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Inspection following mental health ward’s unexpected deaths found high bed numbers

Mental health ward where four people died exceeded the recommended maximum number of beds

Four patients died unexpectedly on a mental health ward which had more than the recommended number of beds on it, a report says.

The Care Quality Commission (CQC) carried out an inspection of East London NHS Foundation Trust following the deaths on an all-male ward between December 2016 and July last year.

Some wards within the trust still have more beds than the maximum of 16 recommended by the Royal College of Psychiatrists, the report said.

A ward in Bedfordshire, where the deaths occurred, has reduced its beds from 27 to 19, the CQC found, but the health watchdog said the trust should continue to review numbers on acute wards ‘so they are in line with national guidelines’.

Recruiting and retaining nursing staff

Inspectors also found that recruiting and retaining nursing staff in the trust continued to be ‘problematic’ but the report said initiatives were under way to address this, and staff felt the service was improving. Locum agency nurses were being employed in the interim to ensure consistency of staff.

The four deaths were being investigated by the coroner when the inspection took place in November at the trust, which provides acute mental health services for adults in London, Luton and Bedfordshire.

Another near-miss incident related to 'serious self-harm' on an all-female ward, which had 18 beds at the time of the inspection.

Banned items, including a blade found on a ward, were a concern despite the fact that patients were routinely searched after returning to the ward from leave, the CQC said.

Patients’ health put at risk

It also said there was a concern patients' health may have been put at risk because the appropriate checks were not always made after rapid tranquilisation was carried out.

The CQC said security breaches were not being consistently reported and fewer than three-quarters of staff had taken up basic and immediate life support training.

Inspectors found improvements had been made in a number of areas, including staff receiving training on suicide prevention and managing physical health conditions, better risk assessments and safe management of medicines.

There was also good feedback from patients, who reported that staff involved them in care planning and treatment.

Improvements in care quality

CQC deputy chief inspector Paul Lelliott said: 'It's good to see that the trust has learnt from serious incidents and made some improvements in the quality of care at East London NHS Foundation Trust’s acute wards for adults of working age and psychiatric intensive care units in Luton and Bedfordshire.

'However, I would like to see care for patients improve further, when we next inspect this service. I was, though, pleased to see that patients reported that staff involved them in planning their care and treatment.'

The service was not given a rating, but the trust had been rated overall outstanding after a June 2016 inspection.


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