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Bristol: Highest number of mental health patient preventable deaths


Highly vulnerable patients have died after NHS failings. Why?

Hundreds of mental health patients have died since 2012 across the country due to NHS failings – and Bristol’s Avon and Wiltshire Mental Health Partnership NHS Trust (AWP) had the highest number. What’s causing these failures and how can future deaths be prevented?

The shocking numbers came to light earlier this month, after a Guardian investigation analysed ‘reports to prevent future deaths’ (PFD reports) issued between 2012 and 2017. Coroners must issue these reports if shortcomings by a person, organisations or public bodies, such as hospital trusts, are so serious that more could die unless urgent action is taken. Guardian journalists identified 15 categories of failings that led to preventable deaths of 271 NHS mental health patients: 706 separate failings occurred across the deaths.

The failures

The number of times each failing was implicated in an AWP patient death

Analysis of the Bristol PFD reports shows the most common failings were poor communications between agencies and/or staff; poor record-keeping; and insufficient risk assessment. This mirrors the national picture, where poor communication and non-observation or lack of protocols or policies were the most common failings.

Underpinning these three failings— and indeed all fifteen types of failure the Guardian identified— is the lack of time that burnt-out and under-resourced staff have to communicate, or to properly assess and document patient risk. Staff shortages mean tasks are increasingly left to untrained healthcare assistants.

Some examples: in September 2014, a healthcare assistant was left to carry out hourly checks on 19 patients, two of whom were on 10 minute observations.  A patient killed herself between checks.

In August 2015, a healthcare assistant was tasked with conducting an inpatient’s risk assessment before an unescorted outing. His mental state was not noted and he killed himself while off grounds. Earlier that year, the same patient’s referral to a psychiatric unit was delayed because no beds were available.

In April 2016, a patient placed on 10 minute observations took their own life on a busy shift staffed by just one registered nurse. The nurse was newly qualified.

Most failings cropped up time and time again. For example, a PFD report from 2013 stated that AWP had not followed protocols or policies on record keeping, which had led to staff being unaware of a particular patient’s suicide risk. Four reports in 2015, another four in 2016, and another one in 2017, cited the same failing.

Speaking to the Cable, Kerry McCarthy, Bristol East MP said: “Earlier this year I met with Hayley Richards, AWP chief executive, who told me that despite demand on their services increasing by almost 20% in a year, funding has remained the same. The Conservatives must provide the funding these services so desperately need.”

What is the government doing?

Jeremy Hunt, secretary of state for health, told the Guardian his government has dedicated “record spending” and introduced a “zero-suicide ambition” and “parity of esteem” — giving mental and physical health equal status in access to quality care and treatment.

Last year, 84% of mental health trusts received a significant funding increase. It might be ‘record’ but it’s not enough. And the health and care charity King’s Fund has shown that parity exists only in Hunt’s rhetoric: the spending gap between NHS acute hospitals and NHS mental health providers widened in 2017.

“Staff are expected to keep up with increases in referrals while juggling mammoth caseloads.”

Nationally, student bursary cuts and high-stress-low-pay conditions have led to a 13% reduction in qualified mental health nurses in England since 2009, amounting to around 5000 fewer nurses. High staff turnover means fewer mental health nurses are employed annually. In December 2016, approximately 10,000 mental health nursing positions were unfilled—for example due to recruitment freezes.

Regarding AWP, the Care Quality Commission noted in its 2016 inspection report that reorganisation and job restructures meant clinicians were left to do management tasks, “staff morale was variable”, and improvements to ward safety would require “significant capital funding”.

Karin Smyth, Bristol South MP and former NHS manager told the Cable: “We know local mental health services are under pressure and sadly that too many families are feeling the brunt. But rhetoric from the government about improving mental health services is coupled with a lack of funding and action.”

What next for AWP?

AWP has cut the suicide rate by 31% since 2012. Speaking to the Cable, they said they “have improved suicide awareness and suicide prevention training for all clinical staff”. In 2016, they “devised and implemented a new mechanism for sharing learning about patient safety improvements with all staff”. Their 2017 Suicide Prevention Strategy has listed key actions, including learning from investigations into unexpected deaths.

Currently underway is a project to improve risk assessment: a “comprehensive risk assessment and management” initiative and a project “aimed at standardising screening and assessment processes (‘triage’) and revising electronic documentation to ensure key risk information is captured at the earliest opportunity”.

Is this enough? One community worker from a third-sector partner of AWP, said: “There are factors we have no control of: the housing crisis, increased homelessness, spikes in drug-use, social care and benefit cuts and complications, massive waiting times for specialised services, increased student referrals… Staff are expected to keep up with increases in referrals while juggling mammoth caseloads.”

So what needs to happen? Among other changes, “we desperately need more staff—including social workers and nurses—so we can focus on proactive care to prevent crises occurring in the first place,” said the worker.

Another member of staff working in NHS mental health services also told the Cable, “I worry every single day about not having the time and resources to give my patients what they need. The more you care the harder it is: the pressure from being unable to do a good enough job is unbearable. People die because of the government’s lack of funding. How much worse does it have to get before something changes?”

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