systemic failure to provide for basic physical care NHS My mind health Wings kill The patients across the country – despite dozens of warnings from coroners over the past decade, The Independent can reveal.
An investigation has uncovered prevention of future death reports – used by coroners to warn health services of widespread failures – on at least 50 occasions since 2012 involving 26 NHS organizations and private healthcare providers.
The cases included deaths from malnutrition, lack of exercise and starvation of detainees in Cairo Psychological health amenities. Experts warn the lack of training and funding is to blame neglect of patients at risk.
Our investigation revealed:
- Failing employees to perform basic health checks, such as assessing blood clot risk
- Cases of nurses and care assistants without adequate CPR training
- Physicians unable to perform emergency response procedures
- Patients who have not been treated for side effects of antipsychotic drugs
- The rapid deterioration of health goes unnoticed and is not treated
Forensic pathologists uncovered multiple cases of mental health patients receiving inadequate treatment at the General Hospital with their illness considered to be a psychological problem.
The Independent It could reveal that a fifth of patients across mental health units across the country do not undergo basic physical health care exams upon admission, according to a report by the National Confidential Inquiry into Patient Mortality.
The report, which was carried out this year, warned of “significant missed opportunities” by health services to identify and treat mental health patients’ physical health conditions.
The review showed that deterioration in physical health often follows admission to inpatient units.
It comes as the NHS’ National Medical Director for Mental Health has had to write to hospitals to warn them of the need to introduce physical health checks.
Dr Rosina Aline Khan, Labour’s shadow mental health minister, has called for a rapid review of inpatient mental health services. I told Freelancer: “The government needs to get the ongoing crisis in mental health hospitals under control – the current conditions are inhumane. Patients deserve better.”
“I have a lot of questions left.”
Yvonne Ives died while inpatient at Greater Manchester Mental Health Institution in 2020 of a blood clot, after staff within the unit failed to carry out blood clot risk assessments.
The great pathologist Nigel Meadows attributed her death to a “gross failure to provide her with basic medical care”. It is one of four cases in which pathologists have warned of inadequate blood clot evaluation and treatment within inpatient units.
The 69-year-old had been suffering from mental illness since a young age. In January 2020 she was admitted to the Greater Manchester Mental Health Hospital, and was noted to have “several ulcers and infected wounds of deep and serious protraction”.
Al Tafs was taken to hospital where she was given preventative medication for venous thromboembolism, or blood clots, and she was sent back to the mental health unit. However, this treatment did not continue after she was returned to the mental health unit.
talk with The Independent Lauren Fallon, her sister, said: “I’m left with so many questions about Yvonne’s death, such as would Yvonne still be here if she had the right assessments and medications?
“It is impossible to put such a funny and quirky personality into words. Yvonne was magnetic and made an impression on everyone she met. She was a second mother to my son Sam. It is such a great loss and I miss her with every fiber of my being.”
Gill Green, of Greater Manchester NHS Mental Health, said improvements had been made to the provision of physical healthcare including a new strategy and the introduction of new job roles with a focus on physical healthcare.
Last year, the investigation into Jonathan Kingsman, who died aged 47 of clots in a unit run by the Cambridgeshire and Peterborough NHS Foudation Trust, prompted the coroner to write to the Department for Health and Social Care and warn that national guidelines for assessing blood clots had failed. To account for the risks associated with antipsychotic medications.
said his wife, Lara The Independent: “If you have someone who has some sort of severe mental health problem, you kind of feel it’s safer, or hopefully it’s safe [in hospital]. I certainly don’t blame anyone who takes care of Johnny, I know how pressured these people are, and they have to work within the guidelines they’ve been given. A friend looked at the risk assessments and said, “You can drive a truck with this risk assessment in terms of blood clotting.”
“We know we have to do more.”
Dr Leadsmith, Chair of Inequality at the Royal College of Psychiatrists, said: “If you have a severe and enduring mental health problem, you are likely to die 15 to 20 years earlier than anyone in the general population. It’s not fair.”
Investigators’ warnings revealed The IndependentDr. Smith said it highlights the “fragmentation of care,” in which psychiatrists struggle to get patients access to appropriate physical health care.
She said, “As a psychiatrist, we know we have to do more. But we can’t do it alone. We need our long-distance partners and colleagues in the physical health field to become partners in this.”
When people at risk are admitted, they are seen as being there because they are crazy or bad. So they don’t look at People’s physical health care.
During her reviews, she said that patients were sometimes “overfed” and that being overweight was a “major problem”.
Ben King, who had Down syndrome, died at the private Cowston Park Mental Health Hospital in Norfolk. An investigation last year found he “died of inadequate weight management” and failure to diagnose an obesity-related condition, as well as “insufficient attention” to medication.
King’s death was one of three that prompted a major review of the hospital.
In another major NHS review published last year into the death of Clive Tracy, who was held in mental health units for 10 years, report lead Beverley Dawkins said: “People assumed that teams in those units had all the skills needed to manage people’s physical health care, However, the evidence is often to the contrary.
“Many people in those units have recorded that they don’t go out for exercise, they don’t go out for a walk, and sometimes they don’t even get off the ground.”
She said that despite the failures highlighted for more than a decade, adequate funding and focus from governance were still lacking.
“Sent to her death at a young age.”
According to the National Confidential Investigation into Suicide and Safety in Mental Health, an “early warning score”—a national guide to serious deterioration in health—was not used for a quarter of patients who might have benefited from it.
Forensic reports reviewed The Independent Repeated warning of staff failure to identify when a patient’s physical health is deteriorating.
Roxanne Browne, mother of one, died at the age of 31 after being “neglected” by the private Shrewsbury Court Hospital in Surrey, which has since closed following a critical report from the Care Quality Commission (CQC).
According to a joint investigation report with the independent, She was admitted in March 201. Seven months later she showed signs of a high temperature and elevated pulse rate, and an auxiliary worker took her to her GP.
Patients who deteriorate are assessed under a modified Early Warning Score. However, Brown’s score was not shared with the GP, who then diagnosed a chest injury. The inquest’s evidence found that had the GP seen her result, they would have referred her to A&E.
The GP’s advice to take her to A&E if her condition worsens is not written down or followed by the staff.
Matthew Turner, the attorney representing the Brown family, said the staff’s failure to detect deterioration appeared to be “part of a broader problem of poor physical health care for patients in mental health hospitals”.
Brown’s mother, Ruby Brown, said: “Every day feels like the day she died. Worst of all, I wasn’t there to get the medical help she needed so badly, to comfort her and let her know I’d do everything I could to make things right. Unfortunately, I wasn’t told any of it.” The things that happened to her; that were hidden from me.
“She would still be alive to this day if she had not been sent to her death so early at the age of 31, and what would have happened to her relationship with her daughter who is now 14?”
Urgent action is needed
The main problem, Charity Inquest said, was the division of health care between mental and physical health. said Lucy McKay, from Inquest The Independent: “Urgent action is needed across the NHS to increase connectivity and communication between services and ensure mental health units are better integrated with professionals who can monitor and treat physical ill health.”
In 2019, the Center for Quality Control published requirements for mental health providers to conduct physical health assessments and monitoring.
said Jemima Burnage, CQC The IndependentIt 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 people receiving care in inpatient mental health services.”
Andy Bell, vice-president of the charity Center for Mental Health, said: “It can be challenging to get physical health experience in mental health hospitals,” he said. “By and large, this is not part of what is available and mental health hospitals have a high rate of bed occupancy.”
An NHS spokesperson said all mental health and learning disability providers are “contractually” required to provide physical health checks for patients. They added: “The NHS has recently reminded local areas of this as well as providing additional funding to increase the number of multidisciplinary staff at the hospital including operational therapists and peer support workers.”
A Department of Health and Social Care spokesperson said: “Anyone receiving treatment in an inpatient mental health facility should receive safe, high quality care and should be cared for with dignity and respect. We are examining what is required on the broader issues of inpatient mental health care and will be updated in due course.” the appropriate “.