A watchdog is “very concerned” about the safety of people using the services of the Greater Manchester Mental Health NHS Trust.
The condemnatory report says inspectors found that there were not always enough nursing staff and that permanent staff did not feel safe if bank or temporary workers were used as they did not have the appropriate training.
This follows an unannounced inspection in September by the Care Quality Commission “due to persistent concerns about the safety of services”.
READ MORE: Patient’s disgust at ‘outrageous’ condition in psychiatric ward
Three young patients died in nine months at Prestwich Hospital, one of the trust’s units.
As revealed by the Manchester Evening News in July, Rowan Thompson, 18, died last October, followed by Charlie Millers, 17, in December, and Ania Sohail, 21, in June this year.
A campaign group and the families of Charlie and Rowan are fighting for a full investigation into these cases by NHS England.
The CQC’s two-day inspection of eight departments across five of the Trust’s seven sites found:
* The service did not always have enough nursing staff who knew the patients or received basic and essential training to keep the patients safe from unavoidable injury.
* The environment at the Poplar ward (Parkhuset) was not clean on the first day of supervision, and space at the ward was limited to patients.
* It was not clear that immediate concerns or learning from incidents were shared across the locations, even though local learning and reviews took place.
* The departments did not have all updated and recently reviewed league risk assessments. Staff in two departments could not locate the league risk assessments at the time of the inspection.
Emergency wards for working-age adults and psychiatric intensive care units (PICU), which were inspected, were at:
• Griffin ward, an emergency ward for women with eight beds in Junction 17, Prestwich
• Oak ward, an emergency ward with 20 beds at the Rivington Unit, Bolton
• Priestner’s Unit, an eight-bed mixed PICU in Atherleigh Park, Wigan
• Medlock Ward, an emergency ward for women with 21 beds at Moorside Unit, Trafford
• Brook Department, an emergency department for men with 22 beds at the Moorside Unit, Trafford
• Poplar Ward, an emergency ward for women with 20 beds in Park House, Manchester
• Juniper Department, a 10-bed male PICU in Park House, Manchester
• Laurel ward, an emergency ward for men with 23 beds in Park House, Manchester.
Since it was a focused oversight and only looked at the safety of the departments, the overall ratings for the service do not change and remain just as good. But the service remains “requires improvement” to be safe.
Brian Cranna, CQC’s Head of Hospital Inspection (Mental Health and Community Health Services) said: “When we inspected these eight departments operated by the Greater Manchester Mental Health NHS Foundation Trust, we were very concerned about the safety of people using the services.
“There were not always enough nursing and support staff on duty, but where the trust identified significant staff shortages, they had put contingency plans in place.
“It was worrying that permanent staff did not always feel safe when banking and agency staff were used, as they did not always have the appropriate training to provide support in the event of an incident.
“The physical environment across some of the departments was not always suitable for people’s needs or safety.
“Although staff could describe where ligature points were located, it was not clear how the trust was more formally assured that all potential risks had been identified and considered.
“The poplar ward had limited space for patients to spend time away from others as the dedicated quiet lounge was used as an extra bed for capacity.
“The department was also dirty and smelled unpleasant, although we were happy to see that the trust recognized this and some improvements had been made when we visited the other day.
“We were also informed that the department was to be redesigned later in September.
“We have told the trust what further improvements they need to make to keep patients safe in an environment that meets their needs. We will continue to monitor them and return to inspect their progress.”
The inspectorate also found good practice in the fund.
The report states that staff assessed and managed risks for patients and themselves well and followed best practices in anticipating, de-escalating and dealing with challenging behaviors.
Gill Green, Director of Nursing and Governance for the Greater Manchester Mental Health NHS Foundation Trust, said: “We welcome the results of the Care Quality Commission following their unannounced, focused inspections of some of our adult and psychiatric intensive care units in September.
The inspection team found several positive aspects of care, including how well staff managed risks and followed best practices, how they protected patients from abuse and knew how to report it, and easy access to clinical information.
“We accept that there are areas for improvement, such as the level of qualified staff in departments that many NHS trusts struggle with, but we have strong contingency plans in place to ensure we remain safely staffed.
“We ensure that patient safety and learning are embedded across the Trust as well as at the local level. We also continue to improve patient environments where we can, with an area already identified for redesign and refurbishment prior to the inspection taking place.
“An action plan to address these areas is under development and we will share our progress with the CQC. This inspection does not affect our overall assessment, which remains ‘Good’.
At a court hearing in Rochdale Coroners’ Court on September 17, senior forensic pathologist Joanne Kearsley said Rowan Thompson’s cause of death was currently ‘unresolved’.
Rebecca Titus-Cobb, a lawyer representing Rowan’s family, told the investigation that the family had a number of concerns regarding Rowan’s treatment while they were on the ward.
She said there were ‘systemic issues regarding patient observation on the device’ and that the Inquest campaign group had contacted the Care Quality Commission to express concerns after a number of deaths, including Rowans.
The charity INQUEST, which campaigns with families whose loved ones have died in state custody or care, wrote to CQC’s Chief Inspector of Hospital, Professor Ted Baker, in September to demand further action.
In the letter, CEO Deborah Coles said: “In light of these deaths and the serious concerns we have about the safety of the Greater Manchester Mental Health NHS Foundation Trust, I ask you, on behalf of bereaved families, to exercise the CQC’s statutory powers. to visit this Trust as soon as possible and independently assess its treatment of young patients.
“These deaths have all occurred within the last ten months. We are working with the families of Charlie Millers and Rowan Thompson, two of the people who died. It is our understanding that all three of these deaths occurred at Junction 17. Department or the Gardener Unit, which is part of the Trusts CAMHS (Child and Adolescent Mental Health Service) units.
“The fact of these deaths in such a short time – less than a year – is a matter of great concern, and we believe that it justifies immediate action by the CQC.
“We therefore urge the CQC to use the many mechanisms at its disposal to visit Junction 17 and the Gardener Unit at Prestwich Hospital to assess the treatment and conditions of patients and to report publicly on the circumstances surrounding these extremely worrying deaths.”
Charlie Millers, the second youngster to die – a ‘friendly, caring boy’ – was found unresponsive in his room in the Junction 17 wing of Prestwich Hospital on 2 December. He received CPR on the spot and was taken to Salford Royal Hospital, but died five days later.
A Serious Unintended event A review by the trust said Charlie was seen with ligatures around his neck three times an hour before he was found unresponsive with a ligature around his neck.
The review says he was alone at the time he was found without reacting to his room.
His mother, Samantha Millers, told the men she was told her son was checked once every five minutes at the time he was fatally wounded. She believes he should not have been alone at all at the time.
He had previously had one-on-one surveillance because of his history of self-harm and attempts at his own life, the review said.
In response to today’s CQQ report, Ms Millers said: “My thoughts are not so strange that my son died. It was the bank staff who took over his care at 10.15pm. Twenty minutes later he was virtually dead.
“It’s a disgrace. I would like more knowledge to work there, and they might as well throw any person in to work there so the numbers look good – which puts our children at risk.”
An investigation into Charlie’s death is set to take place in February.
A study of Rowan’s is scheduled for June next year. His father, Marc, said: “Within 24 hours of Rowan’s death, the Trust knew there was an observation of staff issues. Within seven days, they had made their own internal report which identified such issues.
“CQQ says it is not clear that learning from incidents was shared across websites. Three months after Rowan’s death, Charlie died. I think if such knowledge had been shared, Charlie’s death could have been avoided.”