SSystemic failures to deliver basic physical care in NHS mental health wards are killing patients across the country, despite numerous warnings from coroners over the past decade. the independent can reveal.
An investigation has uncovered future death prevention reports, used by coroners to warn health services of widespread failures, on at least 50 occasions since 2012 involving 26 NHS trusts and private health care providers.
The cases included deaths caused by malnutrition, lack of exercise and starvation for detainees in mental health facilities. Experts warn that a lack of training and funding is responsible for the abandonment of vulnerable patients.
Our investigation discovered:
- Staff do not perform basic health checks, such as blood clot risk assessment.
- Cases of nurses and care assistants without adequate training in CPR
- Physicians unable to carry out emergency response procedures
- Patients not treated for side effects of antipsychotic medication
- Rapid decline in health that goes unnoticed and untreated
Coroners have exposed multiple cases of mental health patients receiving inadequate treatment at the general hospital and their illness being mistaken for a psychiatric problem.
the independent may reveal that a fifth of patients in mental health units across the country do not receive basic physical health checks upon admission, according to a report by the Confidential National Inquiry into Patient Deaths.
The report, produced this year, warned of “significant missed opportunities” by health services to identify and treat physical health conditions in mental health patients.
The review explained that deterioration in physical health often follows admission to inpatient units.
It comes as the NHS’s national clinical director for mental health was forced to write to hospitals advising them of the need to offer physical health checks.
Dr Rosena Allin-Khan, Labor’s shadow mental health minister, called for a swift review of inpatient mental health services. She said The independent: “The government needs to control the current crisis in mental health hospitals: the current conditions are inhumane. Patients deserve better.”
‘I’m left with so many questions’
Yvonne Eaves died while hospitalized at Greater Manchester Mental Health Trust in 2020 due to a blood clot, after unit staff failed to carry out blood clot risk assessments.
Great Manchester coroner Nigel Meadows attributed his death to “a serious lack of basic medical care”. She is one of four cases in which medical examiners warned about improper evaluation and treatment of blood clots within inpatient units.
The 69-year-old had suffered from mental illness from a very young age. In January 2020, he was admitted to the Greater Manchester Mental Health Hospital and was noted to have “several deep and severe long-standing infected ulcers and wounds”.
Eaves was taken to a hospital where she was given preventive medication for venous thromboembolism, or blood clots, and was released back to the mental health unit. But this treatment did not continue when she was returned to the mental health unit.
Talking with the independent Lorrain Fallon, her sister, said: “I’m left with so many questions about Yvonne’s death, like if Yvonne would still be here if she had the right tests and medication.
“It is impossible to put words to such a funny and eccentric character. Yvonne had a magnetic personality and left an impression on everyone she met. She was the second mother to my son Sam. She is a huge loss and I miss her with every fiber of my being.”
Gill Green, from the Greater Manchester Mental Health NHS Foundation Trust, said improvements had been made to physical healthcare provision, including a new strategy and the introduction of new job roles with a physical healthcare focus.
Last year, the inquest into Jonathan Kingsman, who died aged 47 from clots at a unit run by the Cambridgeshire and Peterborough NHS Foundation Trust, prompted a coroner to write to the Department of Health and Social Care, advising that national guidelines for blood clot tests were failing. to take into account the risks associated with antipsychotic medication.
His wife Lara told him the independent: “If you have someone with acute mental health problems, you feel that they are more secure, or hopefully secure [in hospital]. I certainly don’t blame anyone caring for Johnny. I know how under pressure these people are and have to work within the guidelines they are given. A friend looked at the risk assessments and said, ‘I could drive a truck through that risk assessment in terms of blood clots.'”
“We know we have to do more”
Dr Lade Smith, Lead Inequalities at the Royal College of Psychiatrists, said: “If you have a serious and long-lasting mental health problem, you are likely to die 15 to 20 years earlier than someone in the general population. That’s not fair.”
The forensic warnings discovered by the independentDr. Smith said it highlights the “fragmentation of care,” with psychiatrists fighting for patients to have access to proper physical medical care.
She said: “As a psychiatrist, we know we have to do more. But we cannot do this on our own. We need our distant partners, our physical health colleagues to become partners in this.”
Margaret Flynn, who chaired the review of the Winterbourne View scandal that exposed horrific abuse and mistreatment of hospitalized learning disabled patients, said that when vulnerable people are admitted: “You see they are there because they are angry or mean. So, they are not looking at people’s physical health care.”
Throughout his reviews, he said patients were sometimes “overfed” and weight gain was a “big problem.”
Ben King, who had down syndrome, died at Cawston Park private mental health hospital in Norfolk. Last year, an investigation found that he had “died due to inadequate weight control” and failure to diagnose an obesity-related condition, as well as “inadequate consideration” of medications.
Mr King’s death was one of three that prompted a major overhaul of the hospital.
In another key NHS review published last year on the death of Clive Treacy, who was detained in mental health units for 10 years, report chair Beverly Dawkins said: “People have assumed that the teams in those units they have all the skills necessary to manage people’s physical health care, and yet the evidence is often to the contrary.
“Many people in those units recorded not going out to exercise, not going for a walk, sometimes not even getting up off the ground.”
She said that despite failures being highlighted for more than a decade, proper funding and focus from government is still lacking.
‘Sent to her death at a young age’
According to the Confidential National Inquiry into Suicide and Mental Health Safety, an “early warning score,” a national guideline for severe health decline, was not used for a quarter of patients who could have benefited.
Forensic reports seen by the independent repeatedly warning of staff failures to identify when a patient’s physical health is deteriorating.
Roxanne Brown, mother of one, has died aged 31 following the “negligence” of the private Shrewsbury Court hospital in Surrey, which has since been closed following a critical report by the Care Quality Commission (CQC).
According to a research report shared with The independent, she was admitted in March 201. Seven months later, she was showing signs of a high temperature and elevated pulse, and a support worker took her to her GP.
Patients whose health is deteriorating are assessed under a “modified early warning score.” However, Brown’s score was not shared with the GP, who later diagnosed a chest infection. Evidence from the investigation found that if the GP had seen her score, she would have referred her to A & E.
The GP’s advice to take her to the emergency room if her condition deteriorated was not noted or followed by the staff.
Matthew Turner, the attorney representing Brown’s family, said staff’s inability to detect deterioration appears to be “part of a larger problem of poor physical health for patients in mental health hospitals.”
Brown’s mother, Ruby Brown, said: “Every day seems like the day she passed away. Worst of all, she wasn’t there to get the medical help she so badly needed, to comfort her and let her know that she would do everything she could to make things right. Unfortunately, I didn’t find out about any of the things that happened to him; that he was hiding from me.
“She would still be alive to this day if she had not been sent to her death at the young age of just 31, and what would have become of her relationship with her now 14-year-old daughter?”
‘Urgent action needed’
Chartiy INQUEST said that a key problem was the division of medical care between physical and mental health. INQUEST’s Lucy Mckay said the independent: “Urgent action is needed across the NHS to increase connection and communication between services and to ensure mental health units are better integrated with professionals who can monitor and treat physical illness.”
In 2019, the CQC published the requirements for mental health providers to conduct physical health assessments and monitoring.
Jemima Burnage of the CQC said the independent: “It is essential that staff in mental health settings meet the physical and mental health needs of patients as a matter of priority.
“We are clear that providers must conduct appropriate assessments and regular monitoring of the physical health of individuals seen in inpatient mental health services.”
Andy Bell, deputy director of the Center for Mental Health charity, said: “It can be difficult to gain access to physical health expertise in mental health hospitals,” he said. “In general, it is not part of what is available and mental health hospitals have high bed occupancy.”
An NHS spokesman said all providers of mental health and learning disabilities services were “contractually” obliged to offer physical health checks to patients. They added: “The NHS recently reminded local areas of this and also made additional funding available to increase the number of multidisciplinary staff at the hospital, including operational therapists and peer support workers.”
A spokesman for the Department of Health and Social Care said: “Anyone who receives treatment at an inpatient mental health facility should receive safe, high-quality care and should be treated with dignity and respect. We are considering what is needed on broader issues for mental health inpatient care and will update in due course.”