Law firm to investigate if senior managers were to blame for alleged abuse of patients at Edenfield mental health unit

The purpose of this investigation is to ascertain whether any individual or individuals employed by the Trust in a leadership capacity have caused or contributed towards failings in patient care’

The Edenfield Centre on the site of the former Prestwich Hospital is the subject of an investigation by GMP aftger alleged abuse of patients. Thirty staff are subject of disciplinary action by the Trust that runs it.

Thirty staff are the subject of disciplinary action after claims in a BBC Panorama programme that patients were abused. A dozen have been sacked, the MEN understands, and another 18 are to face hearings.

The action involves staff at the Edenfield Centre in the grounds of the former Prestwich Hospital amid demands for a public inquiry. There are fears, a Manchester City council committee hearing was told, alleged abuse of patients at the Edenfield Centre is happening at other Greater Manchester mental health treatment units.

Now Rupert Nichols, the chairman of the Greater Manchester Mental Health NHS Foundation Trust, which runs the unit has commissioned a law firm to carry out an “independent investigation”. It will scrutinise the role of the executive team, including the Chief Executive Officer, and the heads of specialist services including Edenfield management.

The Trust is also bracing itself for a Care Quality Commission report due to be published imminently which is expected to be damning.

In a letter to stakeholders, including, Bury council, Mr Nichols says the Edenfield Centre itself remains closed to new patient admissions, with a total of three wards closed in recent weeks. An enhanced management team remains in place, with daily oversight of patient care, staffing levels and a focus on safer staffing, additional training has also been provided across the Edenfield Centre.

He adds: “A separate investigation by Greater Manchester Police (GMP), into the allegations of failings in patient care identified by BBC Panorama, continues. We are co-operating fully with the police.

“All of the above forms part of the Trust’s commitment to put right the wrongs that have emerged in recent months – and to do so in a spirit of transparency and collaboration. Therefore, the Trust Board has also recently commissioned Law by Design Ltd to undertake a thorough and wholly independent investigation into the senior leadership of the Trust.

“The purpose of this investigation, delivered by a leading firm of specialist legal and HR experts, is to ascertain whether (and, if so, the extent to which) any individual or individuals employed by the Trust in a leadership capacity have, either through omission or action, caused or contributed towards failings in patient care.

“Their report, also due in December, will inform the Board of lessons to be learned and appropriate actions to be taken. In addition, central to our Improvement Plan is a continued commitment to engaging with service users, staff, carers and our wider stakeholders. This also forms part of our commitment to building back the trust of patients, their relatives and the wider public, and restoring the pride of our staff in working for the organisation.”

Several service user and carer “listening events” are being planned for the coming months. Mr Nichols adds: “Furthermore, our Freedom to Speak Up Guardian role continues to be widely publicised to colleagues across the Trust, as we rightfully ensure that staff have every opportunity to raise concerns and issues in a safe and confidential manner.”

Meanwhile an independent clinical review into the Edenfield Centre, has made 31 recommendations. It was commissioned by the Trust after it became aware of the Panorama findings and was led by Dr David Fearnley, Chief Medical Officer, of the Lancashire & South Cumbria NHS Foundation Trust.

Some staff were filmed by an undercover Panorama reporter embedded in the unit from March to June of this year. The footage in the one-hour programme captured apparent humiliation, verbal abuse, mocking and assault of patients – plus alleged falsification of medical paperwork. A patient called Joanna was filmed apparently being pinched twice by a member of staff, and, against the rules three male patients are found in one room watching porn, it is claimed. A member of staff was apparently filmed having a nap on a wall during her shift.

Full story here

Source: Manchester Evening News, 17th November 2022

Chair of Greater Manchester Mental Health Trust to step down

The move comes after ‘inexcusable behaviour and examples of unacceptable care’ were ‘exposed’ at a mental health unit, he said

Rupert Nichols, chair of Greater Manchester Mental Health NHS Foundation Trust, wrote a letter to the governors, board members and colleagues at the trust, shared this afternoon (November 18). Although Mr Nichols’ term of office ends next July, he announced he would be ‘retiring’ early from the position at the end of December 2022.

The Edenfield Centre is in the grounds of the former Prestwich Hospital and was the subject of a BBC Panorama programme that claims patients were abused. Since the episode aired, 30 staff are facing disciplinary action and a dozen have already been sacked, the Manchester Evening News understands. 

There are fears, a Manchester City council committee hearing was told, alleged abuse of patients at the Edenfield Centre is happening at other Greater Manchester mental health treatment units. Councillors are seeking a public inquiry, and the trust is also bracing itself for a Care Quality Commission report due to be published imminently which is expected to be damning.

The letter from Mr Nichols reads that ‘the trust would benefit from a new chair’ during this ‘recovery period’: ” Our Trust is facing significant challenges following the inexcusable behaviour and examples of unacceptable care that have been exposed at the Edenfield Centre. Both I and the Board have apologised to those affected directly and indirectly. 

“It is clear that it will take some time for the Trust to navigate the challenges of successfully implementing our Improvement Plan and rebuilding faith and confidence in our services. My term of office as Chair ends next July, but I believe that the Trust would benefit from a new Chair, bringing new ideas and energy to lead the Board through this recovery period and beyond.”

Some staff were filmed by an undercover Panorama reporter embedded in the unit from March to June of this year. The footage in the one-hour programme captured apparent humiliation, verbal abuse, mocking and assault of patients – plus alleged falsification of medical paperwork.

A patient called Joanna was filmed apparently being pinched twice by a member of staff, and, against the rules three male patients are found in one room watching porn, it is claimed. A member of staff was apparently filmed having a nap on a wall during her shift.

The outgoing chair says he is ‘absolutely certain’ the trust will ‘come through this difficult period’ to ‘once again be recognised as a provider of high quality, compassionate care’. Mr Nichols’ letter continued: “I have therefore decided to retire from the board at the end of December 2022, to allow the Trust to make a new appointment at the earliest opportunity.

” It has been an immense privilege to chair your Board and the Council of Governors. I am absolutely certain that Greater Manchester Mental Health trust will come through this difficult period, learning from the experience and making the appropriate changes to, once again, be recognised as a provider of high quality, compassionate care.” 

Thirty staff are subject of disciplinary action by the trust that runs the Edenfield site

In a letter to stakeholders, including Bury council, Mr Nichols previously said the Edenfield Centre itself remains closed to new patient admissions, with a total of three wards closed in recent weeks. An enhanced management team remains in place, with daily oversight of patient care, staffing levels and a focus on safer staffing, additional training has also been provided across the Edenfield Centre.

Full story here

Source: Manchester Evening News, 18th November 2022

North East NHS boss reacts to mental health scandals and says exposing failings ‘is a good thing’

The chief executive of an North East NHS Trust welcomed the exposure of failings and abuse in the mental health sector

After a series of NHS scandals highlighting abuse and failings within mental health wards, the top brass at a North East NHS trust has welcomed greater scrutiny. 

Speaking at a board meeting of the Cumbria, Northumberland, Tyne and Wear NHS Trust (CNTW) just hours after the publication of damning reports showing how counterparts at a neighbouring trust had failed three teenage girls in the lead up to their deaths under NHS care, chief executive James Duncan said it was important to “welcome” issues of abuse being highlighted. 

He said media reports such as October’s Panorama documentary highlighting abuse of patients at the Edenfield mental health ward near Manchester – along with further scrutiny of the failings at Tees, Esk and Wear Valleys NHS Trust that led to the deaths of Emily Moore, Nadia Sharif and Christie Harnett – were “a good thing”. 

Mr Duncan told the meeting: “I don’t think there’s ever been a time when the type of services we provide have been more in the news. And on that, I think the first thing to say is let’s not see that as a bad thing. Let’s see it as a good thing that issues of abuse and poor care are being brought into the public eye.

“Because if we are honest, the people we support are often a group who often can be most easily forgotten. So because of this we welcome the reports.”

CNTW has – on the orders of NHS England and the North East and North Cumbria Integrated Care Board – produced a report, discussed at the same meeting on Wednesday, setting out the “organisational response to findings identified at Edenfield Ward, Greater Manchester Mental Health NHS Foundation Trust”.

Claire Murdoch, NHS England’s national mental health director has told NHS Trusts to have an “it could happen here” mindset, Mr Duncan said, and to conduct urgent safeguarding reviews. 

The report, authored by chief operating officer Ramona Duguid “focussed on where we feel we have areas for further continuous improvement”. These areas, Ms Duguid wrote are around boosting leadership on wards and ensuring patient and carer voices are included in decision making – especially when it comes to long-term segregation and the use of restrictive restraints.

The report also set out “mitigations” in place to prevent risk factors from occurring – and highlighted work already happening including the use of a carer’s charter and “triangle of care” to ensure the involvement of those receiving care and their loved ones in decisions.

It adds that there is “24/7 oversight” and “robust processes in place for support and investigations in relation to maintaining professional standards for medical, nursing, therapies, and allied health professionals”.

Full story here

Source: Chronicle Live, 2nd November 2022

‘Treated worse than animals’: Huntercombe investigation reveals decade of mistreatment in care of more than 20 teenagers

A Sky News investigation into five hospitals run by The Huntercombe Group has revealed repeated allegations of over-restraint and inadequate staffing, which youngsters say left people at increased risk of self-harm

More than 20 former patients or their relatives have revealed how they were “treated worse than animals” and failed by the “awful” care they received at mental health hospitals for teenagers.

Testimonies gathered in an investigation by Sky News raise repeated allegations of over-restraint and inadequate staffing which youngsters say left people at increased risk of self-harm.

Patients described being left in rooms with blood on the walls, and accuse staff of failing to prevent them from hurting themselves.

The mother of one girl, who wishes to remain anonymous, said that patients were “treated worse than animals” with many subjected to “clear trauma, pain and suffering”.

The allegations stretch back more than a decade, impacting teenagers being treated for serious mental health issues by a single provider – The Huntercombe Group – paid for by the NHS.

Sky News has presented its findings to the Department of Health, which described the allegations as “deeply concerning”.

Another patient named Danae reveals bruise from over restraint
A patient named Danae revealed bruises from over restraint during her care

Repeated claims of over restraint

Sky News spent months tracing the group, most of who don’t know each other, in a joint investigation with The Independent.

Eighteen-year-old Alice Sweeting, who was in Huntercombe’s Maidenhead unit for 14 months until autumn last year, told us: “No one’s going to get better in that environment.

“I think it’s awful. It shouldn’t be open. I don’t know why they’re still running.”

Alice Sweeting
Alice says staff failed to stop her self-harming

At least three of the former patients we spoke to revealed they have been diagnosed with post-traumatic stress disorder (PTSD) since leaving the units – with their treatment at the hospital contributing to the diagnosis.

Amber Rehman, 18, said the time she spent in the unit made her mental health condition “much worse”.

“It hasn’t stopped. Every day, guaranteed. It’s been going through my head more than anything else,” she said.

“I just want to move on.”

Amber blames the care she received for the deterioration in her mental health condition

Reviews criticise ‘coercive’ restraint

Sky News has seen independent reviews – commissioned by The Huntercombe Group – which raise concerns into the care of three of the young people we’ve spoken to. Two of the reports describe the use of restraint as “coercive”.

We can also reveal the NHS has paid The Huntercombe Group nearly £190m since 2015 to provide adolescent mental health inpatient services, despite repeated criticisms about the standard of care patients have been receiving in its units.

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A Department of Health and Social care spokesperson said: “The allegations of mistreatment that have been raised are deeply concerning.

“We take these reports very seriously and are investigating the concerns raised and are working with NHS England and the CQC (Care Quality Commission) to ensure all mental health inpatient settings are providing the standard of care we expect.”

Former Children’s Commissioner Anne Longfield, who is chairing an independent review of inpatient mental health care in England, described the allegations as “barbaric” and called on the CQC to re-inspect the units “urgently” and speak to the youngsters we’ve interviewed.

The Huntercombe Group

Police investigate death of patient

The Huntercombe Group was taken over by Active Care Group at the end of last year. Two months after the takeover, a patient died at the group’s unit in Maidenhead, now called Taplow Manor, with Thames Valley police currently investigating.

Taplow Manor and another unit in Staffordshire remain open. Three other children’s mental health units which were part of The Huntercombe Group have closed.

Dr Sylvia Tang, who was CEO of The Huntercombe Group since June 2020 and is now CEO of Active Care Group, said: “The death of a young person at Taplow Manor in February 2022 was a tragic and sad event.

“We have already taken steps to make improvements to the service and remain committed to providing the best possible care for our patients. Our sincere condolences go out to the young person’s parents and all who have been affected.”

In response to our dossier of concerns raised by former patients, Dr Tang said: “At the time most of these incidents are alleged to have taken place, the Active Care Group, did not own the facilities at which they are purported to have happened.

“ACG acquired 12 of The Huntercombe Group services in December 2021 (including the brand), and previous owners retain all the legal entities and associated records for these facilities prior to their acquisition.

“The current group is therefore unable to comment on the services provided prior to this date.”

Active Care Group says it has “robust” processes in place.

The previous owners of The Huntercombe Group – Elli Investments Group – told Sky News: “We regret that these hospitals and specialist care services, which were owned and independently managed by The Huntercombe Group, failed to meet the expected standards for high quality care.”

An NHS spokesperson said: “The NHS has repeatedly made clear that all services must provide safe, high-quality care and deliver on the commitments in their contracts.

“We continue to work closely with the CQC to monitor, identify and take appropriate action where it is needed.”

Full story here

Source: Sky News, 27th October 2022

Redditch mental health ward faces claims of sleeping staff and bullies

Whistle-blowers have described neglect, patient-on-patient assault and staff who bully colleagues and sleep on the job at a troubled mental health ward.

Sources told a BBC investigation that a patient of 25-bed, mixed-gender Hill Crest Ward in Redditch, Worcestershire, suffered a broken jaw during one clash.

They also claimed three nurses were “forced out” amid bullying behaviour. 

The NHS trust that runs Hill Crest said it believed changes there were having a positive impact. 

Accounts have been corroborated via five independent sources to whom the BBC spoke. They follow reports earlier this year of a fire and an incident in which staff locked themselves in an office when a patient ran around armed with boiling water and sugar. 

In the latest reports, the vulnerable male patient whose jaw was allegedly broken was said to have sustained the injury in one of three assaults by other patients. 

Sources said a doctor who saw him in A&E was concerned for his welfare and phoned Hill Crest not only about the injuries but its safeguarding, with the matter reported to watchdog the Care Quality Commission (CQC).

Sources claimed the man had been inappropriately placed at Hill Crest as had an elderly woman, who, they alleged, was punched in the face by a much younger, male patient. 

Another staff member asleep
Image caption, The trust told the BBC it would not comment on each of the specific claims

Additionally, one patient has provided the BBC with images alleged to show the effects of her battering herself out of desperation – without staff intervening.

Sources also described staff being bullied, with one saying a nurse who particularly suffered had her resignation letter read out and mocked by tormentors. 

Sources independently complained of the workplace culture, with the BBC aware of explicit images bearing lewd comments about colleagues.

The BBC has also been provided with images of three members of staff who appear to be asleep in an office in full view of patients. 

Sources reported one nurse fell asleep twice when supposedly on level-three observation – an alert status in which patients should be watched at all times because they were at risk of killing themselves. 

Hill Crest
Image caption, Hill Crest Ward is in Redditch, Worcestershire

One source claimed that while many staff were highly dedicated, there were issues, particularly with some agency staff. 

Worcestershire and Herefordshire Health Care Trust said it was unaware of the “sleep” photos and would investigate. 

‘Lot to answer for’

It added it was aware of incidents in which staff standards were “significantly short of what we would expect” and said new issues shared by the BBC – including use of crude language – had been raised internally and subject to investigation.

The trust told the BBC it would not comment on each of the specific claims but was aware of some of them and had investigated.

The trust added it was best practice to support patients as close to home as possible and it had been one of the best performing trusts nationally for minimising out-of-county placements. 

However, it said it was essential people were accessing the care and treatment that best met their clinical needs. 

Following the boiling water report of July, the CQC carried out an unannounced inspection at Hill Crest, the findings of which are yet to be published. 

The trust said it had introduced changes following the inspection and did not believe the conditions most recently relayed to the BBC occurred since the introduction of the measures. 

A number of staff have criticised the CQC, which has not revisited the site since the summer.

“The CQC have a lot to answer for,” one said. “I know that a number of people have made complaints about what has been going on at Hill Crest – I have made complaints myself and they haven’t been acted upon.” 

The CQC said a report from the focused inspection would be released in due course. 

Mike Wilson, regional officer for the Unison union, said he was aware of allegations that patients were not being looked after safely because of a shortage of psychiatric intensive care beds. 

He also said Hill Crest relied heavily on agency staff. 

“Unison has been raising concerns about health and safety on the ward for three years,” he added.

Full story here

Source: BBC News, 15th November 2022

England’s mental health care lacks money, yes – but it also lacks compassion

We have made great progress in England when it comes to acceptance and knowledge around mental health issues. But have our basic services also improved in tandem? We are told that clinical approaches to mental health are getting better: that the coercive control of the asylum era is over, heralding care in the community; that the blossoming of interest in wellbeing means psychiatric care is no longer the second-class citizen of medicine. But some facts, unfortunately, tell a more harrowing story, reflecting a problem as much with ideology as funding.

In the past few months, scandal after scandal has shone a light on the appalling state of mental health inpatient care (meaning those who have to stay at least one night). First, we had a Panorama investigation into the Edenfield Centre, a secure psychiatric hospital run by the NHS in Manchester, which alleged that vulnerable patients were ridiculed and inappropriately restrained. Then a Dispatches undercover investigation showed wards in Essex where patients appeared to have been cruelly treated, despite repeated inquiries into a series of suicides between 2004 and 2015, hauntingly represented in the ongoing agony of interviewed family members. In the past week, we’ve heard of more than 20 teenagers alleged to have been mistreated in wards managed by the private sector Huntercombe Group, followed by an independent investigationinto a Middlesbrough hospital, describing the failures preceding the suicides of three young women.

The same themes occur again and again. The overuse of restraint, which can spill over into the violence of being dragged down corridors; arbitrary and, at times, punitive boundaries being set; a lack of understanding of autism, eating disorders and self-injury; suicidal patients left at high risk; a lack of compassion.

It is easy to blame “bad apples” to protect our collective fantasy of angelic NHSstaff. But life is more complicated than this, as are the dynamics in health systems. Teams can and do become toxic, caught up in coercive and cruel practices into which new members become socialised. We are all vulnerable to these processes, though it scares us to think so, and never more so than in a brutally underfunded, over-pressurised system.

England has fewer psychiatric beds than ever before, with numbers having fallen by a quarter since 2010, from 23,447 to 17,610. Such a drop would always be catastrophic, let alone at a time of increasing demand and with community services drastically underfunded. The wellbeing agenda, with its focus on milder problems, can lead to great statistics in a way that doesn’t work for severe mental illness; longer-term needs get sidelined and our patients increasingly lurch between neglect in the community and poor treatment in wards.

Good care has simple principles that we too quickly forget. As patients, we benefit from a trauma-informed environment – a paradigm shift from our obsession with labelling what is wrong to asking: “What happened to you?” – that is welcoming and not too sensorily overwhelming. We need a kind word and an open ear from familiar staff who know us. We need medication, at times, to dampen pain or galvanise our mood; activity or bed rest, depending on the state we have arrived in and nourishing soul food. Lacking the ethos to provide this kind of care, staff get caught up in increasingly brutal protocols aimed at extinguishing surface problems rather than deeper exploration.

Everyone loses in this equation. I am in touch with two fellow activists who are inpatients and they report staff who have been in tears at the discrepancy between what they want to do and what they can. A worse fate awaits patients who experience excessive restrictive practices that directly repeat the way society or early caregivers have treated them; a particular problem for Black men and abuse survivors.

Beyond the obvious things required – clawing back the millions spent on private provider beds; specialist units for those with autism; the end of the diagnosis that is most weaponised against patients, borderline personality disorder; and training on self-injury – we need the types of non-carceral approach, those not based on a logic of imprisonment, that grassroots organisations have long lobbied for.

Ask any consultant where they would most like to have a breakdown, and the answer is probably Trieste. This Italian city is recognised by the World Health Organization as a centre of excellence, having little involuntary treatment and few hospitalisations. Trieste focuses on principles that are dear to patients: dignity and respect; inclusion in the city’s daily activities; an emphasis on the social relations that define us; access to nature, and that great enemy of anguish, play. Deinstitutionalisation works in Trieste; once, there were 1,200 beds for a population of 240,000 citizens, now there are only six general hospital beds and 30 overnight community centre beds. But it works only because there is a community scaffolding there to uphold it.

We can make this jump in England, investing in emerging projects such as Bristol’s Link House and London’s Open Dialogue that emphasise the importance of human relationships in responding to mental health crises. The well-intentioned efforts today to create parity between mental and physical health must not lose sight of this. We are not applying a physical procedure, like a bandage to a wound, but hoping to create relationships within which the ailing person can heal. This is what we cannot afford to ignore any longer.

  • Jay Watts is a clinical psychologist, psychotherapist and senior lecturer working in London

Full story here

Source: The Guardian, 10th October 2022

People in Greater Manchester waiting months between NHS therapy sessions for mental health conditions

Exclusive analysis of NHS data shows which health bodies in the city-region are missing targets to get people into a first appointment within six weeks of a referral.

Exclusive analysis of NHS data also shows which health bodies in the city-region are missing targets to get people into a first appointment within six weeks of a referral. 

People seeking help with mental health conditions including depression and anxiety face long waits between their NHS therapy sessions, data shows.

Exclusive analysis of NHS statistics by our sister title NationalWorld has taken a look at the Improved Access to Psychological Therapies (IAPT) programme for adults across England, which provides talking therapies to people with common mental health conditions.

The analysis shows that in Greater Manchester some patients were having to wait more than 90 days between their first and second appointments in the first half of 2022. In addition, some health bodies in the city-region are failing to meet the target that 75% of people who gets referred for IAPT has their first appointment with a therapist within six weeks.

Health organisations and charities say mental health services are struggling to cope with a combination of budget cuts and increased demand, and that the Covid-19 pandemic has added to their workloads and the pressures they face.

What does the data show for Greater Manchester?

The data shows that between January and June 2022 hundreds of people at clinical commissioning groups (CCGs) across Greater Manchester were having to wait more than three months for a follow-up therapy session following their initial one.

At NHS Stockport CCG 705 people, just over half of the 1,390 who had a second session of IAPT, had to wait more than 90 days. At NHS Bury CCG 505 people had to wait more than three months, or 40.1% of people who had a second appointment, while at Tameside and Glossop exactly one in three people having more than one session faced a 90-day wait between their first and second.

At NHS Bolton CCG, NHS Manchester CCG and NHS Oldham CCG almost one in four people having a second therapy session had to wait more than 90 days after their first for it, while at NHS Salford CCG the percentage of people on the IAPT programme for multiple appointments waiting that long was 16.8%.

The data shows that thousands of people on the programme were having to wait more than 28 days for a second appointment with a talking therapist.

NationalWorld’s analysis also looked at how many people were getting to see a therapist within six weeks of a referral in June 2022. Health bodies are supposed to meet a target of getting 75% of those referred for IAPT sessions into a first appointment within that time frame.

Of the Greater Manchester health organisations NHS Bury CCG had the worst figures for that month, with just 38% of IAPT referrals getting to a first appointment within six weeks. The CCGs in Salford (53%), and Oldham (62%) also fell short of the 75% target.

What has been said about the data?

Marjorie Wallace, chief executive of the mental health charity SANE, said: “Psychological therapies are an important part of treatment, and early intervention is vital. It remains deeply concerning that patients still appear to be facing these ‘hidden waits’. 

“Waiting is hard when you are struggling mentally and excessive delays between the first and second appointment for a particular therapy may leave some people more at risk than they were before. It is worrying that there is such variation in waiting times across the country.

“Patients in desperate need may become far more seriously ill. We know that many simply give up on treatment or deteriorate further while waiting for it to commence. This may trigger a patient into self-harm or increase the risk they become suicidal.

“Psychological services are struggling under the dual weight of tightening budgets and increasing demand, leaving too many people without the help they need.”

Louise Ansari, national director at Healthwatch England, said: “Mental health services are under massive strain right now, and despite increased investment in recent years, the pandemic has resulted in unprecedented levels of demand for support.

“Sadly, it is all too common for Healthwatch teams across the country to hear from people having to wait many months at each stage of the pathway, often with little communication about what is happening. This leaves them feeling in limbo and struggling to self-manage their condition. And when they are finally able to access support, it is not always the right sort of help or is time-limited only.

“For some these delays are difficult, for others can be dangerous. Patients in crisis report to us that services seem oversubscribed, particularly community services, which could have helped prevent circumstances escalating in the first place.”

ManchesterWorld has contacted Greater Manchester health organisations and Healthwatch groups for comment.

Full story here

Source: Manchester World, 13th October 2022

‘Happy-go-lucky’ woman died after self-harming at Jigsaw Independent Hospital whilst supervised by mental health staff, inquest hears

Claire Morris, 35, was receiving 24-hour supervision after being granted leave from a mental health unit in Didsbury

Claire Morris died on December 15, 2020

A woman sectioned under the mental health act died after self-harming in her home – where she was receiving 24-hour supervision, an inquest heard.

Claire Morris, 35, had been granted leave from a mental health unit in south Manchester, when she was found critically injured in her bedroom by staff on December 15, 2020.

She was rushed to Manchester Royal Infirmary where despite the best efforts of hospital staff, she was pronounced dead a short time later.

A jury at Manchester Coroner’s Court heard that Ms Morris had been under the care of Jigsaw Mental Health Facility in Didsbury, after being diagnosed with unstable personality disorder as a teenager.

In the summer of 2020, Ms Morris was granted Section 17 leave, which allowed her to return to her flat in Wythenshawe – where she would be supervised by mental health staff 24 hours a day.

Jurors heard that Ms Morris, who suffered with anxiety and had a history of self-harm, had expressed multiple concerns about changes to her nursing team in the lead up to her death.

An inquest into Ms Morris’ death is being heard at Manchester Coroner’s Court (Image: MEN Media)

Despite her history of self-harm, the court heard there was nothing written in her care policy about how often she should be checked on by staff.

Further risk-assessments about Ms Morris’ risk of self-harm which ‘should have been’ completed, were not done so in the months leading up to her death, the court also heard.

On the night of her death, she had been on the phone to her mum, Janet Le Boutillier and had been making arrangements for Christmas, the court heard.

Ms Le Boutillier said: “She said she would not be able to come that year because a member of staff had been rota’d to be with her for Christmas Day who didn’t’ celebrate it.

“She didn’t want to upset that staff member by bringing her along. Claire said she’d ask the hospital if anyone else was available but she was told they weren’t.

“She loved Christmas and was annoyed at the way things were going. I promised I would phone the hospital the next morning. I had no concerns about her and we had actually arranged to go shopping the next day.”

Following Ms Morris’ tragic death, Ms Le Boutillier described her daughter as a ‘happy-go-lucky’ woman who loved singing and cooking, and adored her two cats Angel and Socks.

“She didn’t have much of a teenage life because of her illness so she tried to fit it all in as she got older,” she said. “She loved her cats; they were her everything.

“To begin with, she was very happy with the set up at Jigsaw. She had been given a new flat near to the hospital and she was happy with her care plan.

“The last couple of months of her life it all changed. The staff she had come to rely on started changing and she got very upset because was very uncomfortable with change.”

Ms Le Boutillier said she would usually speak to her daughter over the phone, as due to the ongoing coronavirus pandemic, Ms Morris was worried about passing anything on to her mother.

“She phoned me on many occasions upset and I would tell her to call the hospital and she said she had many times but that she was getting nowhere,” she said.

Ms Le Boutillier told jurors that she believed her daughter wanted to ‘live her life’ and that self-harm was ‘never about dying’ for Claire.

“She wanted to become a counsellor to help other people who had been through what she had,” Ms Le Boutillier said. “Self-harm was the only way she felt able to calm herself down. She would only do it if she knew there was someone around who could help if she needed them.”

Former Hospital manager, Sonya Cunningham, told jurors Ms Morris was the only patient being managed 24/7 at home at the facility, which was ran by Equilibrium Healthcare.

She told the court that when she returned to work from maternity leave in November 2021, Ms Morris voiced that she was unhappy with the way her care was being staffed.

“Claire was unhappy with not knowing who was turning up and it was increasing her anxiety,” Ms Cunningham said.

“I wanted Claire to have notice of the rota as I agreed with her that it was distressing that she didn’t know who to expect. We agreed to give her as much notice as we could. There was never a time where she didn’t have sight of the rota before staff arrived.

“But there was such a high turnover of staff and I was increasingly relying on agencies. It would be 7pm at night and I was trying to find someone who was on her list of agreed staff.”

The court heard that Ms Morris’ care policy stated that “staff should always know the whereabouts of Claire,” but that no prescribed time observations were written.

Ms Cunningham told jurors that despite this not being written down, she would have expected care staff to approach Ms Morris every 15 minutes to check her mood.

“I would expect it to be really clear in the care plan what the minimum times of approaching Claire would be and how it would be recorded,” she said.

Jurors heard that a risk assessment of Ms Morris’ likelihood of self-harming, which was carried out in August 2020, deemed the current risk as “medium” but historically ‘very high.’

When asked by coroner, Zak Golombeck whether another review should have been completed in the run up to December, Ms Cunningham said “yes,” adding “I don’t know why one wasn’t completed.”

Commenting on the proposed Christmas rota provided to Ms Morris, Ms Cunningham said: “It was important for me to make sure everyone had a plan for Christmas.

“Claire wasn’t happy that one of the team was going to be on nights over that period but that was a request from the member of staff due to personal issues not me,” she said.

“Even though Claire felt there were significant concerns there wasn’t actually that many changes made to the rota. I am not undermining how she felt at all but I think she wanted things in a specific way that could not always be implemented.”

Full story here

Source: Manchester Evening News, 8th November 2022

External Clinical Review of Edenfield makes 31 recommendations addressing lack of safety and need to address failings in use of seclusion

A briefing note issued last week by chief executive of GMMH, Neil Thwaite told staff: “The Panorama programme was broadcast on September 28, 2022.

“The board was appalled by the content of the broadcast, which was both deeply upsetting and intensely challenging.”

“The trust board continues to work closely with NHS England, the Ministry of Justice, NHS Greater Manchester (our local Integrated Care Board), GMP and Bury Safeguarding Unit.

“Our principal objective remains the wellbeing of our patients and the provision of the best possible care for the communities we serve.”

The note added that the trust has concluded detailed, senior-led reviews of all affected patients to ensure their safety and well-being and that it has closed a number of wards within the centre.

Following the broadcast of the BBC Panorama programme, the trust commissioned an External Clinical Review of the unit, led by chief medical officer for Lancashire and South Cumbria NHS Foundation Trust, Dr David Fearnley.

Dr Fearnley’s report makes 31 recommendations in a range of areas including safer staffing, safeguarding and leadership.

In regards to safer staffing the report says: “The trust should have clear expectations relating to safe staffing levels; all wards should have a registered nurse on each shift.

“This expectation should be reflected in the trust’s safe staffing procedure.”

On the use of seclusion, it adds: “The trust should review the seclusion facilities and consider a model that reduces isolation, enables greater staff support, and enhances private and confidential communication.

“The trust should urgently review the seclusion facilities and make necessary environmental repairs to the facilities.”

Full story here

Source: Bury Times, 8th November 2022