The report into the deaths at Cawston Park has made 13 recommendations to a series of agencies including the Law Commission, suggesting a review of the law around private companies caring for adults with learning disabilities and autism.
“Given the clear public interest in ensuring the wellbeing and safety of patients, and the public sponsorship involved, the Law Commission may wish to consider whether corporate responsibility should be based on corporate conduct, in addition to that of individuals, for example,” the report said.
Flynn, who was commissioned by Norfolk Safeguarding Adults Board (NSAB) to write the report, said the report highlighted “failures of governance, commissioning, oversight, planning for individuals and professional practice”.
Marmot calls for doubling of healthcare spending in the region over the next five years, as well as a refunding of local government, to tackle and prevent these inequalities and growing problems such as homelessness, low educational attainment, unemployment and poverty.
Future spending should prioritise children and young people, who had been disproportionately harmed by the impacts of Covid restrictions and lockdowns, and had experienced the most rapid increases in unemployment and deteriorating levels of mental health.
As well as damaging communities and harming health prior to the pandemic, funding cuts had “harmed local governments’ capacity to prepare for and respond to the pandemic and have left local authorities in a perilous condition to manage rising demand and in the aftermath of the pandemic”, the report said.
Key Social Determinants and Mental Health issues identified in the report
1. Education: As with inequalities in the early years, inequalities experienced during school years have lifelong impacts – in terms of income, quality of work and a range of other social and economic outcomes including physical and mental health.
Socioeconomic inequalities in educational attainment have persisted since 2010 entrenching trajectories of inequality which begin in the early years.
Young people living in more deprived areas continue to have significantly lower levels of attainment during secondary school, measured by GCSE results and attainment 8 scores, which measures pupils’ performance in eight GCSE-level qualifications.
2. Unemployment and poor quality work: are major drivers of inequalities in physical and mental health. Being in poverty and working in poor quality employment have marked effects on physical and mental health, including on children in the families concerned.
3. Poverty is associated with poor long-term physical and mental health and low life expectancy.
Living in poor quality housing, being exposed to poor quality environmental conditions, poor quality work and unemployment, not being able to afford nutritious food and sufficient heating for example all impact on health.
Poverty is also stressful. Coping with day-to- day shortages, facing inconveniences and adversity and perceptions of loss of status all affect physical and mental health in negative ways
Nearly half of those in poverty in the UK in 2018 – 6.9 million people – were from families in which someone had a disability.
Some ethnic groups also face much higher rates of poverty than others, particularly those who are Black and Bangladeshi and Pakistani origin where rates of poverty after housing costs are as high as 50 percent.
Persistent poverty refers to someone who has been in poverty in three of the past four years.
People in persistent poverty are at particularly high risk ofhaving poor physical or mental health.
Rates have stayed roughly the same since 2010, at about 13 percent. Lone parents with children have the highest risk of being in persistent poverty
4. Empowering and sustaining communities was central to the 2010 Marmot Review, an overarching theme was to ‘create an enabling society that maximises individual and community potential.’
The Review described the importance of communities and places in shaping physical and mental health and wellbeing and described how inequalities among communities are related to inequalities in health.
Since 2010 these community inequalities have, in many ways, widened.
5. Poor quality housing, particularly damp and cold homes, directly harm physical and mental health and poor housing conditions continue to harm health in England and widen health inequalities. Unaffordable housing also damages health, 21 percent of adults in England said a housing issue had negatively impacted their mental health, even when they had no previous mental health issues, and housing affordability was most frequently stated as the reason. The stress levels resulting from falling into arrears with housing payments are comparable to unemployment.
7. Covid – 19: The City Region has also experienced particularly damaging longer-term economic, social and health effects from a combination of local and national lockdowns during the autumn of 2020 and through the first half of 2021.
Impacts include deteriorating community and environmental conditions as the public purse is further strained, widening inequalities during children’s early years and in educational engagement and attainment, increasing poverty and income inequality, rising unemployment, particularly for young people, and deteriorating mental health for all age groups but again particularly for young people.
All of these negative impacts will damage health and widen health inequalities in Greater Manchester. This report assesses these unequal impacts and makes proposals about how to take urgent, remedial action.
There has been an increase in poor mental health among children and young people from already concerning levels before the pandemic. A significant acceleration is needed in the provision of mental health services for young people and in programmes to support mental health in schools, further education and workplaces.
8. Community assets are important to health directly and indirectly: directly through the services and opportunities they offer that support physical and mental health, and indirectly through a sense of control and empowerment, levels of community cohesion and social interaction, all of which support good health.
9. Climate Change: Most residents noted the importance of green environments and local events and facilities to good wellbeing, which are highly supportive of good physical and mental health and help reduce inequalities.
10.The direct and indirect impacts of climate change are a threat to health and health inequalities in Greater Manchester, as globally. Immediate action to reduce greenhouse gas emissions can also improve health and reduce existing health inequalities.
The direct impacts of climate change on physical and mental health include: greater exposure to extreme heat/cold and UV radiation, more pollen, emerging infections, flooding and associated water-borne diseases, and impacts of extreme weather.
Action to reduce air pollution, by reducing the burning of fossil fuels, will not only have immediate health benefits, but will also contribute to achieving net-zero greenhouse gas emissions.
The indirect impacts of climate change on health and inequalities include increases in the price of food, water and domestic energy and increased poverty, unemployment and anxiety (34).
12. Homelessness: In Greater Manchester, huge strides have been made in reducing rough sleeping and further plans made for eliminating it (60).
Greater Manchester’s A Bed Every Night scheme and Housing First policy provide accommodation for people who sleep rough and offer support to improve their physical and mental health.
The NHS provides funding for the scheme as it is viewed as a form of prevention, reducing need for NHS services. The Mayor’s Homelessness Fund enables businesses and individuals to donate towards supporting local services to support homelessness reduction, too (61).
The Let Us ethical lettings agency in Greater Manchester provides management services to private landlords through the services of housing association partners, aiming to improve the private rental sector (62).
In March 2021 the Better Homes, Better Neighbourhoods, Better Health ‘Tripartite Agreement’ between Greater Manchester Housing Providers, Health and Social Care Partnership and the Combined Authority was launched.
The partnership aims to plan new housing and communities to enhance health, support more vulnerable households, support homeless people and those sleeping rough, and expand the ethical lettings agency to make an additional 800 homes available to those who are homeless or sleeping rough by 2024 (63).
The Greater Manchester Good Landlord Scheme, approved in March 2021, could help to address some of the issues by placing the onus on landlords and agents to improve and maintain standards in the private rental sector. The Scheme addresses some of the issues by: strengthening and focussing enforcement capacity in a co-produced model with districts; targeting capacity building for landlords (and agents) to help them better support their tenants, particularly those on low incomes; working with districts and key stakeholders to ensure tenants and landlords have access to accurate and up-to-date information and advice; and promoting the active growth of ethical/social investors in the sector (54).
Greater Manchester’s 2019–2024 Housing Strategy has two key priorities: to provide a safe, healthy and accessible home for all and to deliver the new homes Greater Manchester needs (45). It commits to providing 50,000 affordable homes, of which 30,000 will be for social rent, by 2037 (45).
However, this is too few and too slow to meet the demands for affordable housing, and given the impacts of the pandemic, the Strategy’s priorities are unlikely to be met in the 2019–24 timeframe.
At a meeting of Bury’s Strategic Health Board on Monday, September 6, members were presented with a report from Will Blandamer, executive director of strategic commissioning on the need for investment in community mental health services.
Mr Blandamer, said: “This relates to the service pressures and impact of Covid on emotional health and wellbeing and mental health for our Bury population.
“It initialises a step change in how we will move to redesign our mental health adults and children and young people pathways moving forward as we build back better from Covid.”
The three year plan details an ‘enhanced staffing options proposal’ to allow the recruitment of six mental health practitioner posts in the remainder of the 2021/22 year.
An additional nine staff would need to recruited in the year after that to make the service safe.
Mr Blandamer added that there was also a need to recognise the expansion of the service with the redesign of mental health services.
Once fully recruited, the cost of the extra staff per is calculated at £663,000 in 2022/23 and £764,000 per year after that.
Mr Blandamer asked the board members to be aware of the risks to the service if the investment was not agreed.
Will Blandamer said the recruitment of 15 new staff was needed to avoid a possible ‘crisis’ in Bury’s mental health service
He said: “If staffing is not increased there is a significant risk of a number of patients being on the waiting list without an allocated care coordinator.
“There is a risk of patient conditions deteriorating and reaching crisis with a potential to have an impact on other services and the wider system.
“Staff well-being is a concern as managers may see staff requesting a reduction in working hours due to the pressure and demand of the work which may impact on staff moral and staff resilience.
“There is a possible risk for the service to become non-operational and a risk of adverse publicity and regulatory scrutiny if the service does not mitigate emerging pressures.”
The development forms part of a project for NMGH, aimed at improving health and well-being for people in the local area over the next 10 to 15 years.
The adult mental health unit is predicted to cost £105.9m. GMMH are expecting to receive £91.3m government funding, with the remaining £14.6m funded by the trust.
The FBC will now be formally submitted to NHS England/Improvement who will review the FBC for a final investment decision, which will allow construction to commence.
Neil Thwaite, Chief Executive of GMMH, said: “We passionately believe this investment will greatly improve the quality of specialist inpatient mental health care and will enable us to build a therapeutic, modern environment for patients and workplace for staff. “It is excellent news for people needing in-patient mental health services in Manchester and forms part of exciting regeneration plans being developed for the North Manchester hospital site.”
The development will include the replacement of the current Park House inpatient mental health unit at NMGH, which will be completely rebuilt on the hospital site, but in an alternative location. It will mean that the unit can be completely constructed without disturbing current patients, with the day-to-day operation of services still being able to continue.
The current plans include:
150 single en-suite bedrooms to be provided over nine single sex wards, including a purpose built Psychiatric Intensive Care Unit (PICU), seven adult acute wards for female and male adults, and one older adults’ ward.
An assessment suite (specifically for people needing a place of safety and assessment under Section 136 of the Mental Health Act).
A variety of internal activity areas and multiple outside garden spaces specifically designed to enhance the environment and aid recovery.
During the development of the FBC GMMH discussed their plans with key stakeholders, as well gaining support from the wider health and care system, including commissioners. GMMH will continue to engage with the community to hear feedback, test thinking, and develop the design proposals further.
The local planning authority and Manchester City Council gave full planning approval in January 2021.
The construction on the new building site is expected to start in 2022, with the new facility anticipated to be built and operational by 2024.
His brother, Bradley Hesford, said Zowie had been looking for work, had moved into a new flat and started up his social life again, spending time with family and buying a darts board.
He described how Zowie had been looking forward to the easing of lockdown restrictions and being able to see more of his children.
Zowie had two young children with former partner Bernadette Hesford, known as Bernie.
He also had an 18-year-old daughter, Leah, from an earlier relationship.
Giving evidence in the hearing, Bernie described how following the death of his aunt in 2017, Zowie’s mental health began to suffer.
After the couple separated in July 2018, Bernie said Zowie lived with his dad before choosing to live in what was described as a ‘hut’ on Mortfield Fishing lodge in Halliwell.
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Dr Hannah Cappleman, Consultant Psychiatrist for Bolton Early Intervention Service, whose care Zowie was under, said he had taken some advice in relation to benefits and was happy with his living arrangement, despite their concerns.
She said he liked living there, despite having other options, preferred to just be in his own company and did not want to be around other people.
Despite this, the court heard how Zowie loved having face time conversations with his children as well as seeing as much of them as he could in person.
Occupational therapist Rory Bradshaw described how Zowie’s mood had been flat for three years but said: “He really, really valued these conversations.”
The court heard how Zowie eventually moved to a flat at Hebden Court but, after receiving no response to texts from his children on July 22, Bernie and Leah went to this address to check on him.
When they got no response, Bernie says she took Leah home before returning and noticing Zowie’s phone, wallet and keys in the front room. She contacted the early intervention team who contacted the police.
His body was then found by his family in the utility room.
HM Area Coroner Professor Dr Walsh said a post mortem had shown Zowie to not be under the influence of drugs or alcohol at the time of his death and there was no evidence of a third party intervention.
He gave a conclusion of suicide.
He said: “Zowie was passionate, popular, fun loving and caring.
“He was devoted to his children.
“He had had some mental health problems because of his aunt and the break up of his relationship.
“Sadly relationships end – some people can cope and others can’t.
A young mum devoted to her daughter died after suffering years of ‘significant trauma’ amid years of mental health problems, an inquest heard.
Zebrina Daryl Carden, 26, was found dead at her home on Howard Street, Ashton, Tameside, on February 20 after her family and friends were unable to contact her.
An inquest into her death at South Manchester Coroners’ Court on Thursday heard Ms Carden had a long history of mental health problems.
She has suffered with anxiety and anger issues since her teenage years and had been diagnosed with borderline personality disorder, OCD and psychosis.
Ms Carden, who was said to be very close to her mum Diane Thompson and twin sister Shaunna Carden, had a young daughter and shared custody with her former partner.
Dr Houda, a consultant psychiatrist at Pennine Care NHS Trust, told the court that Ms Carden had often experienced ‘impulsive thoughts of self-harming’ alongside ‘significant trauma’.
In 2016, she stabbed herself in the abdomen after hearing threatening voices and saying the TV was talking about her. On another occasion in 2019, she was admitted to hospital after walking in front of traffic. A few months later, she took an overdose and was admitted to intensive care.
Claire Diggle, a care coordinator and psychiatric nurse at Pennine Care NHS Foundation’s Tameside and Glossop Early Intervention Team, had been working with Ms Carden since 2018 to help ‘normalise’ the experiences she was having.
Miss Diggle said that Ms Carden would often experience rapid mood swings, would report hearing ‘negative, critical and angry’ voices and felt stressed about her finances and relationships.
She had also reported being the victim of sexual assault while living at a flat in Salford.
She said Ms Carden also displayed ‘sudden, dramatic and impulsive’ behaviour which would sometimes make her unreliable and miss appointments when it came to taking her medication in the form of depo injections.
Miss Diggle said that Ms Carden would often recall how her own daughter – who she saw as a ‘significant protective factor’ – was very important to her.
She said: “At times she felt that having mental health problems meant that she wasn’t able to do certain things.
“Particularly with regards to her daughter, she felt it must mean that she was a bad mum and that certainly wasn’t the case.”
Miss Diggle said there had been some concerns that Ms Carden was often ‘self-medicating’ herself with drugs and alcohol.
“In the heat of the moment, I think she would try anything that she felt would help,” she told the court.
Miss Diggle last visited Ms Carden on February 17 when she reported experiencing ‘unpleasant’ side effects to the depo injections.
The care coordinator brought some medication to counteract the symptoms over to Ms Carden’s house.
“She seemed well and said her friend was upstairs with her,” Miss Diggle said.
“I didn’t have any reason to think I needed to make a further assessment.”
Andrew Foden, of Pennine Care, led the investigation into Ms Carden’s care and told the court: “It felt that Miss Diggle had a very strong, therapeutic relationship with her.
“It was an integral part to her care and recovery over the three years with the Early Intervention Team.”
Speaking of Ms Carden, Miss Diggle said: “She was always very polite and well-mannered.
“Everything you did for her, she was very thankful for.”
Ms Carden’s mum told the court her daughter was a ‘caring, kind and good person’.
“When she was doing well, she was active and regularly went to the gym,” Mrs Thompson said.
“She was great with her daughter but when her mental health was bad, she wasn’t always able to be a mum and that upset her.
“I don’t feel like she was taken seriously when she asked for help.
Emily Miller, 23, from Stockport, had serious mental health problems including psychosis. The academically gifted post-graduate was studying at York University, and had been sectioned several times between March 2019 and October 2020 due to ongoing psychological problems including an emotionally unstable personality disorder, depression and anxiety.
The sections came after near lifelong struggles with mental health, with Emily first being referred to mental health teams for anxiety at the age of 10.
Matthew Houghton, a nurse consultant at the psychiatric hospital, said that when Emily was first admitted in March 2020, at the start of the Covid outbreak, she was “quite frightened and scared”.
She had been seeing a psychiatrist and an occupational therapist before being discharged in April last year, only to be re-admitted in May. She was discharged again a week later – part of a pattern of short-term admissions in the run-up to her death.
Although Emily’s fears around the coronavirus “seemed to be wavering”, after a negative Covid swab she “just broke down in tears”.
Emily was “quasi psychotic” and “very anxious” about starting a new job, but had a masters degree from university and was described as “very bright”.
The nurse then told of Emily’s reaction to the news that she was being discharged, saying she was “unhappy” at the discharge meeting on October 30 and refused to take her medication with her, saying she had plenty at home.
“I think she was unhappy to be leaving [the hospital],” said Mr Houghton.
“She was quite angry with the decision [to discharge her].”
Mental health nurse Alison McGrath said she was “concerned” at “how somebody could leave a hospital ward and end up in a river in such a short space of time”
The child, known as Y, was physically and chemically restrained in hospital last month and, at points, was handcuffed and guarded by as many as 13 police officers, the court heard.
Other seriously ill children were moved to alternative hospitals across the north west of England due to the disruption and elective surgeries were cancelled.
Judge Mr Justice MacDonald, who overturned an order authorising the deprivation of the boy’s liberty on the ward, said that he demonstrates “challenging, violent and increasingly self-harming behaviour”.
He has been diagnosed with epilepsy and “it is possible, although not definitively established” that he also has ADHD and autistic spectrum disorder.
The boy, who has been known to children’s services since 2011, was taken to A&E after attempting to harm himself and threatening suicide at his children’s home, the court was told.
“On arrival of the child and adolescent mental health services (CAHMS) practitioner at the emergency department Y was in full restraint with several police officers and staff. His legs were strapped together and his face covered with a guard to prevent him from spitting and biting. On the advice from the CAMHS practitioner, Y was given IV lorazepam following a discussion with the psychiatric consultant. Y was admitted to a paediatric ward,” the judge said.
Three days after his admission, Wigan Council received the court order authorising the deprivation of the boy’s liberty on the ward.
However, it was overturned by MacDonald just two days later.
He said: “It would border on the obscene to use a protective jurisdiction to continue the boy’s current bleak and dangerous situation simply because those with responsibility for making proper provision for vulnerable children in this jurisdiction have failed to discharge that responsibility.”
The council was told to find a specialist community placement for the boy.
He added: “Within this context, the adverse impact of the lack of appropriate provision that the courts have to wrestle with week in and week out in cases of this nature is now also impacting on the health and welfare of children and families who have no involvement with the court system.”
“Whilst the focus of this court is, and has to be, on the welfare of Y, it cannot be ignored that the situation that has arisen in this case by reason of an acute lack of appropriate resources for vulnerable children in Y’s situation has impacted severely on many other children and families,” the judge said.
A copy of the ruling has been sent by MacDonald to Education Secretary Gavin Williamson, children’s minister Vicky Ford, Ofsted, chief children’s social worker Isabelle Trowler and chair of the Care Review Josh MacAlister.
Patients in Hertfordshire admitted with acute mental health concerns have been treated as far away as Durham and Bury, according to new data.
The figures also revealed that the responsible NHS Trust in Hertfordshire has spent more than £2.5million on inappropriate placements for people needing mental health treatment.
The figures, published on August 12, revealed how many organisations had active ‘out of area placements’ in May 2021 in relation to acute mental health treatment.
Hertfordshire Partnership University NHS Foundation Trust said they have placed the patients with acute mental health concerns “because a suitable bed has not been available for them closer to home”.
The data has been published every month for five years after the Government committed to eliminate ‘inappropriate’ out of area placements by 2020-2021.
However, the figures reveal that the trust responsible for mental health services in Hertfordshire has spent more than £2.5million on around 140 inappropriate placements in the first six months of 2021.
The newly released information also includes which trust or operator received patients from the Hertfordshire trust. It reveals that in May patients were treated in County Durham, Greater Manchester and West Yorkshire.
John had a telephone consultation with Dr Sam Johnson on March 23.
Dr Johnson told the court that he was concerned that John was experiencing ‘significant delusions’ and said that he believed him to be ‘acutely unwell’. He assessed John as being at high risk and referred him to the community mental health team, with a face-to-face meeting set up for the following day.
On March 24, John told community mental health team assessor Natalie Vassilou about the phone calls he believed to have made and his concerns that the recipients of those calls wanted to kill him.
No evidence of any such threats or phone conversations have ever been discovered.
Miss Vassilou told the court that John had told her he did not want to take his own life in Italy and had only done it to prevent these people coming after him.
She said that she did not believe him to be at immediate risk of self-harm, citing protective factors such as being back in his home country, living with his sister, and the relationship with his parents.
Miss Vassilou added that she did not think John presented as being acutely unwell and made a judgement that he did not require immediate hospital treatment.
After consulting with a colleague, a decision was made that he did not meet the criteria for home-based treatment either.
John was told he would have to wait until April 20 to be assessed by a psychiatrist but that he should ring the crisis team if his condition worsened and he felt as if he needed to be reassessed by the community mental health team.
Despite ringing up on March 29 to tell a member of the team that his anxiety levels had increased, he was not reassessed.
Miss Vassilou told the court that she was on holiday at the time, which is why she did not deal with it.
Asked why her colleague did not reassess John, Miss Vassilou said: “I don’t feel like I could comment on someone else’s conversation because I wasn’t there.”
Dr Ayaz Qureshi, a consultant psychiatrist, said that there is no set criteria on deciding what makes a patient high risk and described it as ‘a very objective judgement’.
He was also asked why John was not reassessed despite informing the service of his increasing anxiety levels.
Dr Qureshi said: “[That member of staff] is not here so I can’t say how she was feeling at the time.”
He admitted that psychiatric assessments can be brought forward if there is urgent need to do so, but that due to John not being deemed high risk, this was not done.
Just over a week after telling mental health services that his anxiety levels had increased, John went missing from his parent’s house on April 6.