Devon’s mental health trust ordered to make urgent improvements after fourth death in a year

Devon Partnership Trust (DPT) has been ordered to make urgent improvements following four deaths in just under a year at mental health units.

The most recent of the deaths – all suspected suicides – was in July at Langdon Hospital in Dawlish.

Care Quality Commission (CQC) Inspectors visited the Ashcombe ward and Holcombe ward, two of the medium secure wards at the Dewnans Centre in August 2020, following the death and “other safety concerns”.

The report describes the shocking incident on July 31 and details how there were high number of vacancies on Holcombe Ward, making it heavily reliant on bank and agency workers.

It says some staff were stressed and exhausted following the demands of the COVID-19 pandemic.

Inspectors said in the report: “We found a number of concerns relating to patient safety and staffing levels and we told the trust to make immediate improvements.”

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CQC’s Head of Hospital Inspection Karen Bennett-Wilson said the Trust “knows what it must do” and added: “We are continuing to monitor the trust closely and will not hesitate to take action if it fails to make the necessary improvements.”

It follows another recent warning by the CQC after three other inpatient deaths in quick succession in similar circumstances.

All of four deaths in the past year involved ligatures, and happened during a year-long delay to the trust’s plan to reduce ligature risks.

DPT today said “deaths by suicide on mental health inpatient wards are classified as never events” and says it is now working with the CQC to make changes and avoid more tragic deaths.

Two patients died by suicide in September and November last year on the trust’s Meadow View Ward at North Devon Hospital in Barnstaple. In March this year, a third patient died by suicide on Delderfield Ward in Exeter.

Langdon Hospital, Dawlish. Photo: Steve Pope HE030307_SP03_03

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Ms Bennett-Wilson, said: “We completed an urgent inspection following the tragic death of a patient at Ashcombe ward. We found a number of concerns relating to patient safety and staffing levels and we told the trust to make immediate improvements.

“The trust must ensure that there are always sufficient numbers of suitably qualified, skilled and competent staff on wards at all times. In addition, it must ensure the environment is safe and that there are robust methods for staff to follow when carrying out observation of patients.

“Following our inspection, we informed the trust’s leadership team of our findings and told them that they needed to take immediate action to address the issues. The trust has made some urgent improvements and knows what it must do to ensure it continues the required improvements.

“We are continuing to monitor the trust closely and will not hesitate to take action if it fails to make the necessary improvements.”

The report states: “There had been an incident on Ashcombe ward on 31 July 2020. Changes had been made to Ashcombe ward to create an isolation area as part of the COVID-19 infection and prevention control strategy.

“The serious incident took place in an area of the ward that did not have good lines of sight due to the changes made to the ward environment. However, the trust had failed to identify that this left blind spots where staff could not easily observe patients.

“There were a high number of vacancies particularly on Holcombe Ward, making it heavily reliant on bank and agency workers. Some staff were stressed and exhausted following the demands of the COVID-19 pandemic. Some shifts showed gaps in staffing which could potentially affect the safe care and treatment of patients.

“However, the trust had recognised the staffing difficulties and was actively recruiting and had plans in place to address staff shortages and support staff.”

Other points made in the report include:

  • The observation of patients needed improving. There was also a need for changes to the environment to ensure clear lines of sight were in place. This would help staff in observing patients.
  • Managers had not ensured the learning from incidents was communicated clearly with staff to allow risks to be managed effectively across all the wards.
  • Some staff told inspectors that the leadership of the service needed to be more supportive, and that managers needed to be more visible on the wards.
  • We also found that staff treated patients with compassion and kindness. They respected their privacy and dignity and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.

Full details of the inspection are given in the report published online here.

Director of Nursing and Practice at Devon Partnership NHS Trust, Chris Burford, said: “We extend our deepest sympathies to the families of the people who have died in these incidents.

“We treat incidents of this kind with the utmost seriousness. The death of each of these people is a tragedy for them, their families and their friends. It is also very traumatic for the staff who have worked closely with these people to support their mental health needs.

“Each of the deaths has been the subject of a rigorous review. In addition, our Safe from Suicide team are undertaking a thematic review to make sure that we identify any issues that may be common to the deaths.

“We are working closely with our regulators and the CQC to ensure that we identify the learning from these tragic incidents and that we make any necessary changes to our systems and processes for managing risk and keeping people safe.”

According to DPT board papers, the trust had accepted a recommendation in March 2019 – six months before the first death – to install anti-ligature sensors in all inpatient wards and bathrooms.

However, the programme to install anti-ligature sensors on doors was delayed by more than a year and will only start this November.

The trust is rated “good” by the CQC overall.

Mr Burford told the HSJ the delay was caused by the sensors not working properly at two newly opened units during 2019.

He said the trust had experienced “humongous problems” including IT issues and the sensors failing to trigger the alarm.

He said the trust had a plan in place to re-launch the programme in 2020, but the coronavirus pandemic then caused further delays.

He said it would take up to two years to deliver the programme, which is costing several millions of pounds, and that the highest-risk wards would be prioritised.

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