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Found 84 results
  1. News Article
    A police investigation into maternity services at two hospitals has started interviewing current and former members of staff. West Mercia Police began the inquiry in June 2020, while a review by senior midwife Donna Ockenden was ongoing - Ockenden would eventually find there had been catastrophic failings at the Shrewsbury and Telford Hospital Trust. The police investigation was set up to explore whether there was evidence to support a criminal case against the trust or any individuals involved. The hospital trust said it recognised it was important people get "the answers they have waited for" and that it was fully cooperating with police. The Ockenden inquiry examined maternity practices at Shrewsbury and Telford NHS Trust over a period of 20 years. Initially set up to examine 23 cases, it was widened to include almost 1,600 cases where there were concerns over maternity care. It found the failures may have led to the deaths of more than 200 babies, nine mothers and left other infants with life-changing injuries. Hundreds of the cases have been examined by police officers involved in Operation Lincoln. The senior officer in the police investigation, Supt Carl Moore, said the start of staff interviews represented a new phase. "We are committed to ensuring that the families involved are fully informed at each stage of our enquiries," he said. Read full story Source: BBC News, 19 June 2025
  2. News Article
    A hospital trust and a staff member have been found guilty of health and safety failings over the death of a young woman in a mental health unit. Alice Figueiredo, 22, was being treated at Goodmayes Hospital, east London, when she took her own life in July 2015, having previously made many similar attempts. Following a seven-month trial at the Old Bailey, a jury found that not enough was done by the North East London Foundation NHS Trust (NELFT) or ward manager Benjamin Aninakwa to prevent Alice from killing herself. The trust was cleared of the more serious charge of corporate manslaughter, while Aninakwa, 53, of Grays in Essex, was cleared of gross negligence manslaughter. The jury deliberated for 24 days to reach all the verdicts, setting a joint record in the history of British justice, according to the Crown Prosecution Service (CPS). Both the trust and Aninakwa were convicted under the Health and Safety at Work Act. It was only the second time an NHS trust has faced a corporate manslaughter charge. During the trial, prosecutors said that not only was Alice repeatedly able to self-harm while she was in hospital, but that these incidents were not properly recorded or assessed. The court also heard there were concerns about Benjamin Aninakwa's communication, efficiency, clinical and leadership skills. The trust had previously placed him on a performance improvement plan for three years, which ended in December 2014. In addition, there was a high turnover of agency staff on the ward, the court heard. Mrs Figueiredo says she raised concerns about her daughter's care verbally and in writing on a number of occasions to the hospital and to Mr Aninakwa. After Alice died, she said the family found it very difficult to get answers about what happened. For nearly a decade they gathered evidence and pressed both the police and the CPS to take action. Read full story Source: BBC News, 9 June 2025
  3. News Article
    A computer file containing the details of cases linked to the NHS’s largest maternity scandal was “intentionally” and “maliciously” deleted, a police investigation has found. Nottinghamshire Police launched a probe earlier this year after records held by Nottinghamshire University Hospitals Foundation Trust (NUH) and linked to the alleged maternity failings were temporarily lost. The data was later recovered and 300 more cases are expected to be added to the inquiry into the scandal after a discrepancy was noted by a coroner. NUH is currently being investigated for potential corporate manslaughter after The Independent revealed babies had died or suffered serious injuries at its maternity units. The investigation into the deleted hospital data is not related to the corporate manslaughter probe. The trust is also the subject of an inquiry led by top midwife Donna Ockenden, who is investigating the cases of 2,400 families who experienced maternity care at the trust, including deaths and injuries. Read full story Source: The Independent, 10 June 2025
  4. News Article
    Police have launched an investigation into the deaths of patients following heart operations at an NHS hospital, the BBC has learned. Documents seen suggest patients suffered avoidable harm - and that in some cases their death certificates failed to disclose that the procedure contributed to their deaths. One woman's operation at Castle Hill Hospital near Hull - that should have taken no more than two hours - has been described as a "disaster" by one medic. She spent six hours in surgery and lost five litres of blood - all while under local anesthetic. But none of this was mentioned on her death certificate, which recorded her as dying from pneumonia. Her family were also not told what had happened. The documents raise concerns about the care that 11 patients received during a TAVI - Transcatheter Aortic Valve Implant - a procedure to replace a damaged valve in the heart, similar to adding a stent. The department's TAVI mortality rate at the time was three times higher than the UK average, something patients and families were also unaware of. The NHS body that runs Castle Hill, the Humber Health Care Partnership, told the BBC it had delivered improvements suggested by the Royal College of Physicians (RCP). In a statement, it said it was happy to directly answer any questions from the patients' families. Read full story Source: BBC News, 4 June 2025
  5. News Article
    Plans for NHS staff to restrain and detain people experiencing a mental health crisis, instead of the police doing so, are “dangerous”, doctors, nurses and psychiatrists have warned. The former prime minister Theresa May has proposed legislation in England and Wales that would change the long-established practice for dealing with people who may pose a risk to themselves or others because their mental health has deteriorated sharply. But a coalition of eight medical groups, ambulance bosses and social work leaders said the switch would put mental health staff at risk and damage their relationship with vulnerable patients. The row has echoes of the controversy stirred by the Metropolitan police’s decision in 2023 to stop responding to 999 calls involving mental ill health unless they involved a threat to life. The force said the change meant officers were attending crimes such as robberies faster, but mental health groups said they feared it could result in deaths. May and two ex-health ministers, Syed Kamall and Frederick Curzon, have tabled amendments to the mental health bill going through parliament which, if passed, would lead to mental health nurses, psychiatrists or other doctors being called out to restrain and detain someone under the Mental Health Act. Those professionals would each become an “authorised person” who is allowed to detain someone under the act. But in a joint statement on Monday the eight groups said the risks posed by someone in a mental health crisis meant police officers must continue to always attend. The groups include the Royal College of Psychiatrists, the Royal College of Nursing and the British Medical Association. The groups said: “Removing police involvement entirely has hugely dangerous implications, as entering someone’s home without permission is fraught with huge risks and is only currently done with the assistance of police intelligence. Without this, professionals may be entering homes without police help and therefore lacking crucial intelligence that could ensure their safety.” Read full story Source: The Guardian, 26 May 2025
  6. News Article
    A trust is being investigated for manslaughter in relation to the death of three patients, HSJ has learned. HSJ understands the three patients died by suicide while inpatients at Leicestershire Partnership Trust’s Bradgate Unit, in Glenfield Hospital, between September 2020 and July 2021. Leicestershire Police confirmed it was investigating “offences relating to corporate manslaughter and gross negligence manslaughter” in relation to the deaths. A police spokesperson told HSJ: “The investigation remains ongoing. No charges have been brought at this time.” The trust said: “Leicestershire Partnership Trust is fully cooperating with the police. We are unable to comment any further while the investigation is ongoing.” It comes as an employment tribunal brought by Mariam Benaris, previously a consultant at the unit, who is alleging wrongful dismissal, has heard concerns about safety on the unit during the peaks of the pandemic. Dr Benaris told the tribunal she and other staff raised concerns with trust leaders and a healthcare regulator about unsafe practices at the Beaumont Ward of the Bradgate Unit at that time. The ward was being used for all new admissions as part of infection control procedures. Read full story (paywalled) Source: HSJ, 2 May 2025
  7. News Article
    Drugs for diabetes, cancer, epilepsy and mental illness are being denied to people held in police cells after they are arrested, according to a shocking new report. Suspects detained in custody suites are even having emergency care withheld as a “form of punishment”, according to the study shared exclusively with The Independent. The report has sparked calls for healthcare for those in custody to be brought under the remit of the NHS, amid claims that basic standards are not being met by the private companies that currently provide it. Deborah Coles, chief executive of the charity Inquest, which represents families whose loved ones have died in custody, said the report is “deeply concerning” and urged ministers to respond before the situation results in “catastrophe”. “This is about the denial of life-protecting medication,” she said. “There is the ever-present risk of death and harm. It shines a light on the standards of healthcare in police custody suites. “This report lays bare many of the concerns Inquest has had for decades around the standards of care afforded to detainees in police custody. The reality of this, denying people medication that is life-protecting, does hold the risk of death and serious harm.” Read full story Source: The Independent, 30 April 2025
  8. News Article
    Drugs for diabetes, cancer, epilepsy and mental illness are being denied to people held in police cells after they are arrested, according to a shocking new report. Suspects detained in custody suites are even having emergency care withheld as a “form of punishment”, according to the study shared exclusively with The Independent. The report has sparked calls for healthcare for those in custody to be brought under the remit of the NHS, amid claims that basic standards are not being met by the private companies that currently provide it. Deborah Cohen, chief executive of the charity Inquest, which represents families whose loved ones have died in custody, said the report is “deeply concerning” and urged ministers to respond before the situation results in “catastrophe”. “This is about the denial of life-protecting medication,” she said. “There is the ever-present risk of death and harm. It shines a light on the standards of healthcare in police custody suites. “This report lays bare many of the concerns Inquest has had for decades around the standards of care afforded to detainees in police custody. The reality of this, denying people medication that is life-protecting, does hold the risk of death and serious harm.” Read full story Source: The Independent, 21 April 2025
  9. News Article
    The NHS trust that failed to stop the killer behind the Nottingham attacks in June 2023 has been accused of failing other victims. It was a sunny morning in June 2023 as news broke that a major incident had been declared in Nottingham. As the hours went by it emerged three people had been stabbed. Students Barnaby Webber and Grace O'Malley-Kumar had been walking home from a night out when they were fatally attacked. School caretaker Ian Coates was heading into work when he was killed. When he heard the news, Delvin Marriott, says he knew instinctively that the killer of Barnaby, Grace, and Ian would turn out to be a mental health patient and blames the loss of his brother on the same system that allowed paranoid schizophrenic Valdo Calocane to be out on the streets armed with a knife. In August 2022, Delvin's brother, Rudi Marriott, stabbed his father 75 times in a frenzied attack at home in Nottingham. The family says they had repeatedly called the police and mental health services about Rudi's violence but their warnings were ignored. A recent NHS report found that in the four years before Calocane carried out his attacks there were 15 incidents of patients either under the current care of the Nottinghamshire Healthcare NHS Trust or who had been discharged perpetrating serious violence towards members of the community. Most of the incidents involved stabbings and three cases resulted in fatalities. Neil Hudgell, a lawyer representing the families, says the public inquiry due to begin into the deaths of the Nottingham attack victims needs to ensure the trust is held accountable for failings. "I think we've seen tragic story after tragic story where patients, their families, and victims have been let down," he says. "We need to get to the bottom of why that happened, who's responsible for that and to have some genuine change." Read full story Source: Sky News, 17 March 2025
  10. News Article
    Police investigating the hospital where the nurse Lucy Letby worked have widened their inquiries to include gross negligence manslaughter by senior staff. Cheshire constabulary says it has expanded its inquiry into the Countess of Chester hospital despite growing questions around Letby’s convictions. The former nurse is serving 15 whole-life prison terms after being convicted of murdering seven babies and attempting to kill another seven. Police launched an investigation into corporate manslaughter and the actions of senior managers at the hospital after Letby’s original trial in October 2023. But the inquiry will now include gross negligence manslaughter by unnamed individuals. The Guardian understands this includes managers. Det Supt Paul Hughes, the senior investigating officer, said: “As our inquiries have continued, the scope of the investigation has now widened to also include gross negligence manslaughter. “This is a separate offence to corporate manslaughter and focuses on the grossly negligent action or inaction of individuals. “It is important to note that this does not impact on the convictions of Lucy Letby for multiple offences of murder and attempted murder.” Read full story Source: The Guardian, 13 March 2025
  11. News Article
    Two women who police allege practised as unregistered midwives have been charged with manslaughter after a baby died after a home birth on the New South Wales mid north coast. The women, aged 41 and 51, appeared in Coffs Harbour local court on Wednesday in relation to the newborn boy’s death in 2022. Emergency services were called to a home in Karangi, north-west of Coffs Harbour, when the baby was unresponsive after the home birth on 11 September 2022, NSW police said in a statement. Paramedics treated the baby before he was airlifted to Coffs Harbour base hospital where he died. Police allege the younger woman was an unregistered midwife at the time of the birth while the older woman held no medical qualifications and had been practising unregistered home-birth midwifery. Read full story Source: The Guardian, 13 March 2025
  12. Content Article
    In December 2022, Harry Vass died after experiencing Acute Behavioural Disturbance (ABD) and a complex disturbance in normal physiology.     In her first blog, Harry’s mother Julie told us about Harry and the events that preceded his death, during which he suffered with anxiety, addiction and psychosis. She talked about the inquest and how they learned of gaps in Harry’s care, that led the coroner to deem it an avoidable death.  In this second blog, Julie explains more about Acute Behavioural Disturbance and the changes she believes are needed to make sure patients like Harry are cared for appropriately.  Right after Harry was pronounced dead, a paramedic presented us with his belongings in a plastic hospital bag and we were sent home. We were told to ring the hospital bereavement office the following morning. We did so to be told that they didn’t have anything to do with coroner cases, so we knew then that Harry had been referred to the coroner. Our inquest was an article 2 inquest as Harry had died whilst detained under section 136 of the Mental Health Act and his liberty had been taken away for his own, and others, safety. This allows for the scope of the inquest to be slightly wider in exploring the issues prior to, and the cause, of death. The jury concluded that Harry had died of: “…sudden death, most likely as a result of terminal cardiac arrhythmia on a background of psychosis and recent cocaine use leading to an acute disturbance in behaviour and complex disturbance in normal physiology.” Acute Behavioural Disturbance is not a condition in its own right, so the term cannot be used on the death certificate as a standalone cause of death. As the coroner felt that this death was avoidable, a Prevention of Future Deaths Report was written and later a response was received from the Royal College of Nursing. What is Acute Behavioural Disturbance? Acute behavioural disturbance is an umbrella term used to describe a presentation which can include abnormal physiology and/or behaviour. Acute Behavioural Disturbance has previously been called excited delirium, acute behavioural disorder, or agitated delirium. The below represent signs which may be present in Acute Behavioural Disturbance - one or more may be present. Agitation Constant physical activity Bizarre behaviour (incl. paranoia, hypervigilance) Fear, panic Unusual or unexpected strength Sustained non-compliance with police or ambulance staff Pain tolerance, impervious to pain Hot to touch, sweating Rapid breathing Tachycardia.[1] Although the term Acute Behavioural Disturbance has been used over a long period, it is still not consistently known, used or understood across different professional groups. Seven key areas for change Throughout the last two years we have become more aware of the gaps in Harry’s care and support in the lead up to his death. I believe focusing on the seven areas below would help to prevent future deaths. 1. Raising awareness and understanding Making sure that healthcare professionals working in emergency departments and mental health units (especially those caring for acutely ill patients) receive training and education in Acute Behavioural Disturbance. This must include nurses who are the professionals most likely to detect physical changes in a patient’s condition. 2. Consistent terminology Although much has been published since Harry’s death, there is procrastination over terminology used to describe this presentation. There should be collaboration on immediate actions needed, using agreed reference terms, for example; “physiological disarray with psychosis, particularly following the use of illicit drugs”. The simple addition of a few words to training policies and packages could be very powerful in saving lives. 3. Collaborative guidance The National Institute for Health and Care Excellence, the Royal College of Nursing, Royal college of Psychiatrists and Royal College of Emergency Medicine need to agree on the wording of appropriate policies to guide and educate professionals facing this presentation. It is essential to bring nurses to this forum as they have previously been excluded. 4. Post-mortem training The Royal College of Pathologists/ Forensic Pathologists could think about training and education for those undertaking post-mortems for these patients. Knowing what to look for and finding evidence is extremely difficult. In our case, we were told that Harry had previously damaged heart muscle caused by illicit drugs which was not the opinion of the expert witness. 5. Data collection and coding NHS England should have the coding reviewed/ adjusted. “Psychosis with physiological disarray with or without illicit drug use“ (or similar wording) should be available as a coding choice for clinicians and coders. This would allow for proper data capture for these presentations in the NHS. 6. Monitoring of prevention of future deaths reports I believe there should be an overarching body to monitor prevention of future deaths reports, and the responses to these. This body should support any learning and the required remedial actions within appropriate timeframes. It should hold organisations accountable for investment and implementation of remedial plans and ongoing measurement of agreed set outcomes. 7. Research and early intervention We need more research to fully understand those at risk of the presentation of Acute Behavioural Disturbance and why. Early warning signs would then be identified and recommendations made for care pathway interventions for better outcomes. What else can healthcare professionals do? Simply be aware of patients presenting with psychosis, particularly with a history of illicit drug use and previous mental health difficulties. Patients with extreme and prolonged agitation can become physically unwell leading to the medical emergency of cardiac arrhythmia and arrest. Take frequent basic physical observations to be alerted to any changes in physical condition. Healthcare professionals already have training and policies on dealing with a deteriorating patient should a change be detected. What else can Trusts do? Make sure relevant staff receive training, education and support in Acute Behavioural Disturbance. Patients taking illicit drugs who may have mental health issues already should be offered support at the earliest possible opportunity to avoid an escalating situation. Drug and alcohol liaison teams working in emergency departments is good practise and can offer clear pathways to support for these patients. Consider partnership working with wider public services to improve mental health support – Avon and Somerset Constabulary have made changes including working with the ambulance service. Trusts should be proactive in providing an appropriate environment for the care and safety of the patient, staff and other patients. An appropriate environment also avoids the potentially discriminatory actions of removing a patient from a busy emergency department because they are disruptive, without proper examination and care. There is a conflict of interest in offering a family a duty of candour when care doesn’t go to plan, and the need to protect the Trust from potential litigation. We found this so frustrating as it meant that what happened to Harry was not fully shared and understood until the inquest some 18 months after his death. I’m not sure how this could be addressed but it’s a wider issue for Trusts to consider. Our family would have felt far less stressed and emotionally exhausted if we had been told more of the facts and what had not gone to plan at an earlier point. Support and advice for other families Over the weeks and months leading up to the inquest there were periods of so much activity that I found it helpful to write a journal. Journal keeping allowed for thoughts to be put down on paper and “parked” but it has also proved to be good for checking back on dates and events. I would recommend keeping a journal to anyone in a similar position. On the good side, there were people and organisations that we were so grateful for and would highly recommend having their support and input. We would not have made it through this period without them. The Mental Health NHS Trust had a Family Liaison Officer who was able to field our questions, update us on issues such as the serious incident investigation and organise meetings with professionals at which she would support us. I don’t know if this is common practice, but we had clear benefit from this role. We found our way to INQUEST, a charitable organisation which supports families like us through the inquest process. We had our own case worker who was amazing at supporting us in both practical ways as well as giving us valuable information and guidance. We really felt we were not alone as she checked on us regularly. She assisted in the appointment of lawyers and a barrister for the inquest and was able to respond to our questions which were many given we had never been in this situation before. We still have contact now. Final thoughts Since Harry’s death there have been further deaths in hospitals with very similar stories to Harry’s. There is a general feeling that there has been an increase of cases. Use of cocaine and illicit drugs, increase of poor mental health in the population and a developing awareness of this presentation are possible associated factors. We have looked at other recent prevention of future deaths reports to find that Acute Behavioural Disturbance is mentioned fairly consistently. Our concern is that these reports are either not responded to, or are responded to inadequately and no effective action is taken. There is no body responsible for the oversight of these reports and to hold those organisations who can effect change to account. Our lives have changed for ever now. We try not to be angry as we know that no one intended for this to happen. We do want learning to be taken away from this unthinkable event in the hope that something similar will not happen to other families, this is so important to us. [1] Royal College of Emergency Medicine, October 2023. Acute Behavioural Disturbance in Emergency Departments (version 2). Share your insights Do you have insights to share around patient safety? Could your experiences help guide improvements? Or perhaps you're a healthcare professional making changes to reduce risk to patient safety? If you would like to contribute, please comment below (you'll need to sign up here first for free) or contact the editorial team at [email protected]. Related reading Harry’s story: Acute Behavioural Disturbance Prevention of future deaths report: Harry Vass (13 June 2024) Mental Health improvements and initiatives implemented in Avon & Somerset Constabulary Consensus on acute behavioural disturbance in the UK: a multidisciplinary modified Delphi study to determine what it is and how it should be managed (9 May 2023) INQUEST: Skills and support toolkit Acute behavioural disturbance: a physical emergency psychiatrists need to understand (14 October 2020)
  13. Content Article
    Harry Vass was a 24yr old, he had a history of ADHD, poor mental health, psychosis, paranoia secondary to recreational drug use and illicit drug dependency including cocaine.  Harry attended the A&E department of Southmead Hospital on 26th December 2022 at 16.42hrs, with the reason recorded as “mental health”, he was expressing paranoid thoughts. He had a high heart rate and was sweating. He underwent a physical assessment and was assessed by the Mental Health Team.   At some point he took cocaine in the toilet of the hospital after which he became more agitated and there were concerns being raised that others in the department felt threatened. At one point he absconded from the unit but was brought back, a doctor in the emergency department gave him medication to calm him down. The police were called but when they attended Harry was calm from the effects of the medication.    The police were called and attended again when Harry’s agitation increased. It was during this discussion that the police officer raised the possibility of Harry having ABD (acute behavioural disturbance). The police officer said that he’d seen close to a dozen cases, that Harry had similar symptoms.   The two mental health practitioners said that they knew very little about ABD. After some discussions with the police officer, the two mental health practitioners and the consultant in emergency medicine Harry was deemed medically fit and he was admitted under s136 Mental Health Act to The Mason Unit (a place of safety) within the hospital at around 23.00hrs.  Once on the Mason Unit Harry continued to be distressed and agitated, he was given further medication to calm him. Harry remained disturbed but had periods of calm, he became fearful of isolation, he became sleepy and at around 3.30hrs on 27th December 2022, he vomited. Observations were carried out confirming that Harry had low oxygen saturations and a high temperature. At 4.45hrs his extremities were discolouring, and he became unresponsive, an ambulance was called. He was transferred back to the A&E department but died at 06.36hrs.  The coroner's report included the following matters of concern: Due to Harry’s level of agitation, he did not undergo the level of observations that would and should have happened either in the emergency department or once on the Mason Unit which may have assisted in assessing his physical health. It was clear that none of the mental health nursing staff were aware of ABD and the fact it is a medical emergency. The decision as to whether a person has ABD is important, Dr Delaney said that” this group are vulnerable to cardiac arrest”, that “deaths are multifactorial”, that “normally in the background a body is maintaining safe limits for e.g. pulse rate, blood pressure, temperature, but with acute disturbance in behaviour the body loses control of these safe parameters.” The full report can be found via the link below. You can also read the Royal College of Nursing response here.
  14. Content Article
    This document from Avon and Somerset Constabulary outlines a number of improvements initiatives they have put in place to help make sure people with mental health issues get the right care from the right person. This includes: Training five constables to perform a new role which is called the Mental Health Link Officer (MHLO). Right Care Right Person (RCRP) Avon & Somerset principles. Partnership working with Western Ambulance Service Foundation Trust (SWASFT). The positive impact of Mental Health Link Officers.  For more detail please see the attached document.   
  15. News Article
    A police investigation into allegations of preventable deaths and injuries at an NHS trust has doubled the number of cases it is looking at, BBC News can reveal. The claims centre on care and treatment provided by University Hospitals Sussex NHS Trust between 2015 and 2021. Sussex Police started looking in 2023 into an initial 105 cases, but BBC File On 4 Investigates has learned that number is now more than 200. The force says the investigation is "active and ongoing", but it will "not be providing specific details around case numbers at this time". Police became involved after two whistleblowers raised allegations of medical negligence at two of the trust's departments - neurosurgery and general surgery, including concerns about at least 40 deaths. The increase in cases is linked to more families having contacted the police. Separate to this investigation, the BBC have spoken to the family of a patient who allege they were "lied" to by a senior surgeon in the trust's general surgery department, before he carried out an operation that left her with life-threatening injuries. Read full story Source: BBC News, 7 January 2025
  16. News Article
    Most integrated care boards report a lack of funding is hampering the NHS’s efforts to respond better to mental health crisis incidents, rather than requiring a police response. The Department of Health and Social Care has published an evaluation of the Right Care, Right Person model, which was introduced nationally last year in response to the police arguing they were spending huge resources on these cases, and would stop answering them. The NHS said it would move to RCRP, based on a pilot in Humberside in which the health service had dealt with more crises without police input. However, mental health service leaders have consistently raised concerns about funding, and the speed of rollout. The concerns have now been confirmed in the DHSC evaluation, which includes a survey of integrated care boards and councils. Of the 34 ICBs asked between autumn 2023 and spring 2024, 62% said they had experienced “barriers”. The majority of these ICBs said “cost/funding pressure” was the biggest barrier (86%), followed by “lack of clarity regarding responsibilities of agencies when responding to incidents” (71%), then “lack of workforce to cope with demands” (67%). Sixty per cent of ICBs reported their “health-based place of safety” — where patients are meant to be taken after being detained under section 136 of the Mental Health Act — did not ”meet demand”. This was mostly because of a lack of adult inpatient beds, followed by a rising number of detentions, ICBs said. Read full story (paywalled) Source: HSJ, 11 December 2024
  17. Content Article
    Right Care, Right Person (RCRP) is an approach that is aimed at ensuring that people of all ages who have health and/or social care needs, are responded to by the right person, with the right skills, training, and experience to best meet their needs. Home Office and Department of Health and Social Care (DHSC) analysts evaluated the implementation of RCRP through a rapid process evaluation covering police, fire, health and social care services. The findings highlighted the importance of communication, openness and transparency across agencies when implementing RCRP. While generally supportive of RCRP principles, participants highlighted some implementation challenges, such as capacity limitations for health and social care services. Early data monitoring showed a reduction of police time spent on health-related incidents post RCRP implementation. Recommendations to support the implementation of RCRP are included.
  18. Community Post
    As someone who works with NHS and actually as a Mental Health and Physical Health patient I've experienced discrimination and out right assault by the police whilst in hospital and ended up under S136 for no valid reason. Although I was assaulted with handcuffs being thrown over the bed rail, breaking my wrist I think. Still not had my mangled wrist xrayed 2 months on. Nothing worse than being in a vulnerable situation and bullies absolutely thrive on people in vulnerable positions. Their bosses think they're wonderful and so kind but they are in a position of power so of course the bully treats them differently or act differently when seniors are around. I recently put in a formal complaint to CEO I knew very well but instead of replying (after I told her I had recordings) she completely blanked me and now retired. Instead of "this is very serious Dominic, please send any evidence etc" I get told "how wonderful" my bully is! Interim CEO took over so I must inform him of Duty of Candour (Robbies Law) too. They don't seem to like that being pointed out but I shall do it anyway in hope we get a decent CEO who isn't just a pencil pusher waiting for band 9 pension. If as a volunteer I've experienced what I have, I dread to think what goes on as full members of staff. What struck me was the impunity these bullies operate with once in band 8 or above roles. You'd be very shocked if you heard what myself and four other service users went through. At the time my bullies refused to apologise (even though she received "disaplinary action") For me bulling and cronyism are both rotting the NHS from the inside out and needs sorting ASAP Please don't get me wrong, I support 99% of NHS staff but I cannot ignore the bullying, certainly at directorate or managerial level. The small percentage who do bullies seem to have no self awareness and those under them seem to think bullying behaviour is just "Leadership" Well no leader worth any salt will abuse you or tell you who you can and cannot speak too. Seeing service users slowly driven out by a particular bullie was extremely hard and not one manager wanted to know (bar one kind soul). Leadership means you MUST act whenever you even sniff the types of behaviours that signal a bully, however things are that bad that management cannot or won't recognise the controlling and mean behaviours Thanks for reading my first post
  19. Content Article
    At 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. Coroner's concerns During the course of the inquest, the evidence revealed matters giving rise to concern. In the coroner's opinion, there is a risk that future deaths will occur unless action is taken. Matters of Concern 1. When Ms Findlay ran off, the HCA escorting her was so panicked that she did not even think of following. Ms Findlay had run across a road and so chasing her at speed did present safety considerations. However, the ELFT policy, training, culture and expectation was such, that there the HCA did not at any point consider attempting to walk after her to keep her in sight. Clinical staff must be adequately prepared for such an eventuality. That means more than simply a change in policy wording. 2. By the time the HCA rang the duty senior nurse for advice Ms Findlay was out of sight, and so the HCA was instructed to return to the ward. Evidence heard that an email is to be sent out shortly to explain that a new ELFT absent without leave policy will be in place by the end of June 2023. The new policy will confirm that, if it is safe to do so an escort may follow a patient who has absconded, keeping them in line of sight whilst ringing the duty senior nurse for instructions. However, there is no ELFT policy for what those instructions should be or even what they could include. No member of ELFT gave evidence of any organisational thought having gone into how then to progress such a situation, other than the ward calling the police to report a missing person. No member of ELFT giving evidence was able to set out what the staff member following should do. This appears to be a significant omission. 3. One of the MPS policy leads in this area gave evidence that in such a situation the police would not necessarily attend, even if called direct by a hospital staff member in the street following a patient about whom they are worried. The impression gave was that a clinician calling the police in what the clinician perceived to be an emergency situation might not be assisted by the police. 4. Right Care, Right Person is an operational model developed by Humberside Police that changes the way the emergency services respond to calls involving concerns about mental health. It is in the process of being rolled out across the UK as part of ongoing work between police forces, health providers and government. The MPS has already created a similar model under the resource and demand team. The protocol is called Affinity. It attempts to target preventable demand from the mental health trusts. From the evidence heard, it appears the police / health trust partnership working allows 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 who is meant to be inside a locked ward for their own safety. Whether this is a matter of policy or practice, the result is the same. If partner agency working is to be effective in caring for this extremely vulnerable cohort of patients, there needs to be crystal clear understanding by all those involved, from the highest policy maker to the most junior member of a team at the sharp end, of how to tackle these difficult situations and exactly who is meant to be doing what. 5. Evidence was given that the police classify a person at high risk as: the risk is immediate and there are substantial grounds for believing immediate risk of self harm. At the time of reporting to the MPS, trusts should volunteer their own grading of the patient’s risk. The police said that they will not necessarily follow the trust grading, but they regard it as a significant factor and it should form part of the MPS thinking. ELFT witnesses said that if the police did not ask for the trust’s grading then the trust would not offer it. Until April 2022, the grab pack prepared by ELFT for the MPS in such a situation was printed out and handed to police if and when the police attended the ward. It is now filled out on a portal as part of the reporting procedure. However, it is not clear ow far the grab pack aligns with local policies, whether all useful information (including the trust’s grading of risk) is recorded as a matter of routine, and how far the police and the trust are using the same terminology with the same definitions. It seems that this would benefit from consideration. 6. ELFT staff said that after Ms Findlay had run off, they still graded her as medium rather than high risk. She had had long term suicidal thoughts, had made previous attempts on her life and, prior to being admitted to hospital on 20 May 2020 had purchased sodium nitrate and had planned to take this to kill herself. However, she had appeared to improve in hospital, and had been granted 15 minutes’ escorted leave twice a day since 1 June without incident. At one point in her evidence it appeared that the matron, taking the point that by running away Ms Findlay had acted in a manner that was wholly unexpected by the trust, was of the view that Ms Findlay should then have been re-categorised as high risk. However, following re-examination by counsel for ELFT the matron appeared to retract this and to return to her former position that, even after she had run away Ms Findlay was only of medium risk to herself. It is of course a matter of clinical opinion what risk grading a patient should be given, and no person can see into the future. However, the jury found a failure by ELFT to recognise that, by 11 June 2020, Ms Findlay was at imminent risk of suicide by sodium nitrate; and any investigation following a death like Heather Findlay’s presents an opportunity for sober and searching reflection. So it is concerning that an element of positional bias may have influenced the thinking of ELFT staff. When giving evidence at inquest, the ELFT serious incident investigation author was adamant that it was only appropriate for the HCA who called the police on 11 June 2020 after Ms Findlay had run away, to tell the police of a risk of self harm not of a risk of suicide. Her rationale for this was that the last time Ms Findlay had articulated a plan to kill herself, was when she was found in hospital with a ligature round her neck on 28 May 2020.
  20. Content Article
    The first 14 minutes of this programme are focused on a Newsnight investigation into allegations of cover-up, avoidable harm and patient deaths relating to University Hospitals Sussex NHS Foundation Trust. At the time of broadcast, Sussex Police were investigating 105 claims of alleged medical negligence at the Trust. This programme features: Simon Chilcott, speaking about the death of his son Lewis. You can read more about this in a blog from Simon on the hub here. Allegations from anonymous whistle blowers at the Trust, talking about a toxic ‘mafia-like’ culture where safety concerns were ignored. These allegations around a toxic culture were refuted by the Trust in comments to Newsnight. Comments from a former neurosurgeon at the Trust, James Akinwunmi, who warned the former Chief Executive, Dame Marianne Griffiths, in 2017 about problems in surgery departments for years around patient safety and avoidable harm.
  21. News Article
    An NHS trust and ward manager have appeared in court charged with the manslaughter of a 22-year-old mental health patient who died in hospital in July 2015. Alice Figueiredo was found dead at Goodmayes Hospital in east London, and an investigation into her death was opened in April 2016. The Crown Prosecution Service (CPS) authorised the Met Police to charge North East London NHS Foundation Trust (NELFT) with corporate manslaughter last month following a five-year investigation. It is just the second NHS Trust to face manslaughter charges. The Trust is additionally charged with an offence under section three of the Health and Safety at Work Act in connection with mental health patient Ms Figueiredo's death. Ward manager Benjamin Aninakwa also faces a charge of gross negligence manslaughter and an offence under section seven of the Health and Safety at Work act. NELFT is just the second ever NHS Trust believed to have been charged with corporate manslaughter, after Maidstone and Tunbridge Wells Trust was charged over the death of a woman who underwent an emergency Caesarean in 2015. Read full story Source: Mail Online, 6 October 2023
  22. News Article
    Two healthcare workers who exchanged vile texts while needless drugging sick people to ‘keep them quiet’ have been found guilty of ill-treating patients. Senior nurse Catherine Hudson, 54, was found to have regularly tranquillised patients unnecessarily for her own amusement and to have an ‘easy’ shift. While Charlotte Wilmot, 48, an assistant practitioner, wrote vile texts encouraging her to carry out the dangerous acts, with complete disregard for the consequences. Preston Crown Court heard the pair worked on the stroke unit at Blackpool Victoria Hospital and had carried out needless sedations between 2017 and 2018. Restrictions on prescription drugs were so lax in the stroke unit that staff would help themselves and self-medicate or steal drugs to supply to others, the court heard. Drugs such as Zopiclone, a powerful medicine used to treat insomnia, were often stolen and used to drug multiple patients. Police launched an investigation in November 2018 after a student nurse raised concerns about the treatment of patients in the stroke unit. A number of staff members were arrested during the course of the investigation and their mobile devices were seized. Read full story Source: The Independent, 6 October 2023
  23. News Article
    Former police officers, including a murder detective, have been hired by NHS hospitals in a move that campaigners have warned risks discouraging whistleblowers. The Sunday Telegraph has revealted that retired officers have been employed by a trust currently under scrutiny for its treatment of doctors who raise patient safety concerns. One of them has taken up a patient safety incident investigator role worth up to £57,349 a year. Meanwhile a senior detective has been called into multiple trusts on an ad hoc basis to conduct investigations. Last night a leading patient group called on the NHS to be transparent about exactly how such personnel are being used, “given the ongoing concerns about how such roles interact with whistleblowers”. Paul Whiteing, chief executive of the charity Action Against Medical Accidents (AvMA), said: “We at AvMA welcome any steps taken by Trusts to professionalise the investigation of patient safety incidents. This is long overdue. “But given the on-going concerns about how such roles interact with whistleblowers, to maintain trust and confidence of all of the staff, trusts need to be clear, open and transparent about why they are making such appointments and the role and duties of those they employ to fulfil them, whatever their backgrounds.” Campaigners have warned that some NHS trusts deliberately seek to conflate patient safety issues with staff workplace investigations. Read full story (paywalled) Source: The Telegraph, 30 September 2023
  24. News Article
    Police forces in parts of the UK have stopped answering urgent calls related to mental health even before alternative support is available to people, under a policy designed to free up officers’ time, MPs were told last week. The move means many vulnerable people are being left without help in areas where the necessary services and arrangements with other agencies are not yet in place, warned Sarah Hughes, chief executive of the mental health charity Mind. Giving evidence to the House of Commons health select committee on Tuesday 19 September, Hughes said, “We know of local Mind and local trust partners who are already experiencing people having no response because the police are saying they no longer respond to mental health calls.” The policy, Right Care, Right Person, which was developed by Humberside Police over nearly three years, is being rolled out in England and Wales from the end of October at varying speeds. Backed by the government and police representative bodies, it aims to ensure that patients in a mental health crisis are treated by the most appropriate agency, rather than have police act as default responder, when they may not be best suited to help. But the Royal College of Psychiatrists is among the organisations to have raised concerns over the levels of preparation and resourcing for the policy and the absence of evaluation of clinical outcomes or benefits and harms to the population. Read full story (paywalled) Source: BMJ, 25 September 2023
  25. News Article
    NHS England has warned the decision by police forces to respond to far fewer incidents involving people in mental distress could pose ‘risks’ to both patients and a service “already under enormous pressure”. National mental health director Claire Murdoch has written to integrated care board leaders and mental health trust CEOs about the possible impact of the “right care, right person” policing model which is being rolled out across England. In July, policing minister Chris Philp gave all forces the green light to implement the RCRP model. The approach was first trialled in Humberside and involves officers only attending mental health calls where there is a risk to life or serious harm. Now, in a letter seen by HSJ, Ms Murdoch has admitted the new model is a “major change for services already under enormous pressure” and warns that implementing all of the actions set out in the national partnership agreement may take time between the police and the NHS. This took three years in Humberside, she notes. Ms Murdoch wrote: “I know you will all be doing your best to make this work, but I am so mindful of the risks to services and people with mental health problems, as I am sure you are too.” Read full story (paywalled) Source: HSJ, 15 September 2023
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