Illustration: Sophia Checkley

Content warning: Descriptions of self-harm

A teenager leaves their room and walks down the corridor, their arms up to the elbow covered in blood. Shocked, Michael* runs to see what has happened, and finds where they have cut themselves. As they mumble, he grabs them by the hands to make sure they don’t hurt themselves any more until the paramedics arrive.

“It was hideous,” says Michael. “Stuff like that wasn’t uncommon, this was near the start of my time at Banksy, but as time went on, as management structures started to dissolve and the team became weaker, those incidents became more frequent.” 

Tucked away in leafy Stapleton, Banksy ward cares for young people at crisis point – the only of its kind in the south west. It is run by the UK’s largest private mental health provider, the Priory Group, which receives hundreds of millions of pounds from the NHS and is owned by a US healthcare giant.

Eventually, Michael left his job at the Priory Hospital Bristol because he couldn’t take it anymore. Today, he is one of a number of workers, nervous about speaking out, who have decided to expose what happened at Banksy ward.

In July, the Cable revealed that Banksy ward was closing down less than three years after opening because of staffing problems. The nearest ward of its kind 100 miles away in Maidenhead, so patients had to be transferred elsewhere. 

But this was far from the whole story. A Cable investigation spanning six months based on testimony from current and former workers and documentary evidence can now reveal that problems on Bansky ward went back over a year, including struggles to keep permanent staff, regular incidents of self-harm and violent attacks on staff by patients. 

Workers also allege that staffing levels on the ward were too low to deal with these incidents and the high needs of the patients. Staff quit their jobs, sometimes after being physically attacked, which left the hospital to rely heavily on agency staff amid national shortages of qualified nurses. The Priory Group denies that Banksy ward had less than adequate staffing, although it acknowledges that staff shortages are a nationwide issue.

After the Priory launched an internal investigation and halted admissions in autumn 2019, the ward reopened to new patients a few months later. However, police are now investigating a serious incident on the ward in June 2020. Shortly after, following discussions with NHS England, the decision was made to close the ward.

In the last 18 months, three separate Priory wards in England for children and young people have closed down after being rated inadequate by regulator the Care Quality Commission (CQC). Each time, the company has blamed a national shortage of qualified staff.

In a sector facing high demand, bed shortages and recruitment problems, Banksy ward is now also going to close. In January 2019, the Priory Hospital Bristol was rated as Good by the CQC. So how did Banksy ward go from that point to having to stop admissions later that year and closing permanently in just 18 months?

“I would regularly walk onto the ward full of anxiety.” Michael tells the Cable about his time working on Banksy ward, speaking on condition of anonymity. He describes graphic incidents of self-harm, as young people hurt themselves with razor blades and tying ligatures around their necks. 

“The conditions that make the incidents more frequent were when the ward is understaffed,” he says. “We were constantly understaffed for most of 10 months, which also had an impact on staff morale. When you come in and there are 6-7 of you for 9-10 young people, who have these severe episodes of self-harm, you walk onto the ward feeling defeated before you’ve even begun your shift, which has an enormous impact on the level of care you can provide.”

Michael is one of a number of workers to allege that staffing levels were not adequate to meet the complex needs of the patients and made it more difficult to prevent self-harm and violent outbursts. However, the Priory Group said the ward was not understaffed, and that there was no evidence that self-harm incidents were caused by patients’ needs not being met or inadequate staffing.

Another worker, Chris*, says when he started, “It was such a good ward to work on.” Higher staffing levels and activities being offered to the young people made it feel like a safer, more pleasant environment, he says, where carers felt like they were able to care.

Banksy ward is a psychiatric intensive care unit (PICU) for up to 12 young people – the only ward of its kind in south west England. It is designed to care for children at high risk for short periods of time, who were often at acute risk of self-harm, had often been detained under the Mental Health Act (MHA) and may be far from home. Some distressing incidents are to be expected on this kind of ward, which aims to keep the young people safe and set them on a route back to recovery, by observing them closely, prescribing medication and offering therapy until they are ready to ‘step down’ to a less restrictive setting.

Staff said that they managed to do this in lots of cases, but as time went on, it became more difficult and distressing incidents became more frequent. They said the hospital struggled to keep regular permanent staff, and the ward manager was absent on sick leave for prolonged periods. The ward did not have a permanent manager on the ward from summer 2019, but the Priory Group said cover was put in place.

Workers said that at times they felt unsafe working on the ward. “Staff safety was non-existent,” says Chris. “I felt sorry for a lot of the women, because they got it worse. I saw a lot of good colleagues leave with dislocated shoulders, broken nose, broken arm. It’s a shame because they didn’t get the support.”

Michael, who described being punched, kicked, spat on, and bitten, said these incidents gave the ward a reputation. He remembers a worker coming over to Banksy from another ward that was overstaffed. “When she came onto Banksy, she was shaking, she had heard the stories about what happened on that ward, she absolutely did not want to be there with us. Permanent members of staff from other wards have flat out refused to work on Banksy. Its reputation also prevented it from being adequately staffed.”

During the CQC inspection in January 2019, which rated the hospital as Good overall, there were seven serious incidents on Banksy ward, including violence towards staff and police, young people swallowing parts from broken equipment, self-harm using a blade and violent behaviour. On Banksy, there were 118 recorded incidents in the 12-month period up to July 2018.

The inspection report found that incidents were managed well, but that some staff experienced significant levels of violence and racial abuse from patients and felt the support following these incidents could be improved.

Multiple workers confirmed that racist abuse happened on the ward. Chris experienced racist abuse personally and said when he reported it, he was told that it was part of his job and he needed to get on with it. The Priory Group said there was no evidence to support this allegation and that the hospital encourages staff to report verbal abuse of any kind. 

Staff also said it was also common to do one-to-one observations – where they are tasked with looking after individual patients – for hours on end without a break, which breaches the Priory’s own policies. The Priory didn’t deny this, but the CQC report said floating staff were available when young people had their observation levels increased. One worker, James*, spoke of anxious and burnt out staff having a knock-on effect on patients. One time he had to observe a patient who had just punched him in the face and kicked him in the genitals.

Staff said these issues pushed colleagues to the point of leaving, which meant turnover rates were high and affected continuity of care. Struggles to keep a team of permanent staff made the ward reliant on agency staff to fill the gaps.

Some agency workers were employed over long periods of time and got to know the ward, but staff reported some agency workers not always being up to the job. Multiple workers said that staff from one agency, Vetro, weren’t always adequately trained in using restraint so refused to intervene when young people were being violent or trying to self-harm. Vetro said that all their staff undergo fully accredited three-day practical training in managing violence and aggression before attending any shifts, and that all their workers had passed checks by the Priory.

Multiple sources said agency workers were the most likely to get the blame if things went wrong. An agency nurse was fired, some staff feel unjustly, after an incident where a patient needed CPR after tying a ligature. The nurse spoke to the doctor and a decision was made to not send the patient to hospital. The Priory Group said there was no evidence to suggest that the clinical decision made was inappropriate.

These issues on Banksy ward culminated in what Chris described as three weeks of “riots” in autumn 2019 as staff were unable to control patients, who tore down alarms and caused damage to the ward. “Every single day, for 12 hours a day, we were on red alert, we couldn’t cope with it,” he says. The Priory said this was “unsubstantiated” and that it was wrong to characterise challenging behaviour as “riots”.

Chris eventually stopped working there, unable to continue. “I went into care work to care, but that wasn’t care. I couldn’t take it anymore. I was seeing my friends get hurt, friends refusing to come in.”

In autumn 2019, the Priory and NHS England decided to halt new admissions to the ward. Young people were referred elsewhere, until the number of patients went from 10 to just a couple. Meanwhile, the Priory carried out an internal investigation into issues on the ward. But what precedent do these problems have at the hospital?

Banksy ward is not the first time staff at Priory Bristol have had concerns about low staffing levels. The Cable spoke to a whistleblower who reported concerns about a different ward to the CQC back in 2013. “It was quite traumatic for the staff and obviously very dangerous for the residents,” they said. “I told management I had patients at risk of neglect and choking, so you need to get somebody here.” They reported to the CQC that a ward for people with complex needs was being staffed by five people instead of nine.

A subsequent CQC inspection found that most standards of care were not being met, including adequate staffing levels. This was due to inconsistent staffing, shifts not always being filled and agency staff being used regularly.

Then in 2015, a routine CQC inspection found issues with recruitment and retention of staff, which culminated in several wards regularly failing to meet their minimum staffing levels. The Priory Hospital Bristol has since received better ratings from the CQC. 

In 2019, 18 allegations were made against staff at the Priory, according to data acquired by the Cable under the Freedom of Information laws. The reports were made to Bristol City Council’s Local Authority Designated Officer (LADO), who deals with allegations that someone who works with children has harmed a child or may pose a risk. Although some of these allegations may be unfounded, the number is much higher than levels in every other year since 2015.

Bristol City Council and the local clinical commissioning group refused to answer questions on what concerns they had about the ward and safeguarding.

The 2019 CQC report said that “staff managed incidents well and managers investigated them thoroughly”, but a source from local Children and Adolescent Mental Health Services (CAMHS) told the Cable he had concerns about safeguarding practices at the Priory being not as good as the NHS, based on experience of placing young people there. 

“It’s a widely held belief that the care provided by most of the private hospitals contracted by the NHS is most of the time of much poorer quality, comes under less scrutiny and is vastly more expensive than the NHS,” he said. However, he added that there was little choice but to send young people there because of national shortages of beds.

Another source from local services who assesses people under the MHA said that, in addition to concerns about low staffing levels, the Priory didn’t seem to take safeguarding seriously enough. There have also been historical problems with safeguarding.

Some of these historical problems aren’t related to Banksy ward, and the Priory Group was owned by a different parent company at the time, but they are issues that hospital management will have been aware of. 

In recent years, the number of mental health beds offered by the NHS has fallen, as part of a wider trend over decades to treat more people in the community. The idea is to send people to hospital only when absolutely necessary in order to prevent people becoming ‘institutionalised’ unnecessarily.

But there are concerns that due to underinvestment, community services haven’t expanded fast enough to compensate for the reduction in inpatient beds, which means people are still reaching crisis point and need to be treated in hospital. This gap in inpatient services is increasingly being covered by large private companies – but funded by the NHS.

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The problems on Banksy ward in Bristol are far from isolated in a CAMHS sector under pressure, and the NHS is not exempt from these issues either. The most recent State of Care report by the CQC found that the overall quality of care in independent hospitals had deteriorated, and expressed serious concerns about the quality and safety of inpatient care. How this was being impacted by workforce challenges was their “greatest concern”.

Banksy ward now joins a succession of CAMHS wards run by the Priory Group that have closed down. In the last 18 months, three separate Priory hospitals or wards in England for children have closed down after being rated inadequate by the CQC. Each of the cases in Buckinghamshire, Norfolk and Dorset showed similar problems, such as hiring too many agency staff, staff being inexperienced, and violent incidents occurring. 

Each time, the Priory has put the blame on the same thing: a national shortage of qualified staff, which is a well known problem in the sector. The same recruitment challenges were cited when it was reported last month that four Priory children’s homes in Birmingham were being shut down after inspectors found them to be unsafe. 

Priory CAMHS wards have hit the headlines before. In 2019, they were fined £300k for their role in the death of 14-year-old Amy El-Keria in 2012 at Ticehurst House in East Sussex. In 2017, an undercover reporter from ITV filmed numerous examples of poor care and young people in distress, and in December 2019, the CQC found Ticehurst House to be inadequate after concerns were reported by families and workers about poor staffing levels, high use of agency staff and a high number of incidents.

This is despite recommendations following Amy’s death back in 2012. INQUEST, the charity who supported Amy’s family, have accused the Priory of resisting scrutiny. The Priory Group said they participate fully in all coroners’ inquests and work collaboratively with all external agencies. However, there is no obligation to provide publicly available information on the number of deaths in privately-run mental health care – in contrast to all other deaths in public settings.

The Priory Group is not the only mental health provider to be struggling with staffing. Banksy ward is a shocking story but also one of a sector under pressure. But what happened in the months leading up to the closure of Banksy?

In December 2019, the Priory offered a week of training for staff on Banksy before restarting admissions again – on a reduced capacity of four patients. Experienced staff from elsewhere were brought in on a part-time basis for support.

“But that was never the problem in the first place,” says James. “The problem was a dysfunctional staffing system that over-relied on agency staff who didn’t know the ward – that was never fixed.”

Despite the lower number of patients, problems continued. There was a serious incident on the ward in June, which is currently under investigation by Avon and Somerset Police. A patient swallowed a number of dangerous items, including batteries, but the doctor decided not to call an ambulance. It was not until many hours later that the patient went into hospital for treatment.  The Priory confirmed this was an agency worker who is no longer working at the hospital. They investigated this incident internally before reporting it to the police.

Shortly after, NHS England and the Priory discussed the future of the ward. It was decided that Banksy should close because the Priory would struggle to staff the ward sufficiently in the long-term.

A spokesman for the Priory Hospital in Bristol said: “Due to challenges in recruiting permanent staff, we have taken the difficult decision to close the ward. We are working with the patients, their families and NHS England to ensure the four young people on the ward receive a smooth transfer to a setting which best meets their needs. Staff from the ward will be redeployed across our hospital in Bristol, which is rated ‘Good’ by the CQC for its child psychiatric and adult services.”

While wards are being closed down, the Priory Group has been put up for sale by its owners, the US giant Acadia Healthcare, who bought the company for £1.3 billion in 2016.

Banksy may be closing, but there is another CAMHS ward at the hospital in Bristol, which staff said also mirrored some of the same problems, including a lack of permanent staff and frequent distressing incidents. The CQC have been inspecting, with their report due out soon.

*Names changed to protect identities.

• WHY I WROTE THIS

  This investigation took months of reporting. It began with a tip-off from a nervous source. Then I set about building a bigger picture of what happened by speaking to more sources. The Priory Group is threatening legal action if we publish this story, which is why it has taken so long to come to light. But we are confident in its accuracy and importance. It is made possible by sources being willing to speak out and the 2,200 Bristol Cable members who support long-term investigative journalism.

  Matty

Read more from this series about private mental health services in Bristol.

Do you have experience of this story? Contact us in strict confidence to help us tell more stories about private mental health services in Bristol. Get in touch by emailing: matty@thebristolcable.org.