Essex mental health ward linked to 11 deaths told improvements still needed
Essex Partnership University NHS Foundation Trust is waiting for sentencing over the deaths
After 11 deaths linked to an Essex mental health ward, health inspectors have warned improvements are still needed.
The Essex Partnership University NHS Foundation Trust is waiting for sentencing over those deaths which covered an 11 year period, from 1 October, 2004, to 31 March, 2015.
In November, the Trust was charged at Chelmsford Magistrates' Court with failing to ensure, so far as was reasonably practicable, that persons not in its employment were not exposed to risks to their health and safety.
Barrister Bernard Thorogood entered a guilty plea on behalf of the Trust at the hearing.
Now, the Care Quality Commission (CQC) has told the Trust to make improvements to its wards for men of working age and psychiatric intensive care units.
Health inspectors visited Finchingfield Ward, the Trust’s 17 bedded inpatient mental health ward which provides care and treatment for men experiencing acute mental health difficulties, in October and November.
The inspection came after the CQC received "concerning information" about safety incidents leading to concerns around risk of harm.
• Individual staff did not carry out their duties as required by patient care plans and Trust policy. Staff did not carry out observations in the garden area, as required to maintain patient safety. This poor practice contributed to incidents of patient absconsion from the ward. Staff made clinical decisions which were outside of their role and responsibility.
• Staff did not keep accurate high quality records of patient care and managers did not check the quality and accuracy of notes. Staff failed to correctly record patient's mental health act status and they did not always make entries to records in a timely way. Documentation did not support staff in recording accurate times they observed patients.
• The provider did not ensure that there were experienced staff available to meet patients' needs on all shifts.
• Staff did not always reflect patient risk in morning handover meetings.
CQC’s head of hospital inspection (mental health and community health services), Stuart Dunn, said they served warning notices to ensure improvements are made around safe care and treatment, staffing and good governance:
"The Trust took immediate actions to address some safety concerns, including the removal of garden shelters and increasing security measures.
"Patients gave positive feedback about the ward staff and the hospital environment.
"The Trust ensured there was support available to patients and staff following incidents, this included access to senior leaders and psychologists.
"We have reported our findings to the Trust leadership, which knows what it must do to bring about further improvements and ensure it maintains any already made.
"We will return to check on the Trust’s progress."
Health inspectors did not rate the service during this inspection, and instead only looked at safety.
The service was rated as 'Requires Improvement' in its last inspection in 2019, but the Trust’s overall rating of 'Good' remains.
Some of the actions taken by Essex Partnership University NHS Foundation Trust include making physical changes to the ward environment, ensuring staff follow procedures correctly, and providing leadership support.
It is part of new safety measures being brought in by new leadership.
Chief executive of the Trust, Paul Scott, said:
"Safety is an absolute priority and we have taken immediate action to make the physical environment safer and improve practices to ensure that staff are supported to provide consistent, safe, high quality care.
"There is still more to do, and we have accelerated work to improve the safety of services, including investing in digital innovations that will support staff to monitor patients’ safety and wellbeing."
The Trust is rolling out a new piece of technology called Oxehealth’s Oxevision to support patient observations, by helping to remotely monitor pulse and breathing rates, and alerting staff if they display activity or behaviour that may present a risk to their safety.
Essex Partnership University NHS Foundation Trust has also made "significant investment" in new safety measures across its mental health inpatient services since it was established in 2017, and a new Trust-wide inpatient safety strategy is being developed with stakeholders.