Handley Law are investigating claims arising out of negligence involving North Essex Partnership University NHS Foundation Trust. The Care Quality Commission (CQC) has recently rated North Essex Partnership University NHS Foundation Trust as inadequate for safety.
North Essex Partnership University NHS Foundation Trust Safety Concerns
It came to light during the CQC investigation that there were 25 incidents on the acute admission wards relating to the use of a ligature attached to a fixed object. In one instance, a patient attempted to strangle themselves with a ligature during the CQC inspection.
The Trust had previously been warned about concerns the CQC had during previous regulatory inspections but these concerns and warnings were not heeded.
Other self-ligature incidents occured in the previous 12 months involving 2 deaths due to self-ligature. Sadly there were a number of similar deaths in the previous years. Lessons are not being learnt despite warnings and serious incidents.
North Essex Partnership University NHS Foundation Trust had made ligature risk assessments and also had plans to address issues yet there were still an unacceptable number of ligature risks identified during the inspection.
Lessons to be learnt
Despite attempts by North Essex Partnership University NHS Foundation Trust to learn from mistakes and guard against them happening again, they did not have robust systems in place to share lessons learnt from incidents.
Teams working at the Trust did not integrate these into their practice and introduce ways of reducing risks. Nothing was done to identify best practice.
In terms of care records and risk assessments North Essex Partnership University NHS Foundation Trust failed to ensure they contained enough detail to be useful. The records were not personalised or kept up to date. This meant that staff did not know the full or current risks presented by the patients that they were caring for.
Men and Women at North Essex Partnership University NHS Foundation Trust
What is also shocking is that in Finchingfield, Gosfield and Peter Bruff wards, Christopher unit and Shannon House there was a failure to provide segregated accommodation for men and women. The Department of Health said this should no longer happen. The revised Operating Framework for 2010-2011 made it clear that NHS organisations were expected to eliminate mixed-sex accommodation, except where it is in the overall best interest of the patient, or reflects their personal choice.
In other areas, some seclusion rooms were not fit for purpose and breached guidance. For example, a lack of respect for the privacy and dignity of patients in seclusion; inadequate furnishing (so that patients are kept in a bare room with only a mattress or blankets for comfort); little or no access to toilets (the Ardleigh ward did not have an ensuite facility); inadequate clothing for patients; and patients being disturbed by staff playing a radio or talking loudly in the observation area. On the Peter Bruff ward, the seclusion room contained ligature points, including toilet rails and taps on the sink.
Restraint at North Essex Partnership University NHS Foundation Trust
In the 6 months before the inspection there were 114 incidents of restraint. Of these, in 36 incidents (representing 32% of incidents) patients were restrained in the prone position. Prone position restraint is when a patient held with the chest down and back up position on a surface. They are physically prevented from moving out of this position.
The latest Department of Health guidance stated that if such a restraint is unintentionally used, staff should either release their holds or reposition into a safer alternative as soon as possible. This guidance forms a key part of the wider new Positive and Safe programme, which aims to end the unnecessary use of restrictive interventions across all health and adult social care.
A similar study by Mind also found that restrictive interventions were being used for too long, often not as a last resort and even to inflict pain, humiliate or punish.
The CQC also found that staff took patients’ preferences into account when administering medicines, but did not always note the arrangements in the patient’s care plan so may not have followed them consistently or accurately.
If you have been affected by treatment received at North Essex Partnership University NHS Foundation Trust that is inadequate then get in touch with Dr Victoria Handley for a free no obligation chat on 0800 470 2009 or email email@example.com