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Content ArticleMorgan-Rose Hart died after she was found unresponsive while being detained under section 3 of the Mental Health Act at the Derwent Centre at the Princess Alexandra Hospital in Essex. Morgan-Rose was last clinically observed at 14.06 on 6 July 2022 and in between the last observation and when Morgan-Rose was discovered the Coroner notes that multiple failings in her care took place, including consecutive hours observations being incorrect and falsified.
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News Article
CQC sorry for failing to act on ‘note tampering’ concerns
Patient Safety Learning posted a news article in News
The Care Quality Commission (CQC) has apologised after admitting it failed to act on whistleblowing concerns “in a timely manner”. Allegations had been made to the CQC about staff at Cambridgeshire and Peterborough Foundation Trust tampering with a patient’s record after they had died by suicide. As previously reported, the accusations by whistleblower Des McVey have sparked a review of the trust’s conduct in more than 60 suicide cases. Mr McVey says the trust only took action following media coverage and that the CQC had ignored his concerns. The regulator has now upheld a complaint from him, with operations manager James DeCothi writing to Mr McVey: “I have established that [the relevant CQC inspector] did not share your concerns with the provider in a timely manner and that our contact with you from July 2022 to June 2023 was inconsistent. I apologise on behalf of CQC for this. [The CQC inspector] has reflected on this and has asked me to offer her apologies to you also. “I can confirm that CQC have followed up the areas of concern that you have shared, and we will continue to use the information you have shared to inform future regulatory activity. I would like to thank you again for sharing this information with us.” Read full story (paywalled) Source: HSJ, 11 December 2023- Posted
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Content ArticleMr Malone was diagnosed with treatment resistant schizophrenia in 1983 and had been sectioned multiple times. In May 2023 he was diagnosed with adult autism. At a review on 31 May he was considered to be stable. On 15 June a routine clozapine review identified sub-therapeutic levels but this was not notified to his clinicians. Sub-therapeutic levels of clozapine are likely to have contributed to a worsening in his symptoms. Around 24 June he was noted to have suffered a significant deterioration – with symptoms of thought disorder, anxiety, and responding to hallucinations – and following a mental health act assessment on 28 June clinicians wanted to detain him under section 2. No inpatient psychiatric bed was available. Whilst he awaited a bed, he remained in the community with daily visits from the mental health team. Last contact was on 1 July when he accepted his medication and appeared more settled. There was no answer when he was visited on 2 July. His room at supported accommodation was entered on 3 July and he was found deceased. Recently he had expressed no suicidal ideation. Post-mortem examination confirmed the medical cause of death was: 1a Cervical spinal cord injury. 1b Laceration. The conclusion of the inquest was that death was the consequence of suicide.
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Content ArticlePeter had a long history of depression, anxiety, and reported suicide attempts. He had acknowledged his reluctance to always engage fully with the treatment offered. On 3 August 2022 he was referred to the home treatment team for crisis intervention. After poor engagement he was transferred back to the community mental health team. On the 14 October he was detained by police under section 136 mental health act after expressing suicidal ideation. He told a psychiatric liaison service nurse he had no ongoing suicidal ideation and was referred to the community mental health team and his GP. He then contacted services further a number of times. On 10 November 2022 Peter was found deceased in his flat having taken a deliberate overdose of his prescribed medication. At the time of his death he was on the waiting list to be allocated a mental health care co-ordinator and there had been no multi-disciplinary meeting with all teams involved to agree how best to work with Peter. His cause of death was confirmed at post-mortem: 1a Carbamazepine toxicity. The conclusion reached was death was a consequence of suicide.
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News ArticleA third of carers with poor mental health have considered suicide or self-harm, data shows. Figures given to the Liberal Democrats by Carers UK reveal that many of the UK’s millions of carers who look after relatives have bad mental health, with some “at breaking point”. In a survey of nearly 11,000 unpaid carers, the vast majority said they were stressed or anxious, while half felt depressed and lonely. More than a quarter said they had bad or very bad mental health. Of these, more than a third said that they had thoughts related to self-harm or suicide, while nearly three-quarters of those felt they were at breaking point. Helen Walker, the chief executive of Carers UK, said: “Unpaid carers make an enormous contribution to society, but far too regularly feel unseen, undervalued and completely forgotten by services that are supposed to be there to support them. “Not being able to take breaks from caring, being able to prioritise their own health or earn enough money to make ends meet is causing many to hit rock bottom.” Read full story Source: The Guardian, 22 November 2023
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News ArticleTwo young people facing mental health crises were left on paediatric wards for months while different agencies across a health system struggled to find appropriate placements. The patients – who were both autistic and had learning disabilities, with special educational needs – were admitted to Maidstone and Tunbridge Wells Trust (MTW) last year after attending emergency departments more than 10 times within a two-month period. They were left on a paediatric ward – one of the patients for four months – as this was the “only available place of safety as opposed to the optimum setting to meet their needs,” according to Kent and Medway Integrated Care Board’s “learning review” of children and young people with complex needs, which the two cases prompted. The review, which HSJ obtained under a Freedom of Information request, revealed several problems with joint working, despite a multidisciplinary team meeting regularly to discuss the young patients’ needs. Since the review, a new escalation process has been introduced, urgent mental health risk assessments in the community have been enhanced and a three-month pilot of a self-harm service has been implemented at Tunbridge Wells Hospital, part of MTW. Read full story (paywalled) Source: HSJ, 17 November 2023
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Content Article
Top picks: men's health
Patient_Safety_Learning posted an article in Men's health
At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That’s why we created the hub; providing a space for people to come together and share their experiences, resources and good practice examples. To mark Men's Health Awareness Month, we are sharing 10 resources relating to men's health, including information about male cancers, how to engage men earlier and insights around the impact of traditional ideas of masculinity on patient safety.- Posted
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News ArticleChildren feel they have to attempt suicide multiple times before they get treatment from NHS mental health services, the former children’s commissioner has warned. Anne Longfield said that schoolchildren were aware that NHS mental health infrastructure was “buckling and far from being able to cope with the demand”. She told the Times Health Commission: “When I first became children’s commissioner in 2015, the thing that children talked about most often was mental health. They said they knew they couldn’t get help and treatment easily, because there just wasn’t enough help to go around. “Some said, we know that we’ve almost got to try and take our own life before we can get help. And I thought that was pretty shocking at the time. Now, young people are saying not only do they have to try to take their own life, they have to try and take their own life several times, and they say there will be an assessment of levels of intent within that.” Read full story Source: The Times, 1 November 2023
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Content Article
Top picks for Mental Health Day
Patient Safety Learning posted an article in Mental health
This year, WHO's World Mental Health Day on 10 October will focus on the theme 'Mental health is a universal human right'. To mark World Mental Health Day, we’ve pulled together 10 resources, blogs and reports from the hub that focus on improving patient safety across different aspects of mental health services.- Posted
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Content ArticleDoctors are dying by suicide at higher rates than the general population—somewhere between 300 to 400 physicians a year in the US take their own lives. This article in The Guardian looks at why so many surgeons are dying to suicide and what can be done to stop the trend. It examines how the culture of working long hours and the expectation to be 'superhuman' leads surgeons to suppress their symptoms and avoid seeking help for mental health issues. The article also tells the story of US surgeon and President of the Association of Academic Surgery Carrie Cunningham, who has lived with depression, anxiety and a substance abuse disorder for many years.
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News ArticleA private healthcare provider has been ordered to pay more than £1.5m – the largest fine issued for such a case – after pleading guilty in a criminal prosecution brought by the Care Quality Commission (CQC) over the death of a young woman at Cygnet Hospital Ealing in July 2019. It is the highest ever fine issued to a mental health service following a prosecution by the CQC. The firm pleaded guilty to one offence of failing to provide safe care and treatment, acknowledging failures to: provide a safe ward environment to reduce the risk of people being able to use a ligature; ensure staff observed people intermittently in line with the company procedures; and train staff to be able to resuscitate patients in an emergency. The offences related to the case of a young woman who was admitted to a ward in Cygnet Hospital Ealing in November 2018. In July 2019, she took her own life while on the ward. CQC said Cygnet Ealing had been aware the young woman tried to harm herself in an almost identical way four months earlier, but had failed to mitigate the known environmental risk she was exposed to. Read full story (paywalled) Source: HSJ, 21 September 2023
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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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News ArticleA London coroner has warned the health secretary that preventable child suicides are likely to increase unless the government provides more funding for mental health services. Nadia Persaud, the east London area coroner, told Steve Barclay that the suicide of Allison Aules, 12, in July 2022 highlighted the risk of similar deaths “unless action is taken”. In a damning prevention of future deaths report addressed to Barclay, NHS England and two royal colleges, Persaud said the “under-resourcing of CAMHS [child and adolescent mental health services] contributed to delays in Allison being assessed by the mental health team”. An inquest into Allison’s death last month found that a series of failures by North East London NHS foundation trust (NELFT) contributed to her death. In her report, Persaud said delays and errors that emerged in the inquest exposed wider concerns about funding and recruitment problems in mental health services. “The failings occurred with a children and adolescent mental health service which was significantly under-resourced. Under-resourcing of CAMHS services is not confined to this local trust but is a matter of national concern,” she said. Read full story Source: The Guardian, 14 September 2023
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Content ArticleOn 3 August 2022 an investigation was carried out into the death of Allison Vivian Jacome Aules. Allison was 12 years old when she passed away on the 19 July 2022. The investigation concluded at the end of the inquest on the 17 August 2023. The conclusion was that Allison died as a result of suicide, contributed to by neglect.
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Content ArticleThis policy paper sets out the Government's visions and aims to prevent self-harm and suicide, including the actions the government and other organisations will take to save lives. The strategy sets out the government’s ambitions over the next 5 years to: reduce suicide rates improve support for people who have self-harmed improve support for people bereaved by suicide. It includes steps and actions from across government and a wide range of organisations to achieve these ambitions with the ultimate aim to reduce the suicide rate over the next 5 years – with initial reductions in half this time.
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News Article
Suicide prevention drive launched in England amid concern for young people
Patient Safety Learning posted a news article in News
Ministers have vowed to reduce suicide rates in England with the launch of more than 100 new initiatives amid particular concerns over rising deaths and self-harm among children and young people. The pledge to reverse the trends within two and a half years came as the government launched its first prevention strategy in more than a decade. In 2022, there were 5,275 suicides in England, equivalent to 10.6 suicides per 100,000 people, according to the Office for National Statistics. “While overall the current suicide rate is not significantly higher than in 2012, the rate is not falling,” a new government document says. “We must do all we can to prevent more suicides, save many more lives and ultimately reduce suicide rates.” It highlights how rates of suicide among children and young people have increased in recent years, despite being low overall, adding: “Urgent attention is needed to address and reverse these trends.” The new measures being launched will also aid other specific groups at risk of suicide, including middle-aged men, autistic people, pregnant women and new mothers. Steve Barclay, the health secretary, said: “Too many people are still affected by the tragedy of suicide, which is so often preventable. This national cross-government strategy details over 100 actions we’ll take to ensure anyone experiencing the turmoil of a crisis has access to the urgent support they need.” Read full story Source: The Guardian, 11 September 2023- Posted
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News Article
Trust told it ‘lacks skills or integrity’ to carry out suicides review
Patient Safety Learning posted a news article in News
A senior clinician has raised fundamental concerns about a trust’s probe into dozens of suicide cases, which was sparked by his allegations that staff had tampered with the notes of a patient. Cambridgeshire and Peterborough Foundation Trust announced in July there would be an internal review of 60 suicide cases dating back to 2017. But a key whistleblower told HSJ he fears it could be a “whitewash” and it should be carried by an external, independent investigator rather than led by the trust. The suicides review was prompted by allegations staff had added a care plan into the patient record of Charles Ndhlovu, a day after the 33-year-old had died by suicide in 2017. The allegations, not contested by the trust, were based on the findings of an internal investigation in 2021 of the trust’s conduct around Mr Ndhlovu’s case. Read full story (paywalled) Source: HSJ, 6 September 2023- Posted
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News ArticleMedical neglect and “gross failures” by a mental health trust contributed to the suicide of a 12-year-old girl in a case that has highlighted national concerns about underfunding, a coroner has ruled. Allison Aules from Redbridge, in north-east London, died in July last year after her mood changed completely during the Covid lockdown, her family told the inquest at an east London coroner’s court. At the conclusion of the inquest, the area coroner Nadia Persaud highlighted a series of failures by North East London NHS foundation trust (NELFT) that contributed to her death. In a narrative verdict she ruled it was a “suicide contributed to by neglect”. Persaud also said failures in Allison’s care raised wider national issues about under-resourcing and “outstanding concerns” about the lack of consultant psychiatrists. These will be addressed later in a prevention of future deaths report. Persaud told the court: “There are national concerns around children and adolescent mental health services … and I’m also going to write a report at the national level to reduce the risk of this happening again.” Persaud said Allison’s case showed “both operational failures of individual practitioners and systemic failings on behalf of the trust”. She added: “This was on a backdrop of a very under-resourced service.” Read full story Source: The Guardian, 17 August 2023
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Content ArticleAt the beginning of 2023, The Jordan Legacy launched a new strategy designed to raise the bar in terms of collective ambition in suicide prevention and to plot a course of collective practical action that can realise that ambition. This report is the first in a series summarising what is emerging from this action research project, as well as the organisation's wider, ongoing action learning initiatives, focusing on reducing the number of suicides in the UK. The researchers asked people affected by suicide to provide responses to two key questions: How can we significantly reduce the annual number of suicides in the UK, from the 6000+ level it’s been at for 15 years? How far can we go?
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Mum fears NHS trust cover-up over Cambridgeshire suicides review
Patient-Safety-Learning posted a news article in News
The mother of a woman who took her own life weeks after being discharged from a mental health ward fears a "culture of cover up" within the NHS trust. Hannah Roberts, 22, died by suicide in 2018 and her mother Sally said there were "discrepancies" in the accounts of the talented musician's discharge. She feels an ongoing internal review into all Cambridgeshire & Peterborough NHS Foundation Trust (CPFT) suicides since 2017 should be independent. CPFT did not respond to her comments. The trust's chief executive Anna Hills previously said the internal review into 63 suicides would "be an important piece of work". Its announcement came after the trust was accused of adding to the records of Charles Ndhlovu, 33, the day after he took his own life to, in his mother's words, "correct their mistakes". Read full story Source: BBC News, 15 August 2023 -
News ArticleMinisters are backing a potentially “dangerous” new model allowing police to reduce their response to mental health incidents after failing to formally assess the risk of harm or death. Officials are monitoring any “adverse incomes” from the National Partnership Agreement, which will see police forces stop attending health calls unless there is a safety risk or a crime being committed. Policing minister Chris Philp said a pilot by Humberside Police gave him confidence in national roll-out, which aims to “make sure that people suffering mental health crisis get a health response and not a police response”. Mental health charities and experts have warned the plans could be “dangerous”, and a coroner raised the alarm following a woman’s suicide after police failed to respond to her disappearance. A report published last month said action was needed to prevent future deaths, warning that the new model could “allow each agency to regard such a situation as the other’s responsibility, whilst nobody is on the ground attempting to retrieve a seriously ill patient”. Read full story Source: The Independent, 26 July 2023
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Content ArticleAt the time of her death, Heather Findlay, aged 28 years, was in the care of the East London Foundation Trust (ELFT), detained under section 2 of the Mental Health Act at Mile End Hospital. At approximately 3pm on 11 June 2020, she was on s17 escorted leave, standing with a healthcare assistant (HCA) at the front gates of the hospital having a cigarette, when she turned to the HCA, said “I’m sorry I have to do this to you” and ran away. ELFT contacted the Metropolitan Police Service (MPS) at 3.17pm, but by 3.58pm, Ms Findlay had been found by a member of the public in a nearby park. At inquest, the jury came to a conclusion of death by suicide and giving a medical cause of death of: 1a hypoxic ischaemic encephalopathy 1b sodium nitrate toxicity.
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NHS trust to review all suicides since 2017
Patient Safety Learning posted a news article in News
The deaths of dozens of people who took their own lives while patients of an NHS trust will be reviewed after concerns were raised. Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) will review all 63 suicides since 2017. It comes after the trust was accused of adding to the records of Charles Ndhlovu, 33, the day after he took his own life to "correct their mistakes". Mr Ndhlovu, who was diagnosed with paranoid schizophrenia and substance misuse, had been under CPFT's care for two months when he died in Ely in 2017. Last month, his mother Angelina Pattison, from Newmarket, Suffolk, told the BBC his care plan "was done when he died - when they were running around to correct their mistakes, which they have done". Read full story Source: BBC News, 25 July 2023- Posted
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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.- Posted
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