A mother who killed herself while suffering from postnatal depression died as a result of a “very serious failure” that allowed her to leave a mental health unit unchaperoned, a coroner has ruled.
Despite having made multiple attempts to kill herself, 32-year-old Polly Ross was allowed to leave the Westlands mental health unit in Hull at about 8.30am on 12 July 2015, telling nurses that she was going to buy cigarettes. She was hit by a train at 11.10am and died instantly.
Speaking at the end of a four-day hearing, coroner Prof Paul Marks said he could not rule that Humber NHS foundation trust had been guilty of clinical neglect, but said the decision to allow her to leave the unit “had a direct causal effect” on her death.
Her mother, Jo Hogg, who was previously employed by the trust as an occupational therapist, thanked the coroner for conducting a “frank and fearless examination” of the circumstances surrounding her daughter’s death.
She said the trust had failed her daughter when she had needed their help the most and that care for women with postnatal depression in the region was “appalling”. She said that mental health services were “not joined up in a way that pays close regard to the complex needs of patients”.
The court heard how Ross, who ran a translation business in Paris before moving back to east Yorkshire in August 2012, had suffered from the extreme form of morning sickness, hyperemesis gravidarum, during both her pregnancies in 2012 and 2014. The condition has received media attention after it was revealed that the Duchess of Cambridge suffered from it during her pregnancies.
The condition caused Ross – who was described as “staggeringly intelligent” – to be hospitalised and put on a drip, which was said to have compounded her mental health issues. The inquest was told that she developed “drug-induced psychosis” after taking cannabis to relieve her symptoms and that when she asked to be admitted to a specialist mother and baby unit in Leeds, she was turned down.
In February 2015, the linguist was sectioned after a breakdown and her children were taken from her care. Over the coming weeks and months she regularly expressed suicidal thoughts and attended A&E on multiple occasions having self harmed or taken an overdose.
In a statement read to the court, Ross’s aunt Emma May, who acted as her carer after she was first sectioned, said she was certain that the few times her niece had left her home since February “were times she attempted to take her own life”. She said: “I cannot understand how she was allowed to leave the unit to buy her own cigarettes the morning she died.”
Giving evidence to the inquest, Dr Robert Kehoe, a Bradford-based consultant psychiatrist, said that while the overall standard of Ross’s care had been good, there were two serious failures on the part of Humber NHS foundation trust.
“One: there was a failure to clarify and state a plan for what should occur in the situation of a patient requesting to leave the unit,” he said. “Two: the effective decision to end the period of 15-minute observations allowed her to leave the unit at around 8.40am that day.”
Ross’s observations had been increased from once an hour to once every 15 minutes on 10 July after a ligature was found in her room. She was not sectioned at the time of her death, but Kehoe said there was “no logic” in increasing her observations only to allow her to leave the unit unescorted.
In a statement, Humber NHS foundation trust said: “We would like to offer our sincerest condolences to Polly’s mother, aunt, other family members and friends for their tragic loss. The thoughts of everyone associated with the trust continue to be with them at this sad time.
“We would also like to offer an unreserved apology to Polly’s family and friends and acknowledge that there were omissions in her care prior to her death on 12 July 2015. The trust acknowledges Prof Marks’ conclusion regarding the circumstances surrounding Polly’s death and has fully implemented all of the recommended improvements highlighted by our investigations.
“The trust will continue to reflect and learn and seek to continually improve the services we provide to patients.”
In October 2015, Marks ruled that Humber NHS foundation trust was guilty of neglect in the case of Sally Mays, 22, who killed herself after being turned away for inpatient mental health care. The same year, a coroner in Bristol raised concerns about mental healthcare for new mothers after 30-year-old Charlotte Bevan jumped off a cliff clutching her baby girl following a “chain of failures” by medical staff.
In the UK the Samaritans can be contacted on 116 123. In the US, the National Suicide Prevention Lifeline is 1-800-273-8255. In Australia, the crisis support service Lifeline is on 13 11 14. Other international suicide helplines can be found at www.befrienders.org.
A suicidal 17-year-old girl is to be moved to a secure unit on Thursday after a senior judge warned that plans to release her because of a shortage of secure beds for mental health patients would leave “blood on our hands”.
But in his latest ruling in the case of the youngster known only as X, Sir James Munby was scathing that the decision to find her a bed only followed his outspoken warnings that a failure to do so could result in her taking her own life.
The president of the family court said that without his intervention last week, NHS England would have not acted as effectively or speedily.
“This, however, is not a matter for congratulation,” Munby added. “On the contrary, it is, of itself, yet further cause for concern. The provision of the care that someone like X needs should not be dependent upon judicial involvement, nor should someone like X be privileged just because her case comes before a very senior judge.”
The case of X has proved an embarrassment to the NHS and shines a light on the lack of resources to cope with the most extreme mental health cases where lives can be immediately at risk.
Munby himself wondered who else might be at risk as the country’s mental health system strains to deal with rising demand from young patients at a time when the supply of beds as not been able to keep up.
In his ruling, he added: “I emphasise this because a mass of informed, if anecdotal, opinion indicates that X’s is not an isolated case and that there are far too many young women in similar predicaments. How are they to be protected?”
X had been detained in a secure unit following a youth court order and was expected to be released in the middle of August. But following several “determined attempts” on her own life, staff at the unit, known as ZX, concluded the care plan to send her back to a community setting was “a suicide mission to a catastrophic level”. They thought she would kill herself within two days of release.
However, none of England’s 124 places in low secure units were currently available and there was a six-month waiting list even though X was due to be released within days.
In his first judgment last week Munby, president of the family division, issued a stark warning about the needs of X and said the inability to find care for her embarrassed the nation.
He wrote: “If, when in 11 days’ time she is released from ZX, we, the system, society, the state, are unable to provide X with the supportive and safe placement she so desperately needs, and if, in consequence, she is enabled to make another attempt on her life, then I can only say, with bleak emphasis: we will have blood on our hands.”
The senior judge ordered the judgement to be sent to Amber Rudd, the home secretary, Jeremy Hunt, the health secretary, Justine Greening, the education secretary and the secretary of state for justice, David Lidington, and it sparked a flurry of activity in the following hours and days among health officials who announced on Friday that they had found X a place.
Last week’s ruling also “prompted substantial coverage” in the media, Munby said in yesterday’s judgment. “It was, for example, the main front page story in both the Guardian and the i. This seems to have had some effect.”
On Monday morning, NHS England finally submitted a detailed plan to keep her in a low secure unit, by creating new beds from those in a psychiatric intensive care unit, instead of trying to care for her in the community. Munby has now approved the plan which also includes new funding for her care – which requires a three-to-one staff ratio.
Munby revealed how the secure facility where X is currently housed could no longer keep her and he said he accepted their case. The facility had told the judge it had already spent £125,200 on looking after the troubled girl in additional staffing and complained that the Youth Justice Board had failed to provide additional resources.
It said that since X arrived she has diverted staff to the extent that 13 of the 24 people who normally live there have complained the quality of care is in breach of their statutory rights. Three staff are also off sick with stress and anxiety from “unusual experiences these staff have observed with X”.
The NHS plan is now to move X this Thursday into a psychiatric intensive care unit temporarily awaiting the conversion of beds to the status of a low secure unit. The same staff will be looking after her in both environments. An agreement has also been made for NHS England to fund an extra package of care in order for her needs to be met, including treatment that will be recommended following a comprehensive assessment.
“This will also include dedicated staff to support her throughout her admission, therapy and treatment including psychological and pharmaceutical input,” according to Munby’s ruling.
When the plan to convert a psychiatric intensive care unit into a low secure unit was announced on Friday the move was welcomed by Prof Wendy Burn, president of the Royal College of Psychiatrists. But she said: “Securing the right support for others like X should not be, and cannot be, dependent on one of the highest judges in the land showcasing his outrage and frustration. We urgently need to devise a national strategy so that people with personality disorders are supported from their adolescence into adulthood.”
Munby agreed with this analysis on Monday saying in his judgement: “Quite so.”
NHS England declined to comment. But on Friday, when it said it had found a hospital to look after her. Dr Mike Prentice, NHS England’s medical director for its north of England region, said: “Following extensive assessments, the NHS has identified a bed for this young woman in a safe and appropriate care setting which will best meet her needs.”
In the UK, the Samaritans can be contacted on 116 123. In the US, the National Suicide Prevention Hotline is 1-800-273-8255. In Australia, the crisis support service Lifeline is on 13 11 14. Hotlines in other countries can be found here
A judge who raised the plight of a suicidal teenager by saying there would be “blood on our hands” if a safe placement was not found for her, has approved a plan for her care.
Sir James Munby, president of the high court’s family division, approved a plan that will mean the 17-year-old girl, known as X, will be moved to a special unit on Thursday after doctors managed to find her a place.
Police have launched an inquiry into a series of deaths among patients at an NHS mental health hospital which has been regularly criticised for safety failings.
Essex and Kent police are jointly investigating an unspecified number of deaths at the Linden Centre mental health unit, which is based at Broomfield acute general hospital in Chelmsford, Essex.
The inquiry has been prompted by the death in November 2012 of 20-year-old Matthew Leahy. He is one of seven fatalities that have occured at the unit since 2000. All took their own lives by hanging themselves.
Channel 5’s 5 News revealed the police action on Friday. The Linden Centre has been castigated by relatives of the deceased and the Care Quality Commission for promising but not implementing vital changes to reduce the risk of patients taking their own lives by using a ligature attached to fixtures or furniture at the unit.
On Friday, an inquest jury found that the state failed to protect the life of Richard Wade, one of the seven, who died in May 2015. He killed himself while the balance of his mind was disturbed, they said.
The jury, sitting at Chelmsford coroner’s court, decided: “Richard’s risk of suicide was not properly and adequately assessed and reviewed. Adequate and appropriate precautions were not taken to manage Richard’s risk of suicide.” They highlighted flaws in “current policies at the time and previous recommendations on risk and environmental factors were not implemented adequately”.
His father, Robert Wade, said: “Our son Richard Wade was an intelligent, witty and compassionate man. On 16 May 2015 arrangements were made to take Richard to the Linden Centre in Chelmsford.
“There he was admitted on to the Finching Field ward. Both he and we thought it to be a place of safety. This proved not to be so as barely 12 hours after admission he sustained injuries from which he never recovered.”
Just before Richard Wade died, inspectors from the CQC visited the unit following the death of John Beecroft, another patient. They pointed out that following a serious incident in 2012 “an action point was to review door hinges to prevent potential use as ligature points. We found that whilst the trust had investigated and trialled options, a final decision had not been taken”.
When inspectors visited again in August 2015, three months after Wade’s death, they found that there were still “numerous ligature risks”. They observed that: “The trust’s leadership style did not promote sufficient grip or pace to bring about changes where necessary. Changes took a long time to implement … ligature free doors had not been installed or even commissioned despite these having been agreed some time ago.” The regulator told the North Essex partnership NHS trust, that ran the unit at the time, to take action.
An Essex police statement said: “Essex police is conducting initial inquiries into the circumstances of a number of deaths [that] have occurred at the Linden Centre since 2000. This work follows further allegations surrounding the death of Matthew Leahy at the facility in Chelmsford on 15 November 2012.
“This is in the very initial stages of work, led by the Kent and Essex serious crime directorate, therefore we cannot confirm numbers at this time, nor timescales.”
In the US, the National Suicide Prevention Hotline is 1-800-273-8255. In the UK, the Samaritans can be contacted on 116 123. In Australia, the crisis support service Lifeline is on 13 11 14. Hotlines in other countries can be found here
The Royal Brompton in Chelsea is one of three hospitals in London with the facilities and staff to treat children with heart defects. An estimated 5,500 to 6,300 babies are born with congenital heart disease in the UK each year, all of whom require specialised care. Some will need many operations throughout their life.
On Friday, the Guardian will be live blogging from the Brompton, where congenital heart disease services are under threat of closure. Advocates of the change say concentrating services in fewer locations makes for better care; the hospital and its supporters say it is the best at what it does in the country. The Brompton treats children with heart and lung diseases aged from just days old to 16 years. It has a paediatric intensive care unit (PICU) for children after surgery with at least one dedicated nurse per child, the Rose ward for 30 inpatients, and four beds in a high-dependency care unit (HCU).
Morning routines: the ward-around meeting, and breakfast on the fly for the nurses
Doctors, consultants and nurses tour the paediatrics department in the morning ward-around. It is a crucial opportunity to discuss the various cases and what to expect for the day ahead.
Kawaljit Kaur spends all day, every day, at the bedside of her first and only child, Ekam, who is five months and 19 days old, she says, and was born with a hole in his heart. “I play with him. He holds my hand. We talk to each other and he gives me a smile,” she says. Ekam, sleeping flat on his back with his face hidden by tubes, flails his limbs in the air. “He is very lively,” says a nurse.
After work, Kaur’s husband joins her before they go home for the night. And in the morning she is back. “On Saturday and Sunday we are both sitting here, watching what he is doing,” she says.
Autumn Russell with her mother Keri
Fifteen-month-old Autumn Russell from Essex was transferred to the Brompton for specialist treatment for a case of empyema, a bacterial infection that develops in the slim space between the outside of the lungs and the inside of the chest cavity.
Time may pass slowly on the ward in the paediatric heart and lung unit, but for children like Ekam and their parents, the hospital becomes part of their life – a second home and a place of hope. Ekam’s veins are still too narrow for the heart operation he needs, so he has a succession of stents fitted – tubes inserted into blood vessels to increase the flow.
Marciee Barnes-Palmer has respiratory problems as well as a congenital heart defect. She underwent a microlaryngoscopy and bronchoscopy procedure to look at her upper airways, and doctors will need to close the hole in her heart.
Dr Jana Kossaibati uses a torch to locate a vein to insert a cannula in Marciee’s hand. Nurse Patience Makuyana holds Marciee’s brother Freddie
Consultant clinical psychologist Michele Puckey supports the families, patients older than about three, and their siblings. “Brothers and sisters have to be reassured that they have not caused it,” she says. “And the child in hospital must not be treated like a princess – or they will not fit in at school when they get back to real life.”
Between four and seven they have this extreme feeling of being in control of everything around them. Children feel responsible for parents arguing and separation – Michele Puckey
Staff need support too and Puckey herself is not immune. “I remember once a boy going down to theatre in the same pyjamas as my son and I just caught my breath.”
Rachel, the mother of Ellarna, speaking with Dr Cathy O’Donoghue
Ellarna is 32 weeks old and has had a catheter procedure today to close a hole in her aorta. Anaesthetic and critical care consultant Cathy O’Donoghue visits to discuss the operation.
For premature babies, the Brompton is the only centre in the UK using this method as an alternative to surgery.
Ellie Bartram, 16, has been coming to the Brompton since she was diagnosed at four months old with cystic fibrosis, a lifelong condition that clogs up the lungs with mucus. She is admitted for two weeks every three months for an intravenous course of antibiotics.
Ellie Bartram in her school class in the paediatric ward, and undergoing lung treatment
There is a schoolroom on the ward, where Ellie has lessons. The teaching is good – she and her mum Sarah credit a tutor at the Brompton for getting Ellie through her French GCSE with a C grade.
I can’t run around. I can’t go out much or go out with friends often. But my friends come and buy me McDonald’s because it’s my favourite thing – Ellie Bartram
In her solitary room, where visitors must wear aprons and gloves for fear of giving her an infection, she talks to her friends via FaceTime. “I’m used to it,” she says. She doesn’t like being different, but she is matter of fact about life at home in Romford, Essex.
Riley Jenkins , 13, grimaces in pain as his mother helps him put on a shirt. Riley had cardiac surgery three days ago
Riley Jenkins, 13, is feeling very sick. He can’t eat the meatballs for lunch. His mother Sally rubs his back to try to make him feel better. It is the after-effects of the anaesthetic and the operation to replace a calcified heart valve that was inserted in his chest when he was just seven months old. “He’s been coming for a checkup once a year since he was a day old,” says his mother, Sally.
Riley was born with a back-to-front heart. “He loves Scouts and being on his computer but he’s been too tired to do a lot of running about. He used to love climbing trees. We’re hoping for more tree-climbing now,” Sally says.
Luke with volunteer music therapist Brian
Luke Eccleston-Barnes, nine, has a needle phobia, perhaps because of the huge number of injections and blood tests he has endured in his life so far. But he is calm now – music therapist Brian Spears has arrived with his guitar to distract him while more blood was taken. He is playing softly to Luke, who tries to accompany him on an electronic keyboard Spears has brought along.
Paediatric nurse Angeline Guzha and Dr Jana Kossaibati help a young girl called Sanaya in the paediatric intensive care unit.
Lilian Leite and Nimla Pentayya are two of the three sisters managing Rose ward, where they have both been for six years. Leite is from South Africa and Pentayya from Mauritius. “We wanted to travel and we stayed – we are getting job satisfaction here,” Pentayya says with a grin. Both always wanted to work with children.
We know that parents are upset and the young nurses are upset but we have to be strong, the three of us will support each other – Lilian Leite
Dan Fossey is a practice educator, a nurse who trains other nurses. He also teaches parents basic life-support techniques in case they need them at home. Often parents are anxious and worry their child is too fragile. “Especially when they have had cardiac surgery they have questions about the scar and can you still do compressions,” he says. He teaches them to overcome their fears if a child has something stuck in his throat.
The last thing a parent wants to do is strike the child on the back – Dan Fossey
Fossey runs a graduate programme for newly qualified nurses, to teach them about caring for children with heart defects. “I came here as a brand new nurse 10 years ago. I know what it’s like to come out of university and be looking after children with quite complex conditions,” he says.
Abdula is being wheeled along a corridor to the operating theatre by robed staff, his mother trailing slightly – out of place and desperately anxious. By far the majority of the complex operations for congenital heart conditions carried out here are a success. Inevitably, sometimes they are not. In some cases, where there is a risk but the baby will die without an operation, surgeons as well as families have to be brave.
Abdula Allanoud, four, on his way to his third heart operation
Consultant paediatric heart surgeon Olivier Ghez specialises in neonates – the tiniest babies, less than a month old, with a heart the size of a nut. He operates wearing binocular-style glasses that enlarge the miniature veins he has to stitch.
I have relatively small hands but it is the instruments, not the fingers – Olivier Ghez
Abdula is undergoing a four-hour Fontan procedure to correct a complex heart malformation, conducted by Ghez
Ghez’s job is exhausting – an operation can last three to five hours and a complex transplant could take 24 hours. But it is challenging and rewarding, he says. Sometimes he saves babies’ lives. Other times he gives them “the best possible future” with their heart condition. He can never be sure how it will go.
A 14-month-old girl, diagnosed after birth with a hole between the two chambers of the heart, comes into theatre for a relatively routine procedure and suffers a cardiac arrest. Suddenly the theatre is flooded with people, calm but purposeful, and the team restarts her heart.
The girl arrested for four minutes during the procedure and was eventually revived by the team after a doctor performed CPR
When a child dies, says Ghez, “it is terrible, terrible – very sad and discouraging sometimes”. It may be a child who has had several successful previous operations at the Brompton. “When the baby dies after all this, it is really difficult,” he says. He worries about the accusations that can fly in the media over child deaths during or after surgery.
There is a danger of producing defensive medicine. That is a really perverse effect of the scrutiny. You can’t treat risky patients and have perfect results – Olivier Ghez
Deaths are rare at the Brompton, but everyone is aware of the risks to the lives of these vulnerable children.
A cleaner prepares to clear and disinfect a bay where an infection was recently present. Everybody is supportive. Theresa Dzade, one of the cleaning staff, says she likes the children and the parents.
It is not easy for someone to leave their house and come here with a small baby. They are sometimes sad because their baby is ill. They talk to me all the time. I tell them I am here to help – anything they want – Theresa Dzade
Her friend Sidratu Kargbo feels the same.
We have to do a good job to make them happy – Sidratu Kargbo
Nursing and other medical staff work through the night as many patients require round-the-clock care. Parents usually leave the ward at night as they are encouraged by staff to rest.
Sandra Gala-Peralta, a PICU consultant, says: “If they don’t have a good rest, especially the mother, the following day they are exhausted. And if they are exhausted they don’t take the information in the same way. If something happens they are extremely fragile. So that is why we encourage them to go to sleep and have a good rest. If they don’t want to then we just let them be in the bed space. Especially if they are teenagers or children, five years old, then they have enough understanding to be be very afraid, so we let the parent in..”
Abdula Allanoud recovers in intensive care after his heart operation
Gala-Peralta adds: “The evening tends to be a bit calmer. But everything depends on how the patients are. If the activity is high, the consultant stays around until … well, this is a personal choice. I’m more OCD, I like to make sure that if I go for a rest everything is in order and that I’m not going to have surprises in the night. We have an on-call room in one of the upstairs floors. I have been called in the middle of the night because a child has had a cardiac arrest. I was so stressed when they called me that I went down barefoot! I was doing cardiac massage in my socks! Now I’m more careful.”
I like to work on nights – it gives a lot of space to the doctor and nurses to focus on the patient, and because the night shifts tend to be a bit longer there is enough time to see how a patient can deteriorate, or improve during that time – Sandra Gala-Peralta
Gala-Peralta photographed at 8am at the end of a 24-hour shift
“There are nights when we sleep one hour … and there are nights when we are able to sleep four or five hours. At least we can put our head down and we can have a bit of rest every night. And then in the morning at 7.30 we need to be sharp, back on the unit,” says Gala-Peralta.
Theresa Might: ‘Today we are taking one much more phase in the direction of giving females a voice and eradicating these harmful practices.’ Photograph: Oli Scarff/Getty Photos
The government is to set up a female genital mutilation unit, as portion of a broad-ranging package of reforms to stop the practice in the Uk.
Speaking at the Lady Summit – a significant international conference in London made to highlight the problems of FGM and kid marriage – the house secretary, Theresa May, said the cross-get together unit would assist defend thousands of girls across the nation.
The unit, which could operate in a related way to the government’s forced marriage unit, has been a important demand of campaigners towards FGM. “These measures will make certain that we can sustain the momentum on stamping out these hazardous practices,” May stated.
The home secretary mentioned the government would also strengthen laws close to FGM, and would hold parents responsible if their child was a victim of the practice. Might also announced a consultation into creating it mandatory for professionals to report FGM and explained victims going by means of court instances would be given lifelong anonymity.
A push to improve police responses to FGM will see forces inspected on their response to honour-primarily based violence, with a concentrate on FGM and forced marriage. The college of policing has also begun a consultation on new tips, which will urge officers to dismiss fears of becoming labelled racist when dealing with FGM. FGM has been illegal in the Uk for 3 decades, but the very first prosecution was only created in March and is at the moment going through the courts.
May possibly mentioned that as part of a £1.4m FGM prevention programme, charities will receive funding to generate local community “champions” with the “cultural expertise and the connections essential to challenge beliefs and behaviours”.
“We are making progress. Nowadays we are taking one much more step on the street in direction of giving girls a voice and eradicating these damaging practices,” she mentioned.
Meanwhile, more than 600 people attended an event at the Walworth Academy in south London as component of the Lady Summit. In a video message, the basic secretary of the UN, Ban Ki-moon, mentioned he had been inspired by youthful campaigners on the concern. He singled out for praise Fahma Mohammed, the encounter of the Guardian’s campaign to get more details FGM into colleges. “I commend international leaders and brave activists confronting these problems specially the courageous from young ladies in affected communities,” he said. “They deserve our complete support. Like Fahma Mohammed, who inspired me so much when we met in March with the Guardian’s campaign. I pledged to her, and I repeat these days, that I will continue to raise my voice about the urgency of ending these damaging practices.”
A year in the past, 18-year-previous Connor Sparrowhawk was admitted to Slade Residence, an NHS assessment and remedy unit in Oxfordshire.
Sparrowhawk, who had autism, a finding out disability and epilepsy, lived at house and went to a special college, but was unsettled and agitated. His family members imagined assessment at the 7-bed unit run by Southern Well being NHS basis believe in would help secure the right assistance for the teenager.
Instead, significantly less than four months later on on 4 July 2013, he was located unconscious in the bath at Slade Property and died. A postmortem showed he had drowned, almost certainly as a outcome of an epileptic seizure.
The trust at first attributed his death to normal leads to, but an independent investigation demanded by Sparrowhawk’s family concluded his death could have been prevented.
Its damning report, published last month, states that Sparrowhawk’s epilepsy was not appropriately assessed or managed. It even more discovered there was no sufficient supervision at bath instances, no loved ones involvement in his evaluation and care, no powerful clinical leadership and no proper attempts to engage the teenager in routines.
Sparrowhawk’s mother, Sara Ryan, a senior researcher and autism specialist at Oxford University’s Nuffield department of principal care health sciences, says: “We thought it [the unit] was risk-free. Connor lived at house with us for 18 years – 107 days in that place and he was gone.”
A social media campaign, Justice for LB (Sparrowhawk’s nickname was Laughing Boy), launches its 107 Days drive to raise awareness each day till the anniversary of his death.
Slade Property is now closed, its individuals moved to option care, and disciplinary hearings for seven workers are due this month. An inquest is expected and healthcare regulator Monitor is investigating the believe in. In November the Care Quality Commission (CQC) failed Slade Property for all 10 quality and safety requirements. CQC inspectors have also identified failings at two of the trust’s other amenities, an Oxfordshire care residence for people with finding out disabilities and a psychological well being unit in Southampton.
In response to campaigners’ calls for the trust’s chief executive, Katrina Percy, to resign, she replies: “I do not see that it truly is acceptable that I would resign.” Percy, who apologised in a statement in response to the report, told the Guardian: “[Connor's death] is utterly tragic and it was preventable.” She adds: “We do absolutely every thing in our energy to safeguard and give the highest top quality of care that we possibly can … but what we need is a culture the place folks are in a position to be open when items never go as effectively as they probably could.”
Sparrowhawk’s death has reignited debate about assessment and treatment method units. Winterbourne View was a privately run unit the place the abuse of individuals with learning disabilities was exposed by BBC’s Panorama in 2011. Soon after the outcry more than the abuse in the south Gloucestershire unit, a £2.86m government-funded improvement programme was launched by the Regional Government Association and NHS England. Its aim was to move absolutely everyone out of this kind of units by 1 June 2014.
Nevertheless these days, about 3,200 people with understanding disabilities and autism are nevertheless in personal or NHS-run settings like Winterbourne See, according to government figures. Far more than 60% have been there above a 12 months and 20% for a lot more than five years. So, why are they nonetheless in such widespread use when they are broadly criticised as warehouses that supply wholly inadequate support at a weekly cost of about £3,500 per patient?
Commissioners of providers and clinicians bemoan the lack of neighborhood-based mostly options, but service suppliers for individuals with studying disabilities propose the commissioners are ignorant of, or can’t afford, existing options.
The improvement programme’s new director, Bill Mumford – who is chief executive of finding out disability charity MacIntyre – describes the June deadline as “an aspirational target and not thought through”. He adds: “I am not expecting a large fall in numbers.” Alternatively, he says he is trying to advertise excellent-practice choices to assessment and treatment units, and supporting commissioners to use these options.
The lack of pooled funding amongst regional authorities and NHS England undermines moves to get men and women out of units simply because income-strapped councils are forced to select up the bill for neighborhood provision. Mumford says: “The challenge is for clinicians and commissioners, they are the crucial choice-makers, we can connect them up, show them what can be completed, preserve the pressure on them.”
Care minister, Norman Lamb, says: “We assume health and care commissioners to function together to transform care and support. We will publish standard progress reviews, which will make extremely clear which commissioners are failing to make the improvements we are committed to.”
However, neighborhood-primarily based very best practice is nevertheless the exception. Despite the closure of a lot of NHS lengthy-stay hospitals in the 1980s, high-priced, harmful “dumping grounds” nonetheless exist. Considering that 1993′s influential Mansell Report, policy and investigation has quite a few white papers and inquiries have advocated greater care for people with complicated demands, from the 2001 report Valuing People, to the 2006 Our Overall health, Our Care, Our Say white paper, and the confidential inquiry into the deaths of folks with finding out disabilities. But in spite of the intentions and proof, the pace of alter for people with complex requirements is slow.
There is an additional reason for slow progress. The Department of Health’s Winterbourne View report, noted: “Failure to listen to people with demanding behaviour and their families [is] a typical expertise and totally unacceptable”. Sara Ryan says of Slade Residence: “It was as if it was an imposition that we visited every single day.”
A senior figure at a national care supplier, who declined to be named, says: “There is an endemic difficulty in the sector of household bashing, it is ‘the family members are difficult and a pain’ … Mother and father are the experts on their son or daughter – and we must tap into that knowledge.”
Jenny Morris is a advisor who advised the Office for Disability Issues below the earlier government. She believes public perceptions of people with studying disabilities are partly responsible for inadequate progress. “There are unfavorable attitudes in society in common towards individuals with understanding disabilities, plus ignorance and lack of knowing about how denying people the ability to communicate their demands, and failure to meet their wants, prospects to ‘challenging behaviour’,” she states. According to Morris, “institutional disablism” persists in many providers.
Sparrowhawk’s death is very likely to force closer scrutiny of premature deaths amid men and women with learning disabilities. Ryan and her husband Richard Huggins, who raised him because he was a infant, met outgoing NHS chief executive David Nicholson and chief nursing officer Jane Cummings. Between their demands have been automatic independent investigations of deaths in evaluation and therapy units, a corporate manslaughter charge towards the believe in and the closure of all this kind of units.
Studying disability charity Mencap, has warned in a joint statement with household-led organisation The Demanding Behaviour Foundation that Connor’s death is not the only tragedy. “We are at the moment operating with households in comparable, dreadful conditions,” it states.
As disparate components of the overall health and social care sectors wrestle yet again with bettering help, society’s most vulnerable men and women are becoming failed by the extremely mechanisms created to safeguard them. As Huggins says: “We put our faith in the system and received desperately allow down.”
Connor Sparrowhawk drowned in the bath at Slade Home assessment unit in July 2013. Photograph: Sara Ryan
If LB (Connor’s nickname was Laughing Boy) hadn’t been understanding disabled, his death would have provoked instantaneous outrage and engagement. We’ve lost count of how many “atrocity stories” considering that LB died have been headline news. We’ve fought like fucking billy-o to get accountability. We managed to get an independent investigation into his death commissioned and, with a battle, published. A report that categorically states that LB need to not have died.
LB must not have drowned in a bath in a hospital. In a unit with four “professional” employees and 5 sufferers. He was diagnosed with epilepsy. He had documented escalating seizure activity as a consequence of the medication adjust imposed by the clinician accountable for him. It was recorded that he was sensitive to medication modify. We told them he was getting seizures when he was in there. Information they chose to dispute.
Why would you dispute seizure exercise in somebody diagnosed with epilepsy, delicate to medicine change, when their family flag up seizure exercise? In which in the fucking curriculum/on the work knowledge does stamping out any sniff of a acknowledged danger feature?
At the very least the appropriate bodies have to have collectively swooped in and sorted issues out. A young man drowning in the bath in a specialist unit? Blimey. At least they must have supported the loved ones in every single way feasible. The a variety of bodies should have chucked in almost everything possible to ease the intense ache this family members have skilled. Yeah.
If LB hadn’t died, the same past-shite provision would be in place. No a single (other than the constantly and successfully sidelined, excluded and silenced households) would be any the wiser. Our son died. Each and every single day I go to bed considering about this. Every single day I wake to the soreness of remembering it. A continuous ache that varies from sheer agony to a boring ache of extreme sadness (on a “very good” day).
In amid the good assistance for #justiceforLB on Twitter, a clinician got embroiled in a protracted debate close to mortality and studying disabled individuals. Doc Anon’s level seemed to be that studying disabled individuals die earlier anyway. If you anticipate particular “types” of men and women not to reside as long as other, a lot more valued, “mainstream” individuals, it gets simpler to sweep the former beneath the “let us not bother with” carpet.
And our dude (along with probably countless other folks) was swept into this room final July.
These are edited extracts from Sara Ryan’s mydaftlife weblog
The report outlined the experiences of sixteen families who complained of poor care at the unit, prompting apologies from each NHS England and the Leeds Educating Hospitals NHS Trust, which runs the hospital.
One mom described how she felt pressurised into getting an abortion, which was towards her Muslim beliefs.
Others complained about a lack of compassion following the death of their child.
NHS England explained in its overview of the report: “We conclude that these households did not get the degree of care or support that they deserved and for this we are truly sorry.”
Operations at the LGI unit were temporarily suspended final 12 months following NHS England raised issues about data on death charges at the centre.
The move provoked an outcry, particularly as mother and father and clinicians from the unit linked it to the ongoing controversy about which children’s heart surgical procedure units were to be closed as portion of a nationwide rationalisation of the service.
Surgery resumed on April ten final yr and NHS England announced it was implementing the full review.
The 1st portion of the report report analysed mortality prices, focussing on the 35 kids who died following surgical procedure at the unit from 2009 to March final year.
A 2nd portion examined the experiences of sixteen families who felt they had been let down by the unit, prompting 6 to have their child’s treatment transferred to another centre.
Michelle Elliott mentioned the unit had been treating her daughter Jessica for eleven many years, and two many years ago explained she needed a transplant.
“My problem was that it took 7 months to get her to the transplant centre, by which time they informed us it was virtually too late,” she advised BBC Radio 4′s Right now programme.
“We acquired there on April 2 for what we believed was a second opinion, only to be taken to the tiny area to be told that actually you are not right here for a 2nd viewpoint, she is very sick and she wants a transplant straight away.”
She received her new heart 27 days later, but in the meantime she had a stroke.
It is the stroke now that is impacting on Jessica’s existence, not the heart.
Ms Elliott stated: “Our argument is that these seven months were wasted, and we could have got her there sooner if I had not been blocked in asking for her to go…
“From the heart stage of view she is doing brilliantly properly, but from the stroke stage of view she is nevertheless not back in mainstream college and she is nevertheless using a wheelchair. But her mind is there.
“We are the lucky ones. There are several mother and father in the group whose infants and children have died.
“We want to operate now with the believe in to make sure other households do not suffer in the way that our family members have suffered.”
Ms Elliott added: “The mortality report says yes, it is protected, but it is not a clean bill of health. There had been quite a few suggestions produced for the heart unit that they have to fulfil more than the coming months.”
An additional mother or father told the investigators: “We had been offered no assistance by the workers after Annie died. We have been provided a leaflet. Nobody asked how we were receiving residence in the early hours of the morning.”
Another described how a book had gone missing in which their son had been creating about his experiences prior to his death.
“It was like shedding an additional element of him,” the parent explained. “We asked the personnel to uncover it. They informed us they could not discover it. They didn’t appear bothered. They didn’t appear to realise what it meant to us.
“We had been going to Leeds for ten many years and no-one particular has rung to see how we are.”
The LGI unit had been earmarked for closure, along with two other individuals in Leicester and the Royal Brompton in west London as portion of a nationwide prepare to streamline children’s cardiac surgical treatment into fewer, far more specialised units.
But, following a fierce campaign by some mothers and fathers whose youngsters have been treated at the LGI and two legal issues, Wellness Secretary Jeremy Hunt halted the prepare and ordered NHS England to re-evaluate the complete approach.
Sir Roger Boyle was head of the National Institute for Cardiovascular Outcomes Study (Nicor) when it raised concerns about outcomes at Leeds final 12 months, and later on explained he would still not send his daughter for treatment method there.
He informed BBC Radio 4′s Today programme the behaviour of MPs who campaigned to keep the unit had been “downright disgraceful”.
Sir Roger stated: “The concepts that I was fighting for remain completely the identical.
“I wanted to minimise danger to these very sick youngsters and make certain that they were cared for in an atmosphere that was caring and compassionate.
“That is what the secure and sustainable programme was aiming to supply.”
Sir Roger insisted there had been an “overpowering consensus” in about 2006 that the NHS needed fewer larger youngster surgical centres that could give a “comprehensive and risk-free services”.
He said he even now believed there were as well a lot of this kind of units, incorporating: “That principle I consider is even now adhered to by numerous but it seems as if the establishment has turned their encounter against it, largely I consider influenced by the power of views of families who have had very good outcomes in each of these centres… but also by way of political intervention.
“The behaviour of some of the MPs was downright disgraceful.
“Notably some of the West Yorkshire MPs vying for position to be the MP who saved the Leeds surgical programme.”
Dr Yvette Oade, the chief medical officer at Leeds Teaching Hospitals, stated: “We are pleased for our patients, households and staff that the Mortality Situation Review has confirmed the health-related and surgical care provided by the children’s heart surgical treatment unit in Leeds is protected.
“We are very sorry nevertheless that the sixteen households who shared their stories with the Loved ones Experience Review felt we did not provide the care they had a appropriate to count on.
“We sincerely apologise to these households and will, of program, make certain we learn from what they had to say and improve our services as a outcome of this.”
NHS England’s deputy health-related director Dr Mike Bewick said: “I am happy to say, on the basis of the proof we at the moment have, that solutions in Leeds are risk-free and are working nicely.”
Dr Bewick thanked the sixteen families whose experiences had been outlined in the assessment.
He mentioned: “This kind of experiences are not able to be defended and I would appear to the believe in to respond positively to this report.”
Mothers and fathers who have campaigned to conserve the Leeds unit welcomed the conclusion the centre was “safe”.
Sharon Cheng, the director of the Children’s Heart Surgical treatment Fund, said: “Leeds’ outcomes and high quality of care are in line with national needs and these of other units, and mother and father can truly feel 100% reassured in the remedy that their youngsters will receive at Leeds.”
Mrs Cheng mentioned: “While 1 complaint is too numerous, the vast majority of households and individuals beneath Leeds’ care inform us on a every day basis what a superb services they get from Leeds and that they come to feel the group has gone above and past to care for their kids.”
But the group Fragile Hearts, which represents dad and mom who have lost their kids or seen them suffer medical harm as a consequence of their heart surgical procedure, stated the report “is proof that the culture which exists at LGI heart unit takes no account of the emotional, psychological or spiritual demands of children or mothers and fathers”.
In a statement, Fragile Hearts mentioned: “We do not believe that the changes instigated by NHS England inside of the unit go far enough as we think that the adjustments necessary are not only in the talent and care supplied but in the mindset of these care providers.
“We as a result get in touch with for systemic changes within the unit, but over all we hope that nobody else ever has to stroll in our shoes.”
It mentioned: “It is our belief that the information provided for the mortality evaluation is flawed and we get in touch with for accessibility to the data by an independent physique a public overview of this data and, indeed, the method followed when a unit fails to meet these targets.”
Anne Keatley-Clarke, chief executive of the Children’s Heart Federation, welcomed “the report’s suggestions that address the unacceptable care obtained by the households”.
But she additional she was “concerned that troubles we raised with the CQC back in 2011 have been totally missed”.
“These contain the top quality of heart surgery and repeat operations, along with the morbidities of children who had received remedy at Leeds Basic Infirmary,” she said.
“We search forward to seeing the third strand of the review which investigates issues that have been raised by other clinicians in relation to inter-unit transfers and patient pathways and hopes that the potential report will deal with our issues.”
Giggles for a infant. The NHS needs suggestions on maternity providers to ‘improve the whole childbirth experience’. Photograph: Edward Carlile Portraits/Getty/Flickr RF
3 in 4 ladies say it is “really probably” they would recommend their maternity unit to friends and family, a survey by NHS England has identified.
Given that one October final year females in every NHS maternity unit in England have been asked questions below the new close friends and family members check (FFT), and the outcomes from the initial three months had been published on the web on Thursday.
Females are asked up to 4 inquiries, each focusing on a distinct element of the pregnancy and birth.
The solutions, relating to antenatal services, birth experiences, postnatal wards, and postnatal local community companies, had been published individually for every month from October to December.
Asked whether they would suggest the labour ward, birthing unit or property-birth support they had employed, 76.five% of the women questioned in the most recent month, December, explained it was “really very likely” they would, even though 17.four% said it was “likely” they would.
Less than 2% answered that they would be “incredibly unlikely” or “unlikely” to do so. The remainder either explained it was “neither probably nor unlikely” they would recommend the support, or answered “don’t know”.
Catherine Calderwood, NHS England’s national clinical director for maternity and women’s health, said: “The FFT is about transparency, and we know that women and their households value us becoming open and honest, even when it has not been an ideal birth or experience.
“By listening to women and acting on their FFT suggestions, we can and will enhance factors. Not just the clinical or security problems, but the whole childbirth knowledge.”
In all ten,001 girls responded to the query about their baby’s birth in December. That represented just 19.one% of the complete eligible number, but NHS England said it was above its target of 15%.
A FFT score has been given for every single region, believe in and hospital in England for every of the 4 concerns primarily based on a formula that subtracts the proportion of girls who responded saying they have been “neither most likely nor unlikely”, “unlikely”, or “incredibly unlikely” to suggest a support, from the variety of ladies saying they would be “incredibly very likely” to recommend it.
Employing this formula, which can give a greatest of 100 or minimum of -a hundred, the general family and close friends score for England for the birth question was 75 in December, albeit with wide variations.
Bath, Gloucestershire, Swindon and Wiltshire was the area team with the highest FFT score (92, with a response charge of 14.three%), although the London location crew had the lowest (62, with a response fee of 15.9%).
At trust level, six had the maximum FFT score of a hundred% but only one of these had a response charge greater than 10%, which was Salisbury NHS foundation believe in, exactly where 29 people responded to the birth question out of 198 entitled to do so.
The Isle of Wight was the trust with the lowest score (38), despite the fact that this was primarily based on the response of only eight girls of 136 who have been eligible.
The following lowest was King’s College hospital NHS foundation believe in in London with a score of 41 based on 110 responses (a response charge of twelve.1%).
Six of the bottom twelve trusts on the birth question had been in London. This mirrors the benefits of a survey final yr by the NHS regulator, the Care High quality Commission, which identified that London was the region of England with the worst perceived maternity care, with 6 of the trusts supplying mothers “persistently worse than average” care.
At the level of personal hospitals there have been once more broad variations, the web sites with severe scores tending to be those with low numbers of responses.
The general FFT scores for England for the other concerns had been 63 for antenatal care, 66 for postnatal ward care and 74 for postnatal ward provision.
Belinda Phipps, chief executive of the parents’ charity NCT, welcomed the survey but stated “progress will only be attainable if solutions act on the results”.