Council UK. They enable healthcare organisations provide a high-quality resuscitation service, with guidance tailored for different settings including acute care, primary care, dental care, mental health units, community hospitals and in the community.
  17. Content Article
    This National Institute for Health and Care Excellence (NICE) guideline covers the components of a good experience of service use. It aims to make sure that all adults using NHS mental health services have the best possible experience of care. It includes recommendations on: access to care assessment community care assessment and referral in crisis hospital care discharge and transfer of care assessment and treatment under the Mental Health Act
  18. Content Article
    In this debate the Parliamentary Under-Secretary of State for Health and Social Care, Maria Caulfield MP, responds to an Urgent Question asking for a statement on abuse and deaths in secure mental health units. The Minister discusses the recent findings from investigations into the deaths of Christie Harnett, Nadia Sharif and Emily Moore who were in the care of the Tees, Esk & Wear Valleys NHS Foundation Trust, reflecting on these in the context of broader concerns highlighted by other recent patient safety scandals concerning NHS mental health services. This is followed by questions from MPs in the chamber and the Minister’s responses.
  19. 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.
  20. 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.
  21. 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.
  22. 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.
  23. Content Article
    "It’s time to halt, take a break, and redraw the relationship between patient care and self-care. Self-care isn’t an optional luxury. It must sit at the heart of what we do, to ensure our teams can continue to rise to the challenges of working in the 21st century NHS, to give our patients the best of both ourselves, and the organisation so many of us are proud to be a part of."
  24. 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.
  25. 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.
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