This site is intended for UK healthcare professionals
Medscape UK Univadis Logo
Medscape UK Univadis Logo

Midlands Trust Warned Over Serious Patient Safety Concerns

An NHS trust in the midlands was ordered to make immediate improvements to its adult psychiatric services, after a host of serious patient safety issues were identified following the deaths of three patients and a number of fire-setting incidents.

The Care Quality Commission (CQC) has today published a report following an inspection of acute wards for adults of working age and psychiatric intensive care units (PICU) at St George's Hospital in Stafford, and The Redwoods Centre in Shrewsbury, which operate under Midlands Partnership NHS Foundation Trust.

An unannounced focused inspection of the service (looking at the areas of safe and well-led only) was carried out by the CQC in November after it was alerted to a number of serious incidents during September and October 2022. 

This included three incidents where patients had taken their own lives during a period of leave from the ward they had been admitted to, and four fire-setting incidents that had occurred at The Redwoods Centre. CQC also received concerns in relation to these incidents from Shropshire Fire and Rescue Service, British Transport Police, and Staffordshire Police.

Due to the seriousness of its concerns following the site visits, the CQC issued a warning notice to the trust and a deadline by which they were required to make significant improvement to the areas identified in the notice. Following the inspection, the overall rating for the acute wards and PICU, as well as the ratings for how safe and well-led the service is, went down from 'good' to 'inadequate'.

After the inspection, the trust provided a comprehensive action plan with evidence addressing how they would respond or had already responded to the concerns raised.

Environmental Issues 'Needed Addressing'

Andy Brand, CQC's deputy director of operations in the midlands, said: "When we inspected this service, improvements were needed to ensure people were receiving appropriate care in a safe environment, and staff were fully being supported to carry out their roles properly. Inspectors had noted that staff shortages impacted the level of care being offered.

"Managers needed to do more to mitigate the impact of staff shortages as understaffing was negatively affecting the quality of care being provided, with many staff reporting they felt unable to meet the needs of people due to these challenges," he said.

The inspection also found environmental issues, "that needed addressing", Mr Brand noted. For example, ligature risk assessments to identify any risk areas hadn't been completed effectively, meaning people could be placed at risk of harm.

The trust responded to these issues raised and submitted an action plan detailing how they would make improvements.

The inspectors also noted some positive areas of care.

"For example, managers debriefed and fully supported staff after any serious incident, including psychological support if needed," Mr Brand detailed. "We also noted there was a dedicated safeguarding team in place to support staff. The team linked with external agencies to ensure staff followed correct procedures should a safeguarding issue occur."

The CQC will continue to monitor the trust, including through future inspections, to ensure the necessary improvements are made so people can receive safe and appropriate care.

Details From the Report

CQC inspectors also found the following during this inspection:

  • The trust failed to demonstrate how staff always safely managed items of potential risk as part of people's personal property, which had resulted in incidents of avoidable harm.
  • Records failed to demonstrate that staff always assessed people's mental states at the point of taking leave and recorded these assessments.
  • There was a significant increase in mixed sex accommodation breaches since CQC's previous inspection and there were concerns about the implications of mixed sex ward environments contributing to sexual safety incidents.
  • Environmental assessments, including ligature risk assessments and fire safety assessments, were not always sufficient to ensure safety and failed to identify all areas of potential risk.

The CQC report also noted that between May 2022 and October 2022, the trust recorded 48 fire incidents across their acute wards for adults of working age and PICU. Of these, 85% involved fire activation but did not involve an actual fire. Patients' use of electronic cigarettes in bedroom areas was a common cause of fire alarm activation. During the same period, the trust recorded 158 incidents specific to sexual safety across the acute wards for adults of working age and PICU. This included incidents of assault, verbal threat of sexual assault, and sexual orientation related abuse.

However, inspectors also made a number of positive findings, including that ward areas were clean, well maintained, well-furnished, and fit for purpose. Staff competency in completing observations was regularly checked and they felt confident to undertake these. Also, physical interventions were avoided by using de-escalation techniques and were only used when necessary to keep people safe.

A Robust Improvement Plan

In a statement issued in response to the CQC report, Neil Carr, chief executive of Midlands Partnership University NHS Foundation Trust, said: "Any concerns regarding patient safety are always treated with the upmost importance. A robust improvement plan was developed at pace to address areas of concern identified by the CQC and a significant amount of positive change has happened in the 6 months since. This includes rapid work to improve fire safety assessments, recruitment of more substantive employees to reduce our use of temporary staffing, and enhanced ways of working across ward environments.

Mr Carr said the Trust was "pleased" with the report's highlights of areas of good practice, including the maintenance and cleanliness of the wards and adherence to infection control guidance, as well as positive feedback from patients.