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Paediatric Wards May Not Be Safe for Patients with 'High-Risk' Behaviours

Children presenting with 'high-risk' behaviours are being cared for in NHS paediatric wards that may put them and others at risk of harm, according to a new report from a health care safety watchdog.

The interim report from the Healthcare Safety Investigation Branch (HSIB) warns that the placement of children and young people with complex mental health issues on NHS paediatric wards can impact on the wellbeing of these patients and their families, and pose a risk to other patients and staff.  

The report emphasises that paediatric wards are designed to care for patients who only have physical health needs and not for those who are exhibiting high-risk behaviours, which include attempts to die by suicide, self-harm, attempts to leave the hospital without permission, and episodes of violence and aggression.

Examples of children and young people being restrained or sedated in front of other sick and vulnerable patients, families feeling concerned for their and their children's safety during incidents, rooms being stripped down to remove any risk of self-harm or death by suicide, and paediatric staff being physically assaulted are cited in the report.

HSIB has called for immediate action to be taken by Integrated Care Boards and NHS organisations to facilitate a system-wide response to reduce the safety and wellbeing risks associated with children and young people with high-risk behaviours who are admitted to an acute paediatric ward.

Growing Problem

The HSIB's interim report comes as it undertakes an investigation into the risks associated with the current design of paediatric wards in acute NHS hospitals. These wards are increasingly caring for children and young people who have mental health needs. In 2022, 18% of children aged 7-16 years and 25.7% of young people aged 17-19 years had a probable mental disorder – a significant rise on 2017 figures, according to data from NHS Digital.

The reference case that triggered the HSIB’s national investigation involved a young person with suicidal thoughts who was admitted to a paediatric ward while awaiting a mental health assessment. During their stay they had episodes of violence and aggression where they attempted to self-harm and to harm staff. They also absconded several times, and on two of these occasions took paracetamol tablets and needed medical treatment.

The HSIB's investigation to date has confirmed that there are significant challenges in caring for children and young people who exhibit high-risk behaviours on paediatric wards. The wards can contain many self-harm and ligature risks, and staff, patients and families have commented to the HSIB that these wards are busy, crowded and noisy, and are thus unsuitable for children and young people experiencing a mental health crisis and/or who have sensory needs. 

A Whole System Response is Needed

Commenting, Saskia Fursland, HSIB national Investigator, explained that they publised the report while the investigation is ongoing because "while the paediatric wards can provide safety and comfort to most children and young people, the environment comes with significant risks for those exhibiting high-risk behaviours".

"The conversations we had with the hospitals about the challenges were also reinforced by our own observations as an investigation team whilst on visits – the focus needs to be on better supporting staff to care for patients on paediatric wards while finding or creating more suitable and safer places of care for children and young people exhibiting high risk behaviours," she said.

Ms Fursland said the examples used to illustrate this in the report are "shocking" and "show that on a regular basis patients cannot receive the therapeutic care they need, while other patients, families and staff face the risk of distressing and threatening situations, long-term trauma after incidents and even physical harm".

"We know that NHS staff are trying to provide a safe environment for their patients, but they are facing difficult choices in wards that are not designed to support children and young people displaying high-risk behaviours," she added. "Our ongoing investigation will take a longer-term look at effective design, adaptations and risk management in the wards. A whole system response is now needed to ensure we can keep children and young people safe."

Safe Care is a Top Priority

In response to the report, Saffron Cordery, deputy chief executive of NHS Providers, said: "Safe care for vulnerable young people is a top priority for NHS trusts. Overstretched services are seeing many more young people, often with more complex needs, particularly as a result of the pandemic."

Ms Cordery said that NHS Providers welcomed the efforts by several hospitals to make the environments as safe as possible, but "the findings are concerning and underline the need for mental health services to have the same support as those for physical health".

"Services for children and young people have come under increasing pressure over the last few years. We need a sustained focus on investment in capital, resources and staff with the right skills, expertise and support to boost capacity in hospitals and ensure that patients with the most severe needs are cared for in first-class, therapeutic, safe and appropriate environments," she said.

"We also need much more care in the community and earlier intervention and prevention services for children and young people," Ms Cordery added. "And we need to see urgently from the government a fully costed, fully funded workforce plan for the NHS to tackle severe staff shortages and to recruit and retain people to work in mental health services, to meet the challenges and growing demand they face."