Systematic failure to deliver basic physical care in NHS mental health departments is leading to patient deaths across the country despite repeated warnings from forensic pathologists over the past decade.
An investigation revealed at least 50 “prevent future deaths” reports that coroners used to warn the NHS of common failure points, submitted since 2012 and involving 26 NHS trusts and private healthcare providers.
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Cases included deaths from malnutrition, lack of movement and starvation among patients held in mental health facilities. Experts warn that poor training and lack of funding are among the reasons why vulnerable patients are neglected.
Our investigation revealed the following:
The staff failed to perform a basic health check, such as ensuring that there is no blood clot
Nurses and assistants did not receive the necessary training related to resuscitation
– Inability of doctors to carry out emergency response procedures
– Patients did not receive treatment for the side effects of antipsychotic drugs
Not noticing and treating rapidly deteriorating health
Forensic doctors presented a number of cases of psychiatric patients who received improper treatment in public hospitals and were misdiagnosed as a psychological problem.
The Independent revealed that a fifth of patients in psychiatric units across the country do not receive basic physical healthcare checks on admission, according to a report from the National Confidential Patient and Mortality Inquiry.
The report, which was conducted this year, warned of “a lot of missed opportunities” by health services in identifying and treating the physical health condition of psychiatric patients. The report explained that declines in physical health often follow admission to inpatient units.
This coincides with the NHS England’s National Clinical Director of Mental Health having to write to hospitals warning them about the need for physical health checks.
In a related context, Dr. Rosina Aline-Khan, the shadow mental health minister in the Labor government, called for a rapid review of internal services (within hospitals) for mental health. She told The Independent: “The government needs to take care of the ongoing crisis in psychiatric hospitals, the current conditions are inhumane. Patients deserve better.”
“I have many unanswered questions.”
Yvonne Ives died of a blood clot while an inpatient at Greater Manchester Mental Health NHS Trust in 2020, after staff within the unit failed to carry out a blood clot risk assessment.
Greater Manchester Coroner Nigel Meadows attributed her death to a “major failure to provide her with basic medical care”. Her case is one out of 4 other cases in which the forensic pathologists warned that an appropriate blood clot monitoring and treatment assessment was not conducted within the inpatient units.
The 69-year-old woman suffered from mental illness since her youth. In January 2020, she was admitted to a unit run by the Greater Manchester Mental Health Trust and had “numerous long-standing, deep, infected sores and wounds”.
Ives was then transferred to a hospital where she was given preventive treatment for venous thromboembolism (VTE) or a blood clot and was then discharged back to the mental health unit. However, treatment had not been completed when she returned to the mental health unit.
Speaking to The Independent, her sister, Laurette Fallon, said: “I have been left with unanswered questions in relation to Yvonne’s death, such as would Yvonne have survived had she received the proper assessment and treatment? It’s hard to find words to describe her hilarious spirit and quirky personality. “Yvonne was charismatic and touched everyone she met. She was like a second mother to my son Sam. It’s such a great loss and I miss her so much.”
Gill Green of the NHS Greater Manchester Mental Health reported improvements in the provision of physical health care, including a new strategy and the introduction of new job roles with a focus on physical health care.
Over the past year, the inquest into the death of Jonathan Kingsman, 47, from a blood clot at the NHS Cambridgeshire and Peterborough Institution unit prompted a coroner to write to the Department of Health and Social Care warning that national guidance on the assessment of blood clots was failing to deliver. Consider the risks associated with antipsychotic medications.
Kinsman’s wife, Lara, told The Independent: “If you have someone in your family with severe mental health issues, you feel they will be in a safer place or so you hope (in hospital). I certainly don’t blame the people who looked after Johnny. I understand the pressure they are under and they have to work within the directions they are given A friend went over the risk assessment and said to me “You can find a lot of weaknesses in this risk assessment for blood clots”.
“We know we had to do more.”
Dr Ladysmith, director of addressing inequalities at the Royal College of Psychiatrists, said: “If you have an acute or chronic mental health problem, you have a 15-20 year earlier risk of dying compared to someone in the general population. That’s not fair.”
Dr Smith said the warnings from forensic pathologists exposed by The Independent highlight the problems caused by the “fragmentation of care”, with psychiatrists struggling to get patients to receive appropriate physical health care. “As a psychiatrist, I know we have to do more. But we can’t do it alone. We need our long-distance partners and colleagues in the mental health field to become partners in this,” she added.
Margaret Flynn, who chaired the 2011 investigation into the Winterbourne View abuse scandal, which revealed horrific abuse and ill-treatment of inpatients with learning disabilities, said that when vulnerable people are admitted, “they are seen as being there because they are crazy.” Or bad. That’s why people’s physical health care is ignored.”
During her review, Flynn said she found patients were sometimes “overfed” and being overweight was “a major problem”.
In another case, Ben King, who suffered from Down syndrome, died at Cawston Park Private Mental Health Hospital in Norfolk. Over the past year, an investigation conducted on him concluded that he “died of mismanagement of his weight” and of failing to diagnose an obesity-related health condition, as well as “miscalculation” of the medications he was prescribed.
King’s death was one of three cases that required immediate hospitalization.
In another major NHS review published last year into the death of Clive Tracy, who was held in mental health units for 10 years, Beverly Dawkins, the lead author of the report, said: “People assumed that the teams working in those units had all the skills needed to manage mental health.” Individuals’ physical health care, however, the evidence is often the opposite.Many people in these units reported not going out to exercise, not going out for a walk, and sometimes not going out at all.”
She said that despite the failures highlighted over more than a decade, there is still poor funding and focus by government agencies.
“Sent to die at an early age.”
According to the National Confidential Investigation of Suicide and Safety in Mental Health, a quarter of patients who would have benefited from the Early Warning Index were not used. This indicator is a measure intended to detect signs of serious deterioration in health.
Forensic doctors’ reports seen by The Independent repeatedly warn of the staff’s failure to identify a decline in a patient’s physical health.
Roxanne Brown, a 31-year-old young mother, died of ‘negligence’ at the private Shrewsbury Court Hospital in Surrey, which has been closed following a critical report by the Care Quality Commission (CQC).
According to an investigative report, also seen by The Independent, Brown was admitted to hospital in March 2019. Seven months later, she began showing signs of a high fever and an elevated pulse rate and a support worker took her to her doctor.
Patients whose health is deteriorating are usually evaluated and given an ‘early probation index’. However, the Brown Index was not shared with the doctor who then diagnosed her with a chest infection. The evidence examined during the investigation found that if the doctor had seen her indication, he would have sent her to the Accident and Emergency Department.
More than that, the doctor’s advice to transfer her to the emergency and accident department in case her condition worsened was not written down, and that advice was not followed by the staff.
Matthew Turner, the attorney representing Brown’s family, said the staff’s failure to monitor her deteriorating health seemed “part of a broader problem involving poor physical health care for patients in psychiatric hospitals.”
Brown’s mother, Ruby Brown, said: “I think every day is the day she died. Even worse, I wasn’t there to get the medical help she desperately needed, to console her and tell her I was going to do everything I could to make it all right.” None of the things that happened to her were told to me, I keep it from me. She would be alive and well today if she had not been sent to die so young at the age of barely 31. What relationship would she have with her daughter, who is now 14?”
‘Need emergency steps’
Inquest reports that the main problem is the health care dichotomy between mental health and physical health. Lucy Mackay of the Society told The Independent: “Urgent steps need to be taken across the NHS to increase communication between services and ensure mental health units have experts who can monitor and treat physical health conditions.”
In 2019, the Care Quality Commission published requirements for mental health care providers to conduct and monitor mental health assessments. In a related context, Jemima Burnage of the committee told The Independent: “It is important that mental health staff meet the physical as well as psychological needs of patients as a priority issue. We clearly say that caregivers should undertake appropriate assessments and periodic monitoring of physical health For people cared for in hospital mental health services.”
Andy Bell, executive vice president at the Center for Mental Health, said: “It can be difficult to access physical health expertise in mental health hospitals. To a large extent, that’s not part of what it is. available, and mental health hospitals suffer from a high rate of bed occupancy.”
An NHS spokesperson said that all mental health and learning disability providers are “contractually” obligated to provide physical health checks for patients. Multidisciplinary work in hospitals including occupational therapists and additional support workers for colleagues.
A spokesperson for the Department of Health and Social Care said: “Anyone receiving treatment in an inpatient mental health facility should also receive safe, high quality care and be cared for with dignity and respect. We are looking at what is required in the broader issues of inpatient mental health care.” We will post an update on that in due course.”