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Showing results for tags 'Schizophrenia'.
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Content ArticleCoroner's concerns Substantial evidence was heard at the inquest with regard to observations which were not carried out in respect of Eliot Harris in accordance with NSFT’s Policy and with regard to staff not undergoing training and assessment of their competency to carry out observations correctly. Quality audits undertaken following Eliot Harris’s death, show that observations are still not being carried out and recorded in accordance with NSFT’s most recent policy – more than two years following Eliot’s death. Not all staff have completed training with regard to carrying out of observations or have undergone and assessment of their competency to carry out observations. On the night of Eliot’s death, a Nurse in Charge had not been allocated and members of staff were not allocated specific tasks – they were told to “muck in”, as a result there was some confusion as to who was responsible for specific jobs. The evidence at the inquest was not clear as to whether specific tasks are allocated to specific members of staff on Night Duty and whether and how a Nurse in Charge is appointed for each night’s rota. Multi Team Meetings were not fully and properly recorded in the clinical records. At the inquest, evidence was heard there “is still some way to go” with regard to improving record keeping and for ensuring important matters such as rationale for decisions is fully recorded. Eliot’s Care Plan was not up to date at the time of his death. At the inquest evidence was heard that although audits show there has been an improvement in completion of Care Plans, there “is still some way to go” and staff still need to be prompted to complete these. Staff were reluctant to enter Eliot’s room following concern for his wellbeing. The evidence did not reveal what is now in place to ensure staff enter a patient’s room immediately if there are concerns for a patient’s welfare (having considered their (staff’s) own safety). It is not clear from the evidence what is now in place to ensure that relevant and requested physical health checks are carried out. The process of ensuring health checks are carried out has not changed since Eliot’s death and remains a retrospective process.
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News Article
Up to 100,000 on antipsychotics with no review
Patient Safety Learning posted a news article in News
A national strategy is needed to tackle health risks linked to antipsychotic drugs because current policy is letting tens of thousands of people fall through the gaps, commissioners in London are warning. Commissioners and clinicians in City and Hackney found more than 1,000 patients in their area who were on these drugs without having regular medication reviews or health checks. They warned that, if their findings applied across England, 100,000 patients could be in the same position. Although NHS England funds GP practices to carry out regular health checks on patients who are on the serious mental illness register, this excludes patients who are prescribed antipsychotics without having an SMI diagnosis — which typically covers psychoses, schizophrenia or bipolar active disorder. An audit by City and Hackney Clinical Commissioning Group, carried out in July 2019 and shared with HSJ, found 1,200 patients in the area were taking antipsychotics but did not have a formal SMI diagnosis. The audit found most of these patients were not receiving regular health checks and a significant number may have benefited from having their medication reduced. Read full story (paywalled) Source: HSJ, 27 January 2020 -
News Article
Coroner warns of lack of change since man's death
Patient Safety Learning posted a news article in News
A coroner has raised concerns about a mental heath trust where staff falsified records made on the night a man died. Eliot Harris, 48, died in the Northgate Hospital in Great Yarmouth, run by the Norfolk and Suffolk Foundation Trust (NSFT), in April 2020. Norfolk coroner Jacqueline Lake said that, two years on, staff were still not recording observations properly. The 48-year-old, who had schizophrenia, had been sectioned under the Mental Health Act after he became agitated at his care home and refused to take medication. He was taken to Northgate Hospital and, after a period in a seclusion room, was transferred to a private room on the ward. Mr Harris was discovered unresponsive in bed during the early hours of 10 April and pronounced dead half an hour later. In a Prevention of Future Deaths Report (PFDR), Ms Lake said: "Quality audits undertaken following Eliot Harris's death, show that observations are still not being carried out and recorded in accordance with NSFT's most recent policy - more than two years following Eliot's death." She said that on the night Mr Harris died there was no nurse in charge and instead of being allocated specific tasks, staff were told to "muck in", causing confusion about job responsibilities. These issues were not resolved at the time of the inquest, she said, with no evidence provided about whether specific tasks were allocated on the night shift. Not all staff had been trained in recording observations, there was a lack of evidence about procedures for entering a patient's room over concerns for their welfare, and there was "still some way to go to make sure care plans are completed", Ms Lake said. Read full story Source: BBC News, 6 October 2022 -
News Article“Unacceptable” failures by a mental health hospital to manage the physical healthcare of a woman detained under the mental health act contributed to her starving to death, The Independent has learned. A second inquest into the death of a 45-year-old woman, Jennifer Lewis, has found that the mental health hospital to which she was admitted “failed to manage her declining physical health” as she suffered from the effects of malnutrition. Ms Lewis had a long-term diagnosis of schizophrenia. Her family described how she had lived a full life, completed a degree, and given lectures about living with mental illness. However, after undergoing bariatric surgery, against the wishes of her family, her mental state declined and she was admitted to the Bracton Centre, run by Oxleas, in 2014. In an interview with The independent, her sister, Angela, described how, in the year before her death, Ms Lewis lost her hair, suffered from diarrhoea, and developed sores on her legs as she effectively “starved to death” from malnutrition. Ms Lewis’s sister told The Independent that in the year leading up to her death, when the family warned doctors she was “starving to death”, their concerns were dismissed and they were told that the hospital “will not let it come to that”. Mental health charity Rethink has called for improvements to physical healthcare for patients with severe mental illness, whose physical needs they say are “all too often ignored”, while experts at think tank the Centre for Mental Health have warned that patients with mental illness are dying too young as the system “still separates mental and physical health”. Read full story Source: The Independent, January 2022
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