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CQC criticises Essex trust over ligature-related deaths

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North Essex Partnership NHS Foundation Trust has been told to urgently address safety issues after several patients died by strangling themselves on the wards.

The trust was strongly criticised by the Care Quality Commission for failing to deal with ligature risks, despite ongoing safety concerns and warnings.

“Work that addresses all the CQC’s comments is either under way or planning”

Andrew Geldard

During an inspection visit in August last year, inspectors witnessed the risks first-hand when a patient was found unconscious having tried to strangle themselves with a ligature.

Their report revealed that two people had died in the past 12 months by killing themselves in this manner and “there were a number of similar deaths in previous years”.

On acute admission wards there were “25 incidents relating to the use of a ligature attached to a fixed object”, said the report, which was published today.

Yet inspectors – who rated the trust “inadequate” for safety – found managers had been slow at implementing vital safety measures, including removing potentially dangerous doors and fittings.

“The Care Quality Commission and Mental Health Act reviewers have inspected the trust several times over the last five years,” stated the report.

“Each time they identified areas where the trust must act. Each time the trust made assurances that they would make changes,” it said. “The trust did not address the concerns fully even though patients had died by self-ligature while on the wards.”

Inspectors identified other areas of concern including the fact staff did not always follow best practice when assessing patients’ mental capacity and obtaining consent.

They also highlighted staffing issues, with occasional staffing shortages on acute admissions wards and an “over-reliance on the use of bank and agency staff”.

“This had an adverse effect on care continuity and the consistency of the nursing approach,” said the inspection report.

The staff turnover rate of 14% was above the national average for similar-sized mental health trusts.

“Some patients on the acute admission wards felt that they did not receive appropriate protected time with their key nurse,” added the report. “They complained of feeling bored particularly at the weekend.”

However, inspectors – who gave the organisation an overall rating of “requires improvement” – also noted good practice, including in support and training for nursing staff.

Newly-qualifieds underwent a “well-structured and in-depth preceptorship programme”. Meanwhile, inspectors praised a scheme to support unqualified staff to train as associate practitioners and then go on to do nurse training.

North Essex Partnership NHS Foundation Trust

CQC criticises Essex trust over ligature-related deaths

Andrew Geldard

In a statement, trust chief executive Andrew Geldard admitted he was disappointed with the “requires improvement” rating, but said the CQC report was a “call to action”.

He said the trust had already begun a £1m programme of physical improvements to wards and other areas.

This will include work to remove ligature risks such as replacing doors, windows and taps on wash basins, he said.

“We have made changes to our care planning process to ensure it is focused on the individual and are improving the range and number of activities for patients,” said Mr Geldard.

He added: “More work that addresses all the CQC’s comments is either under way or planning. I would assure our patients and their families and friends that improving these areas are out overriding priority in the coming months.”

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