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Community Post
Are you currently working on an inpatient mental health ward in the UK?
AmaniKrayem posted a topic in Calls for research/funding opportunities
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Are you currently working on an inpatient mental health ward in the UK? We would like to learn about how you feel towards restrictive practices on mental health wards. Go to https://tinyurl.com/restrictivepractices to find out more.
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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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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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Content ArticleToo many women are dying from disadvantage in one of the poorest parts of England, according to ground breaking new research which serves as an urgent wake-up call for levelling up efforts. The report by Agenda Alliance and Changing Lives, Dismantling disadvantage has found that in 2021 a woman in the North East of England was 1.7 times more likely to die early as a result of suicide, addiction, or murder by a partner or family member than in the rest of England and Wales. Today’s new research was conducted to better understand the lives and needs of disadvantaged women in the North East, including Newcastle, coastal areas and Gateshead and Sunderland; some of the poorest regions in the country. Working with women with lived experience at every stage, the study involved 18 in-depth interviews, 47 survey responses; focus groups; data analysis and multiple meetings with affected women, practitioners and policy makers.
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Content ArticleA number of serious concerns were raised about the University Hospitals Birmingham NHS Foundation Trust, relating to patient safety, governance processes and organisational culture. The Trust has been under review by the Birmingham and Solihull Integrated Care Board (ICB), following a junior doctor at the trust, Dr Vaishnavi Kumar, taking her own life in June 2022. In response to these concerns, a series of rapid independently-led reviews have been commissioned at the Trust. A follow up report into concerns raised about University Hospitals Birmingham NHS Foundation Trust has now been published showing the progress made against the recommendations made in the clinical safety (phase 1) report. It also collates the evidence from phase 2 and 3 of the review and assesses how the lessons learned can at this point be incorporated into the recovery and development plan that the Trust is already progressing. It also takes account of any other concerns that have arisen or been communicated to the review team.
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Content ArticleMr Stevenson was a 63-year-old man who was a very respected and experienced Consultant Cardiologist and General Physician at Huddersfield Royal Infirmary, who resigned from his post in May 2022 to enter full retirement. On 6 May 2022 he was referred to the urology department for the investigation of possible prostate cancer, when a decision was also made to consult a private Consultant Urologist. In order to relieve his symptoms of prostatitis and to make him ready for an investigative biopsy, he was prescribed ciprofloxacin on the 19 May. He had no previous history of depression or mental health problems. Subsequently on the morning of 30 May 2022, Mr Stevenson left his home address on his own for his usual walk. He had not previously given any indications to his family for them to be concerned for him. At approximately 12.30pm his wife received a Facebook message from Mr Stevenson to indicate that he had left a note under the pillow of his bed. The note was found to be uncharacteristically confused and illogical given his reference to his baseless concerns that he may have developed AIDs after taking a HIV tester kit he had previously bought on line. Mr Stevenson was found hanging nearby. Upon the arrival of the paramedics, although resuscitative attempts were made, it was confirmed that he had passed away. During the inquest the coroner was referred by Mr Stevenson’s treating urologist to published literature relating to ciprofloxacin and quinolone antibiotics and a potential rare link to suicide behaviour in patients; although it remained unclear that he was suffering from this side effect, it remained possible for this to be the case.
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Content Article
Attention deficit hyperactivity disorder (ADHD) is a condition that affects people's behaviour. It has a wide range of symptoms and can affect both children and adults—people with ADHD may find it hard to focus on or complete tasks, feel restless or impatient, experience impulsiveness and find it hard to organise their time and their things.[1] ADHD can have devastating mental health implications and research studies have linked ADHD to increased suicide and mortality rates. This means that being unable to access effective treatment can be a patient safety risk for people with ADHD. In this blog, Lotty Tizzard, Patient Safety Learning’s Content and Engagement Manager, explores the state of ADHD diagnosis and treatment in the UK. She looks at why many are concerned about the waiting times for adults and children seeking an ADHD assessment and speaks to Elsa*, who was diagnosed with ADHD in her 30s, about her experiences. *Name changed -
News Article
Record levels of self-harm found at Derbyshire women’s prison
Patient Safety Learning posted a news article in News
Inmates held in a women’s prison are making 1,000 calls a month to Samaritans amid record levels of self-harm, increased violence and low safety levels usually only seen in men’s facilities, a damning report has found. Nearly a third of women held at Foston Hall in Derbyshire, which holds 272 residents, told inspectors they felt unsafe, while the use of force in the prison has doubled over nearly three years and is the highest on the women’s prison’s estate. The women’s prison and youth offender institute is the first to be given a score of “poor” – the lowest – for the safety of female prisoners, since HM Inspectorate of Prisons developed its current framework more than a decade ago. Charlie Taylor, HM chief inspector of prisons, said the rating of “poor” for safety levels was a “rare and unexpected finding” in a women’s prison. Recorded levels of self-harm were also the highest in the women’s estate and two prisoners had taken their own lives since the last official inspection in February 2019, he said. “As an indicator of the level of distress, women were making 1,000 calls a month to Samaritans. The prison had no strategy to reduce self-harm or improve the care for those in crisis,” Taylor said. The response to women in crisis was too reactive, uncaring and often punitive, Taylor observed. “This, taken with other safety metrics and observation, meant it was no surprise that in our survey nearly a third of women told us they felt unsafe,” he said. The report also found that the majority of women who harmed themselves did not have enough support or activity and faced daily frustration in getting the help they needed. Read full story Source: The Guardian, 9 February 2022 -
News ArticleThe class B drug ketamine could help to treat people suffering from severe suicidal thoughts, a study has suggested. Researchers from the University of Montpellier in France said the sedative could save lives, as it appears to alleviate dark thoughts in patients admitted to hospital for their mental health. The finding was based on a controlled trial involving 156 adults with severe suicidal ideas, which ran from April 2015 to March 2019 in seven French teaching hospitals. The participants included people with bipolar disorder and major depressive disorder. However, patients with a history of schizophrenia were excluded from the study. Although the team found the side effects of ketamine were minor and had diminished by day four, they cautioned that more research was needed to examine its benefits. “Ketamine is a drug with a potential for abuse. Longer follow-up of larger samples will be necessary to examine benefits on suicidal behaviours and long term risks,” they wrote. Commenting on the study, Riccardo De Giorgi, a PhD student at the University of Oxford, said: "These findings indicate that ketamine is rapid, safe, and effective in the short term for acute care in hospitalised suicidal patients.” Read full story Source: The Independent, 4 February 2022 Ketamine for the acute treatment of severe suicidal ideation: double blind, randomised placebo controlled trial
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News Article
Survey of Americans who attempted suicide finds many aren’t getting care
Patient Safety Learning posted a news article in News
The number of people who try suicide has risen steadily in the U.S. But despite gains in health coverage, nearly half are not getting mental health treatment. Suicide attempts in the United States showed a “substantial and alarming increase” over the last decade, but one number remained the same, a new study has found: Year in and year out, about 40% of people who had recently tried suicide said they were not receiving mental health services. The study, published in JAMA Psychiatry, traces a rise in the incidence of suicide attempts, defined as “self-reported attempts to kill one’s self in the last 12 months,” from 2008 to 2019. During that period, the incidence rose to 564 in every 100,000 adults from 481. The researchers drew on data from 484,732 responses to the federal government’s annual National Survey on Drug Use and Health, which includes people who lack insurance and have little contact with the health care system. They found the largest increase in suicide attempts among women; young adults between 18 and 25; unmarried people; people with less education; and people who regularly use substances like alcohol or cannabis. Only one group, adults 50 to 64 years old, saw a significant decrease in suicide attempts during that time. Among the major findings was that there was no significant change in the use of mental health services by people who had tried suicide, despite the passage of the Affordable Care Act in 2010 and receding stigma around mental health care. Over the 11-year period, a steady rate of about 40%t of people who tried suicide in the previous year said they were not receiving mental health care, said Greg Rhee, an assistant professor of psychiatry at the Yale School of Medicine and one of the authors of the study. The Affordable Care Act, which took effect fully in 2014, required all health plans to cover mental health and substance abuse services, and also sharply reduced the number of uninsured people in the U.S. However, many respondents to the survey in the new report said the cost of mental health care was prohibitive; others said they were uncertain where to go for treatment or had no transportation. “It is a huge public health problem,” Dr. Rhee said. “We know that mental health care in the U.S. is really fragmented and complicated, and we also know not everybody has equal access to mental health care. So, it’s somewhat not surprising.” Read full story (paywalled) Source: New York Times,19 January 2022 -
News Article
NHS trust failings may have contributed to Bristol student’s death, inquest finds
Patient Safety Learning posted a news article in News
A string of failings may have contributed to the death of a “deeply vulnerable” law student who killed herself while being treated in a psychiatric hospital in Bristol, an inquest jury has said. Zoë Wilson, 22, had informed staff she was hearing voices in her head telling her to kill herself and 30 minutes before she died was seen by a nurse through an observation hatch looking frightened and behaving oddly but nobody went into her room to check her. Speaking after the jury’s conclusions, Wilson’s family said that Avon and Wiltshire mental health partnership NHS trust (AWP) should face criminal charges over the case. AWP said it accepted it had fallen short in its care of Wilson. Zoë on the 17 June 2019 she told staff she was hearing voices telling her to kill herself and handed over an item that she could have used to harm herself with. She was not moved to an acute ward and other items that she could have used were not removed. At 1am on 19 June she was observed standing beside her bathroom door looking frightened but staff did not go to her. Thirty minutes later she was checked again and had harmed herself. Emergency services were called but she was pronounced dead. Giving evidence to Avon coroner’s court, the nurse who saw Wilson at 1am said he had only worked in the unit a handful of times and had not met Wilson before that night. The jury concluded that steps taken to keep her safe that night had been inadequate and also criticised communication and information sharing. In a statement, her family, said: “Zoë was a wonderful, bright, and deeply vulnerable young woman. She was on a low-risk ward even when she told staff that voices in her head were telling her to kill herself.” They called for AWP to face a criminal prosecution by the Care Quality Commission (CQC). “We will continue to fight for justice in her name,” they said. “She will never be forgotten.” Read full story Source: The Guardian, 27 January 2022 -
News ArticleA vulnerable woman judged to be at medium risk of self harm was on a mental-health ward that catered for low-risk patients, an inquest heard. Zoe Wilson, 22, died on the Larch Ward at Bristol's Callington Road Hospital in June 2019 after being found unconscious in her room at 01.30 BST. She had previously told staff that voices were telling her to kill herself, her inquest heard. Healthcare assistant Sarah Sharma found her and immediately called for help. Addressing a jury inquest at Avon Coroners' Court, she said that "patients admitted to Larch should have all been low risk". This meant they would "preferably" have hourly observations by staff and be able to take their medication without any issues. Many were ready to be discharged and they were there because something was holding them up, normally housing, she said. The experienced healthcare assistant said if the patient's risk increased they should be placed under "one to one" monitoring with a member of staff until they were moved to a more suitable unit. The inquest heard earlier that Ms Wilson had been judged to be medium risk and was placed on 30-minute observations on 18 June. Her risk level was re-assessed when she handed a belt to staff and informed them voices were telling her to kill herself. Ms Sharma told the court that she was on her first overnight shift in two and a half weeks that night, and was informed in a handover that Ms Wilson was at risk of self-harming. Having never met Ms Wilson - who had schizophrenia - she queried what kind of self-harm the patient was at risk of but said the nurse performing the handover told her he "didn't know". Ms Sharma told the inquest she was unaware of the belt incident or that Ms Wilson had not been sleeping well and had requested medication to calm her down. Read full story Source: BBC News, 24 January 2022
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News Article
GPs should regularly review self-harm patients, says draft NICE guidance
Patient Safety Learning posted a news article in News
GPs should regularly review self-harm patients and offer a specific CBT intervention, according to a consultation on the first new guidance for self-harm to be drawn up in 11 years. The new draft guidance emphasises the importance of referring patients to specialist mental health services, but stresses that, for patients who are treated in primary care, continuity is crucial. If someone who has self-harmed is being treated in primary care, GPs must ensure regular follow-up appointments and reviews of self-harm behaviour, as well as a medicines review, the draft guideline say. They must also provide care for coexisting mental health issues, including referral to mental health services where appropriate, as well as information, social care, voluntary and non-NHS sector support and self-help resources. The guidance says that referring people to mental health services would ‘ensure people are in the most appropriate setting’. However, the committee agreed that ‘if people are being cared for in primary care following an episode of self-harm, there should be continuity of care and regular reviews of factors relating to their self-harm to ensure that the person who has self-harmed feels supported and engaged with services’. The draft guidance, out for consultation until 1 March, also says ambulance staff should suggest self-harming patients see their GP to maximise the chance of engagement with services. It says: ‘When attending a person who has self-harmed but who does not need urgent physical care, ambulance staff and paramedics should discuss with the person (and any relevant services) if it is possible for the person to be assessed or treated by an appropriate alternative service, such as a specialist mental health service or their GP.’ It notes that ‘ambulance staff often felt that the emergency department was not the preferred place that the person who had self-harmed wanted to be taken. They agreed that referral to alternative services could facilitate the person’s engagement with services’. Read full story Source: Pulse, 18 January 2022 -
News ArticleA 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
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News ArticleAround 80% of adolescents who died by suicide or who had self-harmed had consulted with their GP or a practice nurse in the preceding year, shows new research. The large study of 10 to 19-year-olds between 2003 and 2018, published in the Journal of Child Psychology and Psychiatry, also puts forward a series of proposals to deal with the problem. The study, funded by the NIHR Greater Manchester Patient Safety Translational Research Centre (NIHR GM PSTRC), a partnership between The University of Manchester and The Northern Care Alliance NHS Foundation Trust (NCA). It showed that 85% who later took their own lives consulted with their GP or a practice nurse at least once in the preceding year; the equivalent figure was 75% for those youngsters who harmed themselves non-fatally. Lower than expected rates of diagnosis of psychiatric illness, around a third in both groups, were probably down to a lack of contact with mental health services, rather than an absence of psychiatric illness, argue the research team. Depression was by far the commonest of the examined conditions among both groups, accounting for over 54% of all recorded diagnoses. Also, while suicide was more common in boys, non-fatal self-harm was more common in girls. Two-thirds of adolescents who died by suicide had a history of non-fatal self-harm. And while self-harm risk rose incrementally with increasing levels of deprivation, suicide risk did not. Read full story Source: The University of Manchester, 7 December 2021
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News ArticleSuicidal thoughts are three times as common in those living with a spinal cord injury in the UK, according to new research And yet, it’s estimated that only one third of people living with a spinal cord injury (SCI) are getting access to mental health support, and of those, 68% do not feel that support services available are able to meet their needs. These alarming statistics are taken from a new report, ‘It’s not just physical’ which was presented to parliament yesterday (17 November). The report shines a light on the mental health problems faced by people with spinal cord injuries in the UK today. It's calling on the NHS, government and other health policy makers to provide better mental health support services for people with spinal cord injuries – and their unpaid carers – as a matter of urgency. Nik Hartley, Spinal Injuries Association CEO said: “We are at risk of failing thousands of people in the UK living with a spinal cord injury. Our new report highlights that psychological damage caused by a SCI is, at best, considered as an afterthought, and at worst, completely ignored by the medical profession. We need urgent action and for services to be sufficiently specialised to support the thousands of people living with this type of injury before it is too late.” Read full story Source: Spinal Injuries Association, 17 November 2021
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News Article
Patient kills herself on Glasgow hospital ward after 'failure in communication'
Patient Safety Learning posted a news article in News
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 -
News Article
NHS must review ‘all disciplinary procedures’ by March following nurse’s suicide
Patient Safety Learning posted a news article in News
Trusts have been urged to reflect on their disciplinary procedures, and review them annually where required, following the death of a senior nurse who took his own life after being dismissed. NHS England’s chief people officer Prerana Issar has written to trust leaders to highlight Imperial College Healthcare Trust’s new disciplinary procedures, which were put in place following Amin Abdullah’s suicide. Mr Abdullah, a senior nurse at Charing Cross Hospital in west London, was suspended in September 2015 before being let go from his job that December. He died in February 2016 after setting himself on fire. An independent investigation criticised both the trust and its staff and concluded he had been “treated unfairly”. The summary report produced by the trust was labelled a “whitewash”, which “served to reassure the trust that it had handled the case with due care and attention”, and the delay of three months between the events and hearing were “troubling”. The report, which also criticised the delays as “excessive” and “weak” in their justification, said Mr Abdullah found the delay “stressful” and caused him to become “distressed”. In the letter sent on Tuesday, seen by HSJ, Ms Issar said: “The shared learning from Amin’s experience has demonstrated the need for us to work continuously and collaboratively, to ensure that our people practices are inclusive, compassionate and person-centred, with an overriding objective as to the safety and wellbeing of our people… our collective goal is to ensure we enable a fair and compassionate culture in our NHS. I urge you to honestly reflect on your organisation’s disciplinary procedure…" Read full story (paywalled) Source: HSJ, 3 December 2020 -
News Article
CQC orders staffing and safety improvements at trust scrutinised over deaths
Patient Safety Learning posted a news article in News
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 -
News ArticleA fourth suspected suicide has occurred at a mental health trust which was recently warned by the Care Quality Commission after three other similar inpatient deaths in quick succession, HSJ can reveal. All four deaths at Devon Partnership Trust had common themes, including the use of ligatures, and occurred amid a year-long delay to the trust’s plan to reduce ligature risks. Figures obtained by HSJ under freedom of information laws also reveal the trust took nearly a year to investigate the first two deaths. The target is 90 days. The trust told HSJ it had faced “humongous” problems addressing ligature risks and had been too “patient” with another trust which was helping to investigate the deaths. Read full story (paywallled) Source HSJ, 27 October 2020
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News Article
Covid: Lockdown had 'major impact' on mental health
Patient Safety Learning posted a news article in News
Lockdown had a major impact on the UK's mental health, including increased rates of suicidal thoughts, according to new research. The study, led by the University of Glasgow, examined the effects of COVID-19 during the height of the pandemic. Certain groups are said to be particularly at risk, including young people and women. This publication is the most detailed examination of how the UK's adult population coped during the first weeks of lockdown, when people were given strict orders to stay home. Researchers say public health measures, like lockdowns, are necessary to protect the general population, but warn they may have a "profound and long-lasting" effect on mental health and will extend beyond those who have been affected by the virus. The study, published in the British Journal of Psychiatry, looked at three blocks of time between March 31 and May 11. Just over 3,000 adults in the UK were surveyed and a range of mental health factors were considered, including depression, loneliness, suicide attempts and self-harm. The study found suicidal thoughts increased from 8% to 10% and they were highest among young adults (18-29 years), rising from 12.5% to 14%. The researchers say that, even though those are relatively small rises, they are significant because of the short period of time they happened over. "The majority of people did not report any suicidal thoughts, but this creeping rise over a very short period of time is a concern," says Prof Rory O'Connor, chair in health psychology at the University of Glasgow's Institute of Health and Wellbeing. Read full story Source: BBC News, 21 October 2020 -
News Article
Trust ‘reviewing hundreds of patients’ after failings discovered
Patient Safety Learning posted a news article in News
The suicide of a woman with severe mental illness has prompted a review into the care of hundreds of other patients, according to her family. Frances Wellburn, 56, was under the care of Tees, Esk and Wear Valley Foundation Trust’s community mental health team in York, which before the coronavirus pandemic had categorised her as “medium risk”. This meant she should have had regular contact from the service, but an internal serious incident report into her death, seen by HSJ, found no contact was made with her for three months. In June 2020 she required admission to an inpatient unit for three weeks, but she deteriorated again after being discharged and took her own life in August. Her family have said Ms Wellburn was making a “good recovery” from episodes of psychosis prior to the pandemic, but the lack of support in the spring of last year had contributed to a major deterioration in her condition. According to sister, Rebecca Wellburn, the trust’s director of nursing Elizabeth Moody confirmed in a meeting with the family that a wider review had now been launched into the care of hundreds of patients under its York-based community services. Read full story Source: HSJ, 28 April 2021 -
News Article
Review into series of ‘unexpected deaths’ identifies service shortcomings
Patient Safety Learning posted a news article in News
A review sparked by the ‘unexpected’ deaths of 13 patients has found several shortcomings in the talking therapy services offered by a mental health trust. The internal review at Tees, Esk and Wear Valleys Foundation Trust followed a series of deaths between October 2019 and September 2020. The trust has said the key findings included a lack of family involvement in discussing risks, increased waiting times for face-to-face therapy, and a lack of contact or reassessment for patients on waiting lists. Eight of the 13 deaths, six of which were suicides, were escalated to serious incident reviews, according to a freedom of information response received by HSJ. However, when asked for the findings of the serious incident reviews, the trust said: “To break down the key issues and attribute any single one of them to an individual patient death would in itself lead to potentially identifying that person.” The trust’s improving access to psychological therapies service assessed 11,839 people between October 2019 and September 2020. It comes amid a series of separate investigations into concerns around the trust’s services. Read full story (paywalled) Source: HSJ, 13 April 2021 -
News ArticleA 40-year-old mother of four took her own life at an NHSmental health unit after multiple opportunities were missed to keep her safe, an inquest has found, prompting her family to call for a public inquiry. Azra Parveen Hussain was allegedly the seventh in-patient in seven years to die by the same means while in the care of Birmingham and Solihull Mental Health NHS Foundation Trust (BSMHT). Despite this, an inquest at Birmingham and Solihull Coroner’s Court last week heard that the Trust had not installed door pressure sensor alarms, which could have potentially alerted staff to the fatal danger these patients faced. While BSMHT is now taking action to install pressure sensors at Mary Seacole House, where Hussain died on 6 May, Coroner Emma Brown noted a lack of national regulation or guidance on the risks presented by internal doors in patients’ bedrooms and is issuing a Prevention of Future Deaths report calling for this to be remedied across the country. Read full story Source: The Independent, 28 March 2021
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News Article
Suicide inquest sparks warning on 'nine month wait' for treatment
Patient Safety Learning posted a news article in News
The government has been called on to take action over the national “backlog” for a specialist mental health service after a woman died after a substantial wait to access treatment. Carole Mitchell, who died by suicide on 22 November 2019, waited almost seven months for a first appointment after being referred to Greater Manchester Mental Health Foundation Trust for psychology services. In a prevention of future deaths report, published earlier this month, coroner Alison Mutch said the inquest was told waits had since increased and “someone in Mrs Mitchell’s position today would be more likely to wait nine months”. The coroner added evidence heard suggested the delay experienced was “reflective of both the regional and national backlog for appointments”. The report has been sent to both the Department of Health and Social Care and Greater Manchester Health and Social Care Partnership. Read full story (paywalled) Source: HSJ, 1 March 2021
