Mental health care is the next big scandal brewing in the NHS

Subject to its findings, the Essex inquiry could turn out to be one of the worst scandals of NHS treatment in its history

Beth Matthews saved lives with her brutally honest, often shockingly graphic, posts about surviving a suicide attempt. She was an extraordinary young woman, whose blogs and social media threads often reached other unwell people at the darkest moments in their lives. She met the police officer who had held her hand after her own suicide attempt, shared X-rays of her shattered pelvis and told her followers that suicide was not the answer. Yet that was how Beth died in March 2022.

An inquest this week concluded that neglect by the Priory Hospital Cheadle Royal contributed to her suicide. Beth had ordered poison from Russia, which she had opened near staff, but had told them it was something else. Her care plan had stated that they should be aware of the contents of her post and that she had made frequent suicide attempts over a long struggle with what had been diagnosed as a personality disorder. After the inquest, it was revealed that two other women had died after being admitted to the same unit in just two months last year. The Priory say the two further deaths, of Lauren Bridges in February 2022 and Deseree Fitzpatrick a month later, are unconnected.

What does connect these deaths and a number of other big inquiries into NHS mental health services – whether provided by private organisations like the Priory or directly contracted – is that mental health care is looking like the next big, appalling, scandal in the health system. We had Mid Staffs and a slew of maternity scandals including Morecambe, Shrewsbury and Telford and East Kent. These have rightly shocked the public. The scandals in mental health may be bigger. 

Today, ministers announced a nationwide ‘rapid review’ into safety in mental health services. Last week, the chair of an inquiry into mental health deaths in NHS trusts across Essex asked the government to upgrade her investigation to a formal public inquiry. Dr Geraldine Strathdee was initially asked to investigate 1,500 deaths over a 21 year period, but in December she was made aware of a further 500. She said only 11 staff out of the 14,000 she had invited to give evidence had agreed, and the inquiry needed stronger powers to compel witnesses. 

The Essex Partnership University NHS Foundation Trust has said it continues to ‘support the ongoing inquiry and encourage service users, family, carers and staff to share their experiences with the inquiry team so they have a full picture to draw on to make their recommendations’. 

The Essex inquiry is already bigger than Mid Staffs. Subject to its findings, it could turn out to be one of the worst scandals of NHS treatment in its history. Yet, like Mid Staffs, the alleged failings Strathdee and her team are investigating have been highlighted all over the country and not just in Matthews’ untimely death. The Priory has had a number of high-profile incidents, with the Care Quality Commission regulator giving highly critical inspections of four of its units which then closed. 

Matthew Caseby was a patient at Priory Woodbourne Hospital in Birmingham in September 2020 when he climbed over a fence and was hit by a train. He was just 23. He had suffered a psychotic episode which had led to his admission to the hospital, where his family had hoped he would make a full recovery. Instead, the inquiry into his death found 32 ‘contributory factors’ in his suicide which the jury at his inquest concluded had been ‘contributed to by neglect’. He was the third patient to have climbed over the fence – and a fourth did so shortly after his death.

It’s not just the Priory. Cygnet is another private provider of mental health services; campaigners have been tracking deaths in this provider’s facilities. Emma Pring was transferred from the Sussex partnership NHS trust to a ward at Cygnet in Maidstone in July 2020. She died in April 2021, and her inquest found an ‘insufficient level of observation and misjudgement of Emma’s actual risk’. Directly-provided NHS services suffer from similar inadequate assessments and procedures – often as a result of short staffing. Earlier this month, the coroner at Luton and Bedfordshire coroner’s court said the death of Desmond Maddix, a patient at an acute psychiatric unit run by East London NHS foundation trust, died as a result of ‘failure of the most serious kind’ when he was injected with heroin by another inpatient.

Mental health has always felt like an optional add-on to the NHS, both in terms of the availability of treatment and the ability of the system to reform at all. It took nearly thirty years between Enoch Powell declaring in 1961 he wanted to close down mental institutions and the first outdated Victorian asylum closing in 1986. By then, the ‘care in the community’ system that Powell had advocated was in serious trouble, in part down to a lack of funding. Even today, the funding for long-term inpatient treatment is thin, to the extent that sufferers, Beth included, are lucky to end up in units 300 miles away from their families and wider support networks. The basic political problem is that while it is now finally fashionable to talk about mental health, it is still not politically expedient to do much about the particularly severe end of the psychiatric spectrum.

Inpatients in mental health services will say they don’t feel the recent global conversation about mental illnesses has made much of a difference to them, not least because the popular discourse tends to focus on three illnesses – anxiety, depression and PTSD. While debilitating, these illnesses are a bit easier for the public to understand. 

Beth Matthews had a personality disorder, one of a number of diagnoses that can lead to patients being labelled ‘manipulative’ within the health system. This can lead them therefore to be overlooked by overworked, underpaid and often under-skilled staff in residential units. She was relieved when her specialist multidisciplinary team and consultant agreed that a personality disorder wasn’t her primary diagnosis, changing it to depression/PTSD. Other patients with a personality disorder diagnosis say it instantly leads to hostility from medical professionals, and that they wish they’d never been given that label.

Beth’s family were relieved when the NHS agreed to funding for her placement at the Priory, believing that finally she was in a safe place where she might start to recover. She had written of wanting to ‘grab this opportunity with both hands’, and on arrival was happy that her room felt like a ‘hotel’ compared to her previous ward. 

The Priory says it has changed its procedures around care plans and other weaknesses in Beth’s care. Beth, meanwhile, changed other people’s lives. Her life should have been so much longer. But her name could be one that we always remember as a turning point in how seriously society takes the treatment and safety of mental health inpatients, after decades of trying not to think too much about it.  

Full story here

Source: The Spectator, 24th January 2023

Ministers order ‘rapid review’ into mental health inpatient care in England

Dr Geraldine Strathdee to investigate care units after series of scandals involving abuse or neglect of vulnerable patients in psychiatric in-patient services

Denis Campbell

Edenfield hospital, where a BBC Panorama investigation found staff had been mocking, slapping and pinching patients.
A BBC Panorama investigation found staff at Edenfield hospital had been mocking, slapping and pinching patients. Photograph: Mark Waugh/Alamy

Ministers have ordered an inquiry into the quality of care in mental health inpatient units in England after a series of scandals in which vulnerable patients were abused or neglected.

Maria Caulfield, the mental health minister, announced the establishment of a “rapid review” in a written ministerial statement in the House of Commons on Monday.

The inquiry “is an essential first step in improving safety in mental health inpatient settings”, she said. In recent years, coroners and the Care Quality Commission, the NHS care watchdog, have repeatedly raised concerns about dangerously inadequate care that inpatients have received.

It will examine the evidence of “patient safety risks and failures in care” in units that hold and treat patients who have serious conditions including psychosis and personality disorder. It will look in particular at evidence of failings brought forward by patients and their families and how better use of data can help show that care has fallen below acceptable levels.

The inquiry will be headed by Dr Geraldine Strathdee, a psychiatrist who used to be NHS England’s national clinical director for mental health. She is likely to look at problems including patients being subjected to controversial restraint techniques, left at risk of being able to take their own lives and segregated from fellow inpatients, and the impact of their experiences on their recovery.

The investigation follows media exposes in recent years of how people with very fragile mental health in a number of units have been mistreated and left at risk in often understaffed facilities. In the most recent case last September the BBC’s Panorama programme found that staff at the Edenfield hospital had been mocking, slapping and pinching patients. The police said it would investigate the evidence.

Mental health charities welcomed the move.

“The harrowing cases reported recently, combined with the dedicated campaigning by families who tragically lost loved ones that they expected to be safe and cared for in hospital, highlights the gravity of the situation and the urgency with which standards must improve”, said Mark Winstanley, the chief executive of Rethink Mental Illness.

Strathdee is already the chair of a government-ordered nonstatutory inquiry into an estimated 2,000 potentially avoidable deaths of mental health patients in Essex between 2000 and 2020. However, she told the health secretary, Steve Barclay, last week that she could not fulfil the terms of that inquiry because only 11 of the 4,000 staff invited to give evidence to it chose to attend.

Sarah Hughes, the chief executive of the charity Mind, called the inquiry “a positive step”. It has been urging ministers to initiate a full statutory inquiry into inpatient mental health care.

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“This announcement comes in the wake of deeply concerning reports over the last few months and indeed years from some patients and their loved ones about failings in mental health hospitals across the country.

“This review needs to gather information on the much deeper-set systemic failings in mental health care, and establish what works in successful mental health settings that provide therapeutic and safe care,” she added.

Full story here

Source: The Guardian, 23rd January 2023

Hospital staff ‘could have done more’ to help man, 35, killed by taxi outside A&E

Daniel Kirton attended A&E to ‘detoxify’ from Spice but ended up getting killed when he rolled into a road outside Manchester Royal Infirmary and was hit by a taxi. Hospital staff ‘could have done more’ to help a man who was threatening to take his own life in the minutes before his death, a coroner ruled.

Daniel Kirton attended A&E to ‘detoxify’ from Spice but ended up getting killed when he rolled into a road outside Manchester Royal Infirmary where he was hit by a taxi.

A coroner has ruled that mental health staff who dealt with Mr Kirton were not guilty of ‘gross failings’, but could have done more.

The 35-year-old, who was homeless, was discharged following a mental health assessment on December 3, 2020.

Once outside, Mr Kirton told security staff he ‘wanted to die’.

He was not re-admitted for further assessment, Manchester Coroners’ Court heard, having earlier been deemed fit for release by Greater Manchester Mental Health NHS Foundation Trust staff.

Security remained with Mr Kirton until he left the hospital grounds around 11.35pm.

At 11.37pm, he rolled onto a road, before being hit by a private hire vehicle.

He was rushed back inside, but died at 12.57am on December 4.

His cause of death was given as ‘chest injuries’.

Mr Kirton’s death has been the subject of a coronial investigation. Mr Kirton’s family were in court as the case concluded on Friday, Manchester Evening News reports.

Area coroner Zak Golombek told the court Mr Kirton was initially seen by members of the mental health liaison team at around 10.15pm.

He was ‘calm and polite’ during the initial stages of the assessment, saying he wanted to detox from Spice and address his homelessness.

Mr Golombeck referred to previous hearings, in which it was said there were no signs of depression or psychosis.

Mr Kirton, the court heard, started to become threatening when medics discussed discharge and offered community treatment.

Members of the hospital’s security team overheard a ‘commotion’, Mr Golombeck said, and Mr Kirton was escorted from the building at around 11.15pm.

Once outside, he told staff on ‘numerous occasions’ he ‘wanted to die’. Security staff stayed with him in a bid to calm him down and distract him, the court heard.

Mr Kirton attempted to take his own life on hospital grounds.

Security asked for members of the mental health liaison team to go outside see him, with one member of staff going to A&E in search of a medic.

“The security officers displayed integrity and went above and beyond their brief,” Mr Golombeck said.

Mental health nurse Godfrey Chiveya saw Mr Kirton outside at around 11.23pm. Security told him Mr Kirton had said he wanted to take his own life. Mr Chiveya said he did not believe there was a threat to his life, Mr Golombeck said.

After around four minutes, they had reached an ‘impasse’. Mr Chiveya told Mr Kirton he would be seen by a member of the community mental health team the next day and left.

“They thought the risk was the same as in A&E,” Mr Golombeck said.

“The security didn’t think they were taking him seriously, they didn’t appear in control of the situation,” he added.

Mental health nurse Cara Oates, from North Manchester General Hospital, investigated the case.

She said the mental health liaison team’s assessment of Mr Kirton in A&E was reasonable, but interactions with him outside ‘were not appropriate and he required further assessment’.

Reviewing the evidence, Mr Golombeck said the initial assessment was ‘reasonable’ and that it was an ‘incredibly difficult’ task to carry out considering Mr Kirton’s aggressive behaviour.

The coroner said this impacted on the team’s ‘personal views’ of Mr Kirton in a ‘negative sense’.

The mental health liaison team’s interactions with Mr Kirton outside the hospital were criticised throughout the hearing by those representing his family, but Mr Golombeck said: “There were failings outside the hospital building, but not total and complete failures – not gross failings.”

He said Mr Kirton ‘required further assessment’ due to ‘his presentation outside the hospital building’.

But Mr Golombek said he was unable to determine if Mr Kirton would have gone back to A&E, adding that he ‘actively chose’ to leave the hospital site when he could have gone back .

Recording a short form conclusion of suicide, Mr Golombeck said: “Daniel intended to take his own life when laying in the road. There was no significant planning to this and it appears to be somewhat impulsive, and done with the intent of ending his life.”

At a previous hearing Mr Kirton’s brother David said his sibling had ‘struggled with mental health for a long period of his life’, but was ‘kind and compassionate’.

“He was someone who struggled with mental health for a long period of his life. He was kind, compassionate and would help out anyone,” he added.

Full story here

Source: The Mirror, 16th January 2023

The mental health patients dying on NHS wards from starvation and neglect

Investigation: Scores of patients in mental health units have died from physical illnesses that could have been avoided. Rebecca Thomas uncovers systemic issues in the health service that experts say are leading to the neglect of the vulnerable.

Yvonne Eaves died from a blood clot while an inpatient at the Greater Manchester Mental Health NHS Foundation Trust in 2020, after staff within the unit failed to carry out a risk assessment for blood clots.

Great Manchester coroner Nigel Meadows attributed her death to “a gross failure to provide her with basic medical care”. Hers is one of four cases in which coroners warned of inadequate blood clot assessment and treatment within inpatient units.

Gill Green, of the Greater Manchester Mental Health NHS Foundation Trust, said improvements had been made to physical healthcare provision, including a new strategy and the introduction of new job roles with a physical healthcare focus.

Experts warn that poor training and a lack of funding are factors in the neglect of vulnerable patients

A systemic failure to provide basic physical care on NHS mental health wards is killing patients across the country, despite scores of warnings from coroners over the past decade, The Independent can reveal.

An investigation has uncovered at least 50 “prevention of future death” reports – used by coroners to warn health services of widespread failures – since 2012, involving 26 NHS trusts and private healthcare providers.

Cases include deaths caused by malnutrition, lack of exercise, and starvation in patients detained in mental health facilities. Experts warn that poor training and a lack of funding are factors in the neglect of vulnerable patients.

Our investigation uncovered:

Staff failing to carrying out basic health checks, such as assessment for risk of blood clots
Cases of nurses and care assistants without adequate CPR training
Doctors unable to carry out emergency response procedures
Patients not treated for side effects of antipsychotic medication
Rapidly deteriorating health going unnoticed and untreated
Coroners have exposed multiple cases of mental health patients receiving inadequate treatment in general hospitals, with their illness being mistaken for a psychiatric problem.

The Independent can reveal that a fifth of patients in mental health units across the country are not receiving basic physical healthcare checks upon admission, according to a report by the National Confidential Enquiry into Patient Outcome and Death.

The report, carried out this year, warned of “significant missed opportunities” by health services to identify and treat physical health conditions in mental health patients. The review explained that deterioration in physical health often follows admission to inpatient units.

It comes as NHS England’s national clinical director for mental health was forced to write to hospitals, warning them of the need to offer physical health checks.

Dr Rosena Allin-Khan, Labour’s shadow mental health minister, called for a rapid review of mental health inpatient services. She told The Independent: “The government needs to get a grip of the ongoing crisis in mental health hospitals – current conditions are inhumane. Patients deserve better.”

Yvonne Eaves died from a blood clot while an inpatient at the Greater Manchester Mental Health NHS Foundation Trust in 2020, after staff within the unit failed to carry out a risk assessment for blood clots.

Great Manchester coroner Nigel Meadows attributed her death to “a gross failure to provide her with basic medical care”. Hers is one of four cases in which coroners warned of inadequate blood clot assessment and treatment within inpatient units.

The 69-year-old had suffered from mental illness from a young age. In January 2020 she was admitted to a unit run by the Greater Manchester mental health trust, and was noted as having “several long-standing serious deep infected ulcers and wounds”.

Eaves was transferred to a hospital, where she was given preventative medication for venous thromboembolism (VTE), or blood clots, and was then discharged back to the mental health unit. But the treatment was not continued when she was returned to the mental health unit.

Speaking to The Independent, Lorraine Fallon, her sister, said: “I’m left with so many questions surrounding Yvonne’s death, like would Yvonne still be here if she’d had the right assessments and medication?

“It’s impossible to put such a funny, eccentric character into words. Yvonne had a magnetic personality and left an impression on everyone she met. She was a second mum to my son Sam. She is a great loss and I miss her with every fibre of my being.”

Gill Green, of the Greater Manchester Mental Health NHS Foundation Trust, said improvements had been made to physical healthcare provision, including a new strategy and the introduction of new job roles with a physical healthcare focus.

Last year, the inquest of Jonathan Kingsman, who died from a blood clot aged 47 in a unit run by the Cambridgeshire and Peterborough NHS Foundation Trust, prompted a coroner to write to the Department of Health and Social Care to warn that national guidelines for blood clot assessments were failing to take into account the risks associated with antipsychotic medication.

Kingsman’s wife Lara told The Independent: “If you’ve got someone with acute mental health problems, you feel that they’re safer, or hopefully safe [in hospital]. I certainly don’t blame any individuals looking after Johnny. I know how under pressure these people are, and they have to work within the guidelines that they’re given. A friend looked at the risk assessments and said, ‘You could drive a truck through that risk assessment in terms of blood clots.’”

‘We know we’ve got to do more’

Dr Lade Smith, inequalities lead for the Royal College of Psychiatrists, said: “If you have a severe and enduring mental health problem then you are likely to die 15 to 20 years earlier than someone in the general population. That’s not fair.”

Dr Smith said that the coroners’ warnings uncovered by The Independent highlight the problems caused by a “fragmentation of care”, with psychiatrists struggling to get patients access to the appropriate physical healthcare.

She said: “As a psychiatrist, we know we’ve got to do more. But we can’t do this on our own. We need our distant partners, our physical health colleagues, to become partners in this.”

Margaret Flynn, who chaired the 2011 review into the Winterbourne View scandal, which exposed the horrific abuse and poor treatment of inpatients with learning disabilities, said that when vulnerable people are admitted, “They’re seen to be there because they’re mad or bad. So they’re not looking at people’s physical healthcare.”

Throughout her review, Ms Flynn said, she found that patients were sometimes “overfed” and that weight gain was a “huge problem”.

Ben King, who had Down’s syndrome, died at Cawston Park private mental health hospital in Norfolk. Last year an inquest found he had “died due to inadequate weight management” and the failure to diagnose a condition linked with obesity, as well as “inadequate consideration” of medication.

King’s death was one of three to prompt a major review into the hospital.

In another key NHS review published last year, into the death of Clive Treacy, who was detained in mental health units for 10 years, the report’s chair Beverley Dawkins said: “People have assumed that the teams in those units do have all the necessary skills to manage people’s physical healthcare, and yet frequently the evidence is to the contrary. Many people in those units recorded not going out for exercise, not going out for a walk, sometimes not even getting off the ground.”

She said that despite failures being highlighted for more than a decade, there was still inadequate funding and focus from governing bodies.

According to the National Confidential Inquiry into Suicide and Safety in Mental Health, an “early warning score” – a measure intended to spot signs of serious deterioration in health – was not used for a quarter of patients who might have benefited from it.

Coroners’ reports seen by The Independent repeatedly warn of failures by staff to identify when a patient’s physical health was deteriorating.

Roxanne Brown, a young mother, died aged 31 following “neglect” by the Shrewsbury Court private hospital in Surrey, which has since been closed following a critical report by the Care Quality Commission (CQC).

According to an inquest report shared with The Independent, Brown was admitted in March 2019. Seven months later she was showing signs of a high temperature and an elevated pulse rate, and was taken by a support worker to her GP.

Patients whose health is deteriorating are assessed and assigned a “modified early warning score”. However, Brown’s score was not shared with the GP, who then diagnosed a chest infection. Evidence examined during the inquest found that, had the GP seen her score, they would have referred her to A&E.

Further, the GP’s advice to take her to A&E if her condition worsened was not noted down or followed by staff.

Matthew Turner, the barrister representing Brown’s family, said that the failure of staff to spot deterioration appears to be “part of a wider problem of poor physical healthcare of patients in mental health hospitals”.

Brown’s mother, Ruby Brown, said: “Every day seems like the day she passed away. Worst of all, I was not there to get the medical help she so needed, to comfort her and to let her know that I would do all I could to make things right. Unfortunately, I was not made aware of any of the things that happened to her; that was hidden from me.

“She would still be alive to this day if she was not sent to her death at the early age of just turning 31, and what would have become of her relationship with her daughter who is now 14 years old?”

‘Urgent action is needed’

The charity Inquest said that a key problem is the division of healthcare between mental and physical health. Lucy McKay, of Inquest, told The Independent: “Urgent action across the NHS is needed to increase connection and communication between services and ensure mental health units are better integrated with professionals who can monitor and treat physical ill health.”

In 2019, the CQC published requirements for mental health care providers to carry out assessments and monitoring of physical health. Jemima Burnage of the CQC told The Independent: “It is essential that staff in mental health settings are meeting the physical as well as mental health needs of patients as a matter of priority.

“We are clear that providers must undertake appropriate assessments and regular monitoring of the physical health of people being cared for in inpatient mental health services.”

Andy Bell, deputy chief executive at charity the Centre for Mental Health, said: “It can be hard to get access to physical health expertise in mental health hospitals. By and large it’s not part of what is available, and mental health hospitals have high bed occupancy.”

An NHS spokesperson said that all providers of mental health and learning disability services are “contractually” required to offer physical health checks to patients. They added: “The NHS has recently reminded local areas of this, as well as making additional funding available to increase the number of multidisciplinary staff in hospitals, including occupational therapists and peer support workers.”

A Department of Health and Social Care spokesperson said: “Anyone receiving treatment in an inpatient mental health facility should receive safe, high-quality care and should be looked after with dignity and respect. We are considering what is needed on wider issues for mental health inpatient care, and will update in due course.”

Source: The Independent, 17th December 2022

Hospital trust in Greater Manchester improves mental health wards for privacy and dignity

As part of the improvements, £1.5m has been invested in replacing Pennine Care’s two remaining shared dormitory wards with single ensuite bedrooms

Pennine Care NHS Foundation Trust has transformed mental health hospital wards for adults and older people, to improve care and provide the highest levels of privacy and dignity.

Mental health, learning disability and autism provider Pennine Care NHS Foundation Trust runs 18 acute hospital wards across Bury, Oldham, Heywood, Middleton and Rochdale, Stockport and Tameside. As part of the improvements, £1.5m has been invested in replacing Pennine Care’s two remaining shared dormitory wards with single ensuite bedrooms.

Following a two and a half year programme, all wards now offer single gender accommodation. This means providing same gender sleeping areas, bathrooms, toilets, and communal areas.
All wards now provide care for a single type of mental health condition – functional (e.g. depression, anxiety or personality disorders) or organic (e.g. dementia or other neurological conditions). This will allow staff to provide more specialist care that better meets patients’ needs.

Moorside ward, based at Rochdale’s Birch Hill Hospital, now has 18 bedrooms for women aged 18 to 65 years, with functional conditions. Other improvements include a gym, therapy kitchen and lounge.

Ramsbottom ward, based at Bury’s Fairfield Hospital, has 10 bedrooms for women aged over 65 years, with organic conditions. Patients are also benefitting from a sensory room, with colour changing lights and hand painted fireplace, nature themed relaxation areas, an assisted bathroom and new outdoor area.

Both projects also included a range of improvements to support staff wellbeing, including a staff room and changing facilities.
Laura Challis, Ramsbottom ward manager said: “We’re all delighted with the improvements. We can now carefully tailor our care and therapy for women with dementia and we’ve really seen a difference.

“The single bedrooms have helped with privacy, dignity, and safety. And we have much more space on the ward, which assists in the delivery of therapeutic activities. Now we’re able to focus on single gender and condition, we’re working towards becoming dementia care specialists. This involves undertaking lots of training to build our expertise, so our patients can benefit from the gold standard care they deserve.”

Full story here

Source: In Your Area, 16th December 2022

Bill McCarthy, former NHS boss to take over scandal-hit Greater Manchester mental health services

Bill McCarthy, a former NHS director has been revealed as the new chair of Greater Manchester Mental Health NHS Foundation Trust (GMMH). The appointment follows after ‘inexcusable behaviour and examples of unacceptable care’ were ‘exposed’ at a mental health unit, said the outgoing chair.

Rupert Nichols wrote a letter to the governors, board members and colleagues at the trust in November, announcing he would be ‘retiring’ early from the position at the end of December 2022. He will be replaced by Bill McCarthy, who will take on the interim chair role from from 1 January 2023, for up to twelve months.

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.

The Care Quality Commission carried out a recent inspection of the trust, some concerns being prompted by whistleblowers, and served with warning notices to improve after inspectors found it to be unsafe. The trust has also been placed in ‘the equivalent of special measures’, and is now under the highest level of NHS England intervention.

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 new chair ‘will enable seamless leadership in line with the trust’s progress into the next phase of our improvement process, through the NHS England Recovery Support Programme, for the benefit of all our service users, carers and staff’, said the trust.

Bill McCarthy will be stepping down from his current role at Pennine Care NHS Foundation Trust, where he has been senior independent director since April 2022. Prior to that, Mr McCarthy was NHS Regional Director in the North West, before he retired in 2021.

His previous roles include Director of Policy for NHS England and Chief Executive at NHS Yorkshire. A substantive chair of the trust will be recruited through the council of governors ‘at the appropriate time next year’, said the trust.

Neil Thwaite, Chief Executive of Greater Manchester Mental Health NHS Foundation Trust, said: “On behalf of the Board of Directors, we welcome Bill’s appointment as interim Chair. His vast experience of the NHS and collaboration with partners will be hugely beneficial to our efforts to improve services. I look forward to working closely with him in the coming months.

“I would also like to take this opportunity to thank Rupert Nichols, who will shortly leave us after more than six years as our Chair. I wish him all the best in his retirement.”

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, 12th December 2022

Mental health blogger, 26, died in Cheadle Royal after taking poisonous substance bought online, inquest hears

Beth Matthews collapsed in front of staff at a psychiatric hospital after telling them it was protein powder

Beth Matthews, 26, collapsed in front of hospital staff after telling them it was protein powder. She had been detained under the Mental Health Act and transferred to The Priory’s Cheadle Royal psychiatric hospital in Stockport for ‘specialist therapy’.

The hearing was told Beth took took the ‘poisonous’ substance, which the Manchester Evening News is not naming, after she opened a package bought on the internet. Beth ‘quickly became unwell’ at around 1.15pm on March 21 last year and paramedics were called.

She suffered a cardiac arrest and was rushed to Wythenshawe Hospital where she was pronounced dead at 3.55pm. The inquest heard that Beth, from the village of Menheniot near Liskeard in Cornwall, had suffered with mental health from an early age and was diagnosed with emotionally unstable personality disorder.

She suffered severe injuries in a failed suicide attempt after jumping from a bridge in April 2019, the coroner told the jury of six women and five men women hearing the case at South Manchester Coroner’s Court.
Her injuries caused ‘significant long-term pain and disability’, Assistant Coroner Andrew Bridgman told them opening the case. In 2021 she suffered a ‘further deterioration of her mental health’ and was detained under the Mental Health Act at a hospital in Cornwall.

Then in November 2021 she was transferred to The Priory in Cheadle for specialist Dialectical Behaviour Therapy (DBT), which is where she was a patient at the time of her death in March of the following year.

In a statement read to the court, Beth’s mother Jane Matthews said her daughter was a ‘bright and vivacious girl’ who would ‘light up the lives of everyone she met’.

Ms Matthews described Beth, who she said was ‘proud to call herself a Cornish girl’, as ‘caring, ‘intelligent’ and articulate’ and said she had a ‘quick sense of humour’.

She was rushed to Wythenshawe Hospital but sadly died the hearing was told (Image: Manchester Evening News)

She was a talented sailor who won ‘lots of trophies’ and competed in the renowned Fast Net race aged just 15 as well as becoming a member of the Royal Yacht club.

Keen musician Beth played both the guitar and the piano and had a number of pets including her ‘beloved’ cat Sparkles.

Ms Matthews said she ‘never reached her potential due to the mental illness which overshadowed her later years’. However, she said “People were attracted to her personality” which was evidenced by the “huge Twitter following she gained”.

“She touched the lives of so many people,” Ms Matthews added. “And as a result she was able to help those who reached out to her.”

Giving evidence, Beth’s former partner Matthew Parkinson said he first met Beth in around 2014 when they worked together at a watersports centre and that they bought a house together in 2017.

He said in the early part of their relationship she was very ‘protective’ of her mental health and would ‘put a smile on and carry on.’

However, he said as it progressed her problems became ‘more noticeable.’ He said following her fall from the bridge in 2019 she was ‘in pain every day’.

He said two years on, she believed she ‘wasn’t going to make any more recovery from those injuries.’ And he said she ‘reacted very, very negatively’.

Mr Parkinson said: “I think it was that night or maybe the following night following the two-year mark, that her mental health declined massively. She sort of gave up all hope really.”

He said whilst Beth was at The Priory in Cheadle she broke off their relationship before ‘changing her mind’ and ‘asking him to reconsider’.

He said in March last year she ‘said some unpleasant things’ but said it was his intention ‘to get our relationship back together when she got out of The Priory’, adding ‘I thought that she would want to do that too despite what she had said before.’

The inquest heard on March 15 she attempted to call Mr Parkinson 41 times in less than an hour and that she followed it up with a WhatsApp message in which she said she was ‘completely heartbroken.’ There was also a further message on March 19 to which Mr Parkinson said he didn’t recall if he responded to.

He said lots of his phone conversations with Beth around that time were ‘negative’ where she would be telling him about’ incidents’ which he said included ‘attempting to abscond, not eating or drinking, that sort of thing.’ ‘It got to the stage where it felt like it was every other day’ he said.

In a statement read to the court, Emergency Medical Technician Kate Barnes from North West Ambulance Service (NWAS) said she was called to a ‘category one incident’ at the hospital at 1.36pm on March 21.

She said when she arrived staff advised her that Miss Matthews had had ‘a package delivered which contained (the substance) which she had opened in front of them and managed to consume’.

“When I questioned how the incident had happened, they advised me they had questioned what the package was prior to Miss Matthews opening it to which she responded she had ordered some protein powder to the unit,” Ms Barnes said.

She said the staff told her ‘patients were allowed to have parcels delivered to the unit but they had to be opened in front of staff, at arm’s length, and were usually opened in the communal area’.

Ms Barnes said they told her Miss Matthews ‘managed to open and consume an unknown amount’ of the substance which was in a ‘small plastic, screw top container the type tablets would normally be held in’.

Her NWAS colleague Christopher Bauer said he understood the substance was in ‘tablet/powder form’ and that the container ‘had foreign writing on it’. Dr Susan Kirk, Consultant in Emergency Medicine at Wythenshawe Hospital detailed the lifesaving efforts which included the giving of an antidote.

In her statement, she said ‘the paramedics gave us the information that she was an inpatient at The Priory and that she had taken an overdose of (the substance) that she had bought on the internet.’ She said in her opinion Beth suffered a cardiac arrest due to ‘poisoning’ from the substance.

Following a post-mortem, pathologist Dr Andrew Yates said he believed her cause of death was 1A) Methemoglobinemia caused by 1B) ‘poisoning’ of the substance.

Dave Baxter, a specialist in ‘hazardous materials’ at Greater Manchester Fire and Rescue Service (GMFRS) said in a statement he attended the Fern Unit at The Priory on the evening of March 21 and tested the remnants of the substance, but said ‘no specialist clean up was required’.

The family are represented by Stephen Jones with Maya Ravindran acting on behalf of The Priory and Pravin Fernando representing the Cornwall Partnership NHS Foundation Trust. The inquest, expected to conclude next week, continues.

See full story here

Source: Manchester Evening News, 9th January 2023

Edenfield and Acute Services in Manchester: Open Discussion

Following our successful public meeting on 10 December about Edenfield and Human Rights we have organised an open discussion meeting.  

It will take place on:

Saturday 28th January

2 – 5pm

Percival Room, Unitarian Chapel, Cross Street, , M2 1NL 

This meeting will be focussed on people with lived experience who would like to share their experiences of services and consider how we can take forward the campaign for a mental health system that respects Human Rights.

if you have access to the internet we would like to request that you register for the meeting here:

This will help us organise the space and provide refreshments. 

“We need to be heard and you need to listen” is clear message from CHARM Public Meeting



Saturday, 10 December 2- 4 pm

60 people attended the public meeting. We heard both inspiring and challenging stories from people with lived experience, family members, workers and concerned citizens.

Our keynote speakers were:

Dainius Puras, psychiatrist, former UN Special Rapporteur on Human Rights and Mental Health speaks about the predominant importance of human rights in shifting the thinking and practice of bio-medical psychiatry across the world and in Manchester. Go to his presentation here

Roberto Mezzina, psychiatrist, Vice President of the World Federation for Mental Health, retired director of Trieste Mental Health Department, proving it is possible to create a mental health system that upholds human rights. A service that has full participation of users and is accessible and rooted in the community. Go to his presentation here

The key message from the meeting is that Greater Manchester Mental Health Trust, Commissioners of services and other responsible bodies need to LISTEN.

Robert Lizar, Solicitor

Public statement from the meeting: ‘AFTER EDENFIELD – HUMAN RIGHTS NOW’ held on 10 December 2022 at Central Hall, Manchester

This meeting calls for a mental health service that puts compassion and human rights at its centre. We want a service that is accessible and takes a whole person approach.

We have heard stories of systematic and wilful neglect. We have heard evidence of the systematic abuse of power by mental health services in Manchester and beyond. We have heard patients’ concerns and opinions pathologised and dismissed. These failures are both in community and inpatient services.

All forms of violence, aggression, discrimination and prejudice should be illegal in mental health services. This includes restraint, detention, coercion and neglect. We call for a public inquiry that places users and carers at the centre of any investigation

We will build our own evidence base. The meeting calls for people who have used community and inpatient services to tell their story by contributing to the story bank of experiences being collected by CHARM and the Charter Alliance. Anyone wishing to contribute can contact CHARMat

We have heard accounts proving it is possible to create a mental health system that upholds human rights. To do this we must address the power asymmetry in mental health services. We need a service that has full participation of users and is accessible and rooted in the community.

We must also challenge the dominance of the biomedical model and the iatrogenic harm that it creates. We need recognition of other innovative and creative models of care that use negotiation and dialogue in deciding on care which addresses the power imbalance. This will support the upholding of human rights as well as changing the way people are cared for through creating an alternative system.

CHARM Public Meeting

Supporting organisations: CHARM (Communities for Holistic Accessible Rights-based Mental Health); Greater Manchester Coalition of Disabled People; Manchester User Network; Manchester Hearing Voices Network, GM Mental Health Charter Alliance; Fika Wellie; Unison; Asylum Magazine; GM Keep our NHS Public; Safely Held Spaces; Soteria Network UK; Robert Lizar Solicitors, Talk for Health

Information about the meeting


  • Citizens with lived experience
  • Dainius Pūras, psychiatrist, former UN Special Rapporteur on Human Rights and Mental Health (zoom)
  • Roberto Mezzina, psychiatrist, Vice President of the World Federation for Mental Health, retired director of Trieste Mental Health Department (zoom)
  • Robert Lizar, Robert Lizar Solicitors, Manchester

Why we called the meeting

The Panorama programme on Edenfield showed an abuse of human rights that are system wide. It wasn’t just the acts of individual workers but a system that relies on restraint, seclusion and socialises workers to lose compassion and humanity.  The internal inquiry and findings by GMMH are not enough. GMMH continues to suggest that what happened at Edenfield is an isolated case, when it is clear from the number of recent scandals that the abuses uncovered take place nationally across private and NHS hospitals. Both in-patient and community services are not safe. We need a root and branch review of services and an inquiry that is open and transparent. This can only be co-produced with the community.

We need to listen to the stories of those with lived experience. We call for anyone who wants to share their stories to join us at the meeting in our fight for justice.  CHARM and Manchester Mental Health Charter Alliance are working together to launch a Story Bank of experiences which we will use to support our campaigns to improve mental health support in Manchester. 

We need to speak out against coercive psychiatry, abusive mental health regimes and forced treatment. As our speaker Dainius Pūras has said, ‘our common goal is to liberate global mental healthcare from coercive practices…. If we do not move in this direction, arguments for coercion will continue to be used and misused.’

The meeting was supported by:

Manchester Users Network Supports users and ex-users of psychiatric services in the Manchester area. The organisation provides a forum for services users to have a bona fide say in planning and provision of mental health services.

Asylum Magazine the radical mental health magazine, has been running for 30 years, acting as a platform to voice and discuss all perspectives on mental health.

Greater Manchester Coalition of Disabled People an organisation of disabled people: run and controlled by disabled people. We campaign to promote the rights of disabled people and our inclusion in society

Fika Welie There is a huge stigma in the Black community in regards to mental health and seeking help. This fear of judgment can deter individuals from getting the help they need. At Fika Welie, we will always recognise the traumatic impact of racism on Mental Health.

Manchester Mental Health Charter Alliance This charter is about what people want from mental health services in Manchester. It has been drawn up from what people who use mental health services have said in consultations over the last few years.

Safely Held Spaces vision is of safe, compassionate, empowering support in local communities in the UK for people experiencing extreme mental and emotional distress and altered states, often called psychosis, and for the people supporting them

Soteria Network UK

Soteria promote humane, non-coercive mental health services. A network of people in the UK promoting the development of drug-free and minimum medication therapeutic environments for people experiencing ‘psychosis’ or extreme states. Part of an international movement of service users, survivors, activists, carers and professionals fighting for more humane, non-coercive mental health services.

Justice in Care dedicated to promoting justice for and preventing the abuse or exploitation of disabled people or service-users or residents within the care system. This Justice in Care group is co-ordinated by Parasol in co-operation with the Greater Manchester Coalition of Disabled People.

GM Keep Our NHS Public is a non-party-political organisation campaigning against the privatisation and underfunding of the NHS. They support campaigns to reverse the privatisation and commercialisation of social care and to call for health and social care services to be publicly funded, publicly provided and accountable provision.