An independent review of over a dozen deaths among mental health patients has criticised an NHS trust for what it described as “unacceptable” bed management practices.
It also found “deficiencies in assessing, recording or addressing risks” in more than half of the 19 incidents.
“There was uncertainty about nursing staff’s understanding of the observation policy and thoroughness of actual observations”
The incidents, involving patients from the Camden and Islington NHS Foundation Trust, occurred between November 2013 and May last year.
The review found shortcomings in the comprehensiveness of care planning in a number of cases, and a need for greater out of hours care and better communication between primary and secondary care clinicians and managers.
In two of the cases it said: “There was uncertainty about nursing staff’s understanding of the observation policy and thoroughness of actual observations.”
The review recommended the trust also follow up all patients discharged within seven days, and not just those on the specific Care Programme Approach for mental health patients.
In its conclusions, the review said: “Several patients had experienced a number of moves between wards and/or supported accommodation in the community during the course of their admission.
“Such moves inevitably disrupt the patient’s delivery of care and relationships with staff,” it said. “While some moves were for therapeutic reasons and others were unavoidable, some appeared to be for bed management reasons and this is unacceptable practice.”
Three incidents on an inpatient ward over a three-month period involved the use of hanging. It resulted in one death – the first inpatient suicide at the trust for three years.
This prompted a ligature review of trust sites and a major programme of work to remove potential ligature points, which started in August and will run until February 2016.
The trust commissioned the thematic review by consultant psychiatrist Clive Robinson, following a series of deaths between November 2013 and May last year.
In total, the incidents included one homicide, seven likely suicides, five possible suicides, two attempted suicides and four deaths from accidents or natural causes.
Dr Robinson concluded that, although the number of suicides was higher than what might be expected for the period and population, there was no connection between the individuals or incidents.
“We wanted to ensure that all lessons had been learned and to determine whether or not there were any links between the deaths and attempted suicides”
The trust said it had implemented new policies to ensure no patient was moved for bed management reasons and, following investment from commissioners, plans to open a new inpatient ward.
In 2012-13 the trust cut its number of inpatient beds by 55. Despite this, the trust experienced significant bed pressures in 2013-14, causing the number of patients sent out of the area for a bed to rise from 89 in 2011-12 to 171 in 2012-13.
The trust said the pressure on beds was a combination of new patients and a large increase in patients admitted due to the effects of taking legal highs, which it claimed accounted for 40% of trust bed occupancy.
A trust spokesman said: “The fact that there were a number of incidents is the reason we commissioned the independent review. We wanted to ensure that all lessons had been learned and to determine whether or not there were any links between the deaths and attempted suicides.
“We make sure we learn from each incident and that we are open and honest about our conclusions, what could have been done differently, and what changes we have made,” he said.
“That is why we… developed new practice about discharge follow-up, addressed patient moves between wards for non-clinical reasons, and are undertaking a major programme of works across the trust to remove possible ligature points to help prevent suicides in the future,” he added.