A watchdog is “very concerned” about the safety of people using the services of the Greater Manchester Mental Health NHS Trust.
The damning report states that inspectors found that there was not always a sufficient supply of nursing staff and that permanent staff did not feel safe using bank or agency workers because they had not received the relevant training.
It follows an unannounced inspection in September by the Care Quality Commission “due to ongoing concerns about the safety of services”.
READ MORE: Patient’s disgust at ‘abhorrent’ state of mental health department
Three young patients died in nine months at Prestwich Hospital, one of the Trust’s units.
As revealed by the Manchester Evening News in July, Rowan Thompson, 18, passed away in October last year, followed by Charlie Millers, 17, in December, and Ania Sohail, 21, in June this year.
A campaign group and the families of Charlie and Rowan are campaigning for a full investigation into those cases by NHS England.
The CQC’s two-day inspection of eight wards at five of the Trust’s seven sites found:
* The service did not always have sufficient nursing staff who knew patients or received basic training to protect patients from avoidable harm.
* The environment in the Poplar ward (Parkhuis) was not clean on the first inspection day and the space in the ward was limited for patients.
* It was not clear that immediate concerns or incident learning was shared by the sites, although local learning and assessments took place.
*Not all departments had up-to-date and recently revised ligature risk assessments. The staff of two departments could not find the ligature risk assessments at the time of the inspection.
Acute adult wards of working age and psychiatric intensive care units (PICU) inspected were for:
• Griffin Ward, an eight-bed female acute ward at Junction 17, Prestwich
• Oak ward, a 20-bed female acute ward at Rivington Unit, Bolton
• Priestner’s Unit, an eight-bed mixed PICU in Atherleigh Park, Wigan
• Medlock Unit, a 21-bed acute care unit for women at Moorside Unit, Trafford
• Brook ward, a 22-bed acute care men’s ward at Moorside Unit, Trafford
• Poplar ward, a 20-bed female acute ward at Park House, Manchester
• Juniper ward, a 10-bed male PICU at Park House, Manchester
• Laurel Ward, a 23-bed acute care unit for men in Park House, Manchester.
Because it was a focused inspection and only looked at the safety of the departments, the overall ratings for the service do not change and remain as good. But the service continues to “require improvement” to be safe.
Brian Cranna, Head of Hospital Inspectorate (Mental Health and Community Health Services) at the CQC said: “When we inspected these eight departments of the Greater Manchester Mental Health NHS Foundation Trust, we were very concerned about the safety of people using the services.
“There was not always a sufficient supply of nursing and support staff, although the trust identified a significant staff shortage and had contingency plans in place.
“It was worrying that permanent staff did not always feel safe when deploying bank and temporary staff as they did not always have the relevant training to provide support if an incident occurred.
“The physical environment in some departments was not always suitable for people’s needs or safety.
“While staff could describe where the ligature points were, it was not clear how the trust was more formally assured that all potential risks had been identified and considered.
“The Poplar ward had limited space for patients to spend time away from others as the dedicated quiet lounge was used as an extra bed for capacity.
“The ward was also dirty and smelled unpleasant, although we were pleased to see the trust recognized this and some improvements had been made when we visited on the second day.
“We were also told that the department would be redesigned later in September.
“We have told the confidence what further improvements they need to make to keep patients safe in an environment that meets their needs. We will continue to monitor them and come back to inspect their progress.”
The Inspectorate also found good practice within the Trust.
The report says staff have properly assessed and managed risks to patients and themselves and followed best practices in anticipating, de-escalating and managing challenging behaviors.
Gill Green, Director of Nursing and Governance for Greater Manchester Mental Health NHS Foundation Trust, said: “We welcome the findings of the Care Quality Commission, following their unannounced, targeted inspections of some of our adult wards and psychiatric intensive care units in September .
“The inspection team found several positive aspects of care, including how well staff managed risk and followed best practices, how they protected patients from abuse and knew how to report it, and easy access to clinical information.
“We accept that there are areas for improvement, such as the level of qualified staff in departments, which many NHS trusts are struggling with, but we have strong contingency plans in place to ensure we remain safely staffed.
“We are ensuring that patient safety and learning is anchored in the Trust and at the local level. We also continue to improve patient environments where we can, with an area already identified for refurbishment and refurbishment prior to the inspection taking place.
“An action plan to address these areas is under development and we will share our progress with the CQC. This inspection will not affect our overall rating, which remains ‘Good’.
During a pre-inquest hearing at Rochdale Coroners’ Court on Sept. 17, senior coroner Joanne Kearsley said Rowan Thompson’s cause of death was currently “uncertain.”
Rebecca Titus-Cobb, a lawyer representing Rowan’s family, told the inquest that the family had some concerns about Rowan’s treatment in the ward.
She said there were “systemic issues related to the observation of patients on the ward,” and that the Inquest campaign group had contacted the Care Quality Commission to voice their concerns following a number of deaths, including Rowan’s.
The charity INQUEST, which campaigns with families whose loved ones have died in state custody or care, wrote in September to the chief inspector of the CQC’s hospital, Professor Ted Baker, demanding further action.
In the letter, Chief Executive, Deborah Coles, said: “In light of these deaths and the serious concerns we have about the safety of Greater Manchester Mental Health NHS Foundation Trust, I ask you, on behalf of bereaved families, to take advantage of CQC’s legal powers to urgently visit this Trust and independently assess the treatment of young patients.
“These deaths have all occurred in the past ten months. We are working with the families of Charlie Millers and Rowan Thompson, two of the individuals who died. It is understood that all three of these deaths occurred at Junction 17 ward or Gardener Unit which are part of the CAMHS (Child and Adolescent Mental Health Service) units of the Trust.
“The fact of these deaths in such a short period of time – less than a year – is a cause for great concern and we believe immediate action by CQC is warranted.
“We therefore urge CQC to use the multiple mechanisms at its disposal to visit Junction 17 and the Gardener Unit at Prestwich Hospital to assess treatment and conditions for patients and report publicly on the conditions surrounding these extremely worrying deaths.”
Charlie Millers, the second young person to die, – a ‘nice, caring boy’ – was found unresponsive in his room in the Junction 17 wing of Prestwich Hospital on December 2. He was resuscitated at the scene and taken to Salford Royal Hospital, but died five days later.
a serious one Incident A review from the trust said Charlie was seen three times with ligatures around his neck in the hours before becoming unresponsive with a ligature around his neck.
The review says he was alone at the time when he was found unresponsive in his room.
His mother, Samantha Millers, told the MEN she was told her son was checked once every five minutes when he was fatally injured. She thinks he shouldn’t have been left alone at that moment.
He had previously had one-on-one monitoring due to his history of self-harm and attempts on his own life, the review says.
Commenting on today’s CQQ report, Ms Millers said: “My thoughts are no wonder my son died. It was bank staff who took over his care at 10:15 pm. Twenty minutes later he was as good as dead.
“It’s a shame. I’d be more knowledgeable to work there and they might as well throw everyone in there to work there so the numbers look good — endanger our kids.”
An inquest into Charlie’s death is set to take place in February.
An inquest into Rowan’s is scheduled for June next year. His father, Marc, said: “Within 24 hours of Rowan’s death, the Trust was aware that there was an observation by staff. Within seven days they had prepared their own internal report identifying such issues.
“The CQQ says it’s not clear that incident learning was shared across locations. Charlie died three months after Rowan’s death. I think if such knowledge had been shared, Charlie’s death could have been avoided.”