‘Urgent improvements’ needed after psychiatric patient deaths

The Trust that provides mental health services across Devon has been told to make improvements on ALL of its acute psychiatric intensive care units after a number of patient deaths.

The Care Quality Commission (CQC) told Devon Partnership NHS Trust to improve its “ligature minimisation work” and raised specific serious concerns about patient safety at the Delderfield ward at The Cedars unit it Exeter. It follows high profile inquests into the deaths of patients.

A team of inspectors from the Care Quality Commission visited the trust’s Delderfield and Moorland View wards in June 2020 to look at the quality of care due to concerns about risks to patient safety. It says in a new report: “There had been a number of incidents of patients self-harming, including patient deaths.”

But the report added that there had not been enough learning following those deaths: “Staff on both wards had not received feedback on the learning from investigations following previous patient deaths involving ligatures.”

It also raised concerns into delays investigating those deaths: “The investigations into these deaths had been delayed.

“The trust has provided CQC with a plan of how it will ensure the delays in completing investigations will be addressed so that in future investigations are not delayed.”

And it highlighted that on Delderfield there “hadn’t been a permanent, dedicated psychiatrist on the ward for some time.”

The CQC wrote to the Trust following the inspection of Delderfield and Moorland View at The Cedars, highlighting its serious concerns surrounding patient safety on Delderfield where the risk register was not complete and up to date.

The CQC said: “The Trust responded positively and set out the immediate actions it was taking to ensure the safety of patients.”

In the report the inspectors say: “We continue to monitor the trust closely and will not hesitate to take action if the trust fails to make the necessary improvements.”

After the inspection the CQC told the Trust:

1 – It must make urgent improvements on Delderfield ward at The Cedars in Exeter. Inspectors found the ward had not had a permanent, dedicated psychiatrist for some time.

Also

2 – It must complete its ligature minimisation work on all its acute wards for adults of working age and psychiatric intensive care units to keep patients safe.

Devon Partnership NHS Trust provides mental health and learning disability services across Devon.

The new report says: “This was a focused inspection to follow up on concerns surrounding patient safety. Therefore, the service rating remains unchanged.”

The CQC’s Head of Hospital Inspection for the South, Karen Bennett-Wilson, said: We found a number of concerns relating to patient safety on Delderfield ward and we told the trust it must make urgent improvements. The trust needs to ensure systems are in place to keep people safe, that it can mitigate risks to people’s safety.

“Following our inspection, inspectors gave the trust leadership team feedback of their findings including those concerns which required an urgent response. The trust knows what it must do to ensure it improves its services. In the meantime, we continue to monitor the trust closely and will not hesitate to take action if the trust fails to make the necessary improvements.”

“Inspectors were concerned about the environmental risks on both Delderfield and Moorland View wards, although risks were being managed well on Moorland View. Environmental ligature minimisation work had not yet been completed by the trust which meant risks to patients remained.

“On Delderfield ward there had been frequent changes of leadership and there hadn’t been a permanent, dedicated psychiatrist on the ward for some time.

“There was also a lack of oversight of patient observations despite previous incidents which highlighted the need for robust observations and engagement to prevent serious harm to patients. Following the inspection, the trust introduced audits of observations on Delderfield ward.

“Staff on both wards had not received feedback on the learning from investigations following previous patient deaths involving ligatures. The investigations into these deaths had been delayed. The trust has provided CQC with a plan of how it will ensure the delays in completing investigations will be addressed so that in future investigations are not delayed.

“Delderfield ward’s risk register was incomplete and was not being kept up to date and did not provide assurances on mitigation of known risks. The trust has now confirmed the ward’s risk register has been updated and has provided CQC with a copy of this.

“Patients told inspectors they felt respected, supported and valued and inspectors found staffing levels on both wards were safe.

“Staff on both wards felt able to raise concerns. Staff also knew how to find information about the whistle-blowing process and the role of the speak up guardian.

Full reports of inspectors’ findings will be published on CQC’s website at the following link:

Devon Live – Devon News