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Coroner calls for nurse consultants to go into mental health units to improve physical care

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A coroner has called for nurse consultants, experienced in physical healthcare, to be used in acute mental health settings to train other staff in identifying physically sick patients.

The coroner urged NHS England to improve physical healthcare support for patients in mental health units, sparked by the death of a new mother with post-partum psychosis in an inpatient unit.

“I would be grateful if NHS England would acknowledge my support for the use of nurse consultants”

Sarah Ormond-Walshe

Inner London South assistant coroner Sarah Ormond-Walshe wrote to the national commissioning body in May outlining her concerns following an inquest into the death of Alice Gibson-Watt.

Ms Gibson-Watt died in November 2012 after experiencing a cardiac arrest at West London Mental Health NHS Trust’s Lakeside Mental Health Unit, which is based at West Middlesex University Hospital. She had been admitted with post-partum psychosis.

The 34-year-old Antiques Roadshow jewellery expert died of a brain injury following a cardiac arrest after being given an anti-psychotic drug.

Following the inquest into her death in April this year, Ms Ormond-Walshe sent a report to prevent future deaths to NHS England, in which she called for new measures to improve physical healthcare in mental health units.

“Staff should be competent with the appropriate training and ongoing CPD to meet the full needs of patients”

NHS England

The coroner’s report said monitoring of Ms Gibson-Watt’s vital signs was “inadequate and insufficient and not in accordance with the Lakeside policy”, because staff had not followed the trust’s rapid tranquilisation policy that checks should be done every 30 minutes.

It also said it took three members of staff to realise the new mother had gone into cardiac arrest and no defibrillator had been used until London Ambulance Service arrived, despite there being one on site.

Ms Gibson-Watt was taken to West Middlesex University Hospital and then transferred to King’s College Hospital, where she later died.

Ms Ormond-Walshe said it was not the first incident she had heard about where a mental health patient became physically unwell on a mental health unit, and that she had wider concerns about the identification of physically ill patients in acute mental health settings.

She added: “Identification of patients who are becoming acutely physically unwell does need more attention in general, with or without reconsidering how readily vital sign observations are ordered. Having policies and procedures in place does not appear to be sufficient.”

“Identification of patients who are becoming acutely physically unwell does need more attention”

Sarah Ormond-Walshe

Ms Ormond-Walshe suggested nurse consultants in physical healthcare should be employed to help train more mental health staff in identifying physically sick patients.

Nurse consultants provide clinical intervention for patients in mental health services who are suffering or at risk of suffering physical health problems. Ms Ormond-Walshe said she did not believe there was more than a handful of them nationwide.

She said new technology to remotely monitor patients had “potential merit”, but was only as good as its operators.

She added: “I would be grateful if NHS England would acknowledge my support for the use of nurse consultants in physical healthcare working in acute mental health settings.

“The education and auditing of mental health professionals in identifying the acutely sick, and carrying out appropriate action, is vital to prevent future loss of life,” she noted.

Bruce keogh

Bruce keogh

Bruce Keogh

In NHS England’s response, its medical director Professor Sir Bruce Keogh said the body expected mental health staff to have the necessary “core competencies” to recognise physical ill health.

The letter said: “Whilst NHS England does not mandate which specific job roles should deliver which elements of the physical healthcare agenda in mental health settings, staff should be competent with the appropriate training and ongoing CPD to meet the full needs of patients.

“In parallel, NHS England continues to support the ongoing inspection and regulation of mental health inpatient wards by the Care Quality Commission,” added the letter, according to Health Service Journal.

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