Watchdog ‘very concerned’ about safety of patients at Greater Manchester Mental Health Trust where 3 young people died

CQC is “very concerned” about the safety of people using the services of Greater Manchester Mental Health NHS Trust. 

The damning report says inspectors found there was not always enough nursing staff and that permanent staff did not feel safe if bank or agency workers were used as they didn’t have the relevant training.

It follows an unannounced inspection in September by the Care Quality Commission “due to on-going concerns about the safety of services”.

Three young patients died in nine months at Prestwich Hospital, one of the Trust’s units. 

As revealed by the Manchester Evening News in July, Rowan Thompson, 18, died, in October last year, followed by Charlie Millers, 17, in December, and Ania Sohail, 21, in June this year. 

A campaign group and the families of Charlie and Rowan are campaigning for a full investigation into those cases by NHS England. 

The CQC’s two-day inspection of eight wards across five of the the Trust’s seven sites found:

* The service did not always have enough nursing staff, who knew the patients or received basic and essential training to keep patients safe from avoidable harm. 

* The environment on Poplar ward (Park House) was not clean on the first day of inspection and space on the ward was limited for patients. 

* It was not clear that immediate concerns or learning from incidents was shared across the locations, although local learning and reviews were taking place.

*The wards did not all have up to date and recently reviewed ligature risk assessments. Staff on two wards could not locate the ligature risk assessments at the time of the inspection.

Acute wards for adults of working age and psychiatric intensive care units (PICU) which were inspected were at:

• Griffin ward, an eight bedded female acute ward at Junction 17, Prestwich 

• Oak ward, a 20 bedded female acute ward at Rivington Unit, Bolton 

• Priestner’s Unit, an eight bedded mixed PICU at Atherleigh Park, Wigan 

• Medlock ward, a 21 bedded female acute ward at Moorside Unit, Trafford 

• Brook ward, a 22 bedded male acute ward at Moorside Unit, Trafford 

• Poplar ward, a 20 bedded female acute ward at Park House, Manchester 

• Juniper ward, a 10 bedded male PICU at Park House, Manchester 

• Laurel ward, a 23 bedded male acute ward at Park House, Manchester.

As it was a focused inspection and only looked at the safety of the wards, the ratings overall for the service do not change and remains as good. But the service remains “requires improvement” for being safe.

Brian Cranna, the CQC’s head of hospital inspection (mental health and community health services) said: “When we inspected these eight wards run by Greater Manchester Mental Health NHS Foundation Trust, we were very concerned about the safety of people using the services.

“There wasn’t always enough nursing and support staff on duty, although where the trust identified significant staff shortages, they’d put contingency plans in place. 

“It was worrying that permanent staff didn’t always feel safe when bank and agency staff were used as they didn’t always have the relevant training to give support if an incident occurred.

“The physical environment across some of the wards wasn’t always suitable for people’s needs or safety. 

“Although staff could describe where ligature points were located, it wasn’t clear how the trust was assured more formally that all potential risks had been identified and considered.

“Poplar ward had limited space for patients to spend time away from others as the dedicated quiet lounge was being used as an extra bed for capacity. 

“The ward was also dirty and smelt unpleasant, although we were pleased to see the trust acknowledged this and some improvements had been made when we visited on the second day. 

“We were also informed the ward was due to be re-decorated later in September.

“We have told the trust what further improvements they need to make to keep patients safe in an environment which meets their needs. We will continue to monitor them and return to inspect on their progress.”

The inspection also found good practice within the Trust. 

The report says staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour.

Gill Green, Director of Nursing and Governance for Greater Manchester Mental Health NHS Foundation Trust, said: “We welcome the Care Quality Commission findings, following their unannounced, focused inspections of some of our adult wards and psychiatric intensive care units in September.

“The inspection team found several positive aspects of care including how well staff managed risks and followed best practice, how they protected patients from abuse and knew how to report it, and ease of access to clinical information. 

“We accept there are areas for improvement such as levels of qualified staff on wards, which many NHS trusts are struggling with, however we have strong contingency plans in place to ensure we remain safely staffed.

“We ensure that patient safety and learning is embedded across the Trust as well as at local level. We also continue to to improve patient environments wherever we can, with area already identified for redecoration and refurbishment ahead of the inspection taking place. 

“An action plan to address these areas is in development and we will share our progress with the CQC. This inspection does not affect our overall rating, which remains ‘Good’.

At a pre-inquest hearing at Rochdale Coroners’ Court on September 17, senior coroner Joanne Kearsley said Rowan Thompson’s cause of death was currently ‘unascertained’.

Rebecca Titus-Cobb, a lawyer representing Rowan’s family, told the inquest the family had a number of concerns regarding Rowan’s treatment while on the unit.

She said there were ‘systemic issues regarding observation of patients on the unit’, and that the campaign group Inquest had contacted the Care Quality Commission to express concerns following a number of deaths, including Rowan’s.

The charity INQUEST, who campaign with families whose loved ones have died in the custody or care of the state, wrote to the CQC’s Chief Inspector of Hospital, Professor Ted Baker, in September to demand further action.

In the letter, Chief Executive, Deborah Coles, said: “In light of these deaths and the serious concerns we have about the safety of Greater Manchester Mental Health NHS Foundation Trust I am asking you, on behalf of bereaved families, to use CQC’s statutory powers to urgently visit this Trust and independently assess its treatment of young patients.

“These deaths have all taken place in the last ten months. We are working with the families of Charlie Millers and Rowan Thompson, two of the individuals who have died. It is our understanding all three of these deaths took place on the Junction 17 ward or Gardener Unit which are part of the Trust’s CAMHS (Child and Adolescent Mental Health Service) units.

“The fact of these deaths in such a short period of time – less than one year – is cause for great concern and we believe warrants immediate action from CQC.

“We therefore urge CQC to use the multiple mechanisms at its disposal to visit Junction 17 and the Gardener Unit at Prestwich Hospital to assess the treatment and conditions for patients and report publicly on the circumstances surrounding these extremely concerning deaths.”

Charlie Millers, the second youngster to die, – a ‘kind, caring lad’ – was found unresponsive in his room in the Junction 17 wing of Prestwich Hospital on December 2. He was given CPR at the scene and taken to Salford Royal Hospital but died five days later.

A Serious Incident Review done by the trust said that Charlie was seen with ligatures around his neck three times in the hours before he was found unresponsive with a ligature around his neck.

The review says he was alone at the time when he was found unresponsive in his room.

His mother, Samantha Millers, told the M.E.N that she was told her son was being checked on once every five minutes at the time he was fatally injured. She believes he should not have been left alone at all at the time.

He had previously had one-to-one monitoring because of his history of self-harm and attempts on his own life, the review says.

An inquest on Charlie’s death is due to take place in February. 

An inquest on Rowan’s is scheduled for June next year. His father, Marc, said: “Within 24 hours of Rowan’s death the Trust knew there was observation by staff issue. Within seven days they had done their own internal report which identified such problems. 

“The CQC says that it is not clear that learning from incidents was being shared across sites. Three months after Rowan’s death Charlie died. I believe if such learning had been shared Charlie’s death could have been avoided.”

Full article here

Source: Manchester Evening News, 26th November 2021

Published by CHARM Greater Manchester

CHARM, the Community for Holistic, Accessible, Rights Based Mental Health was launched by The Organic Recovery Learning Community in September 2020.

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