CQC tells Maudsley to make urgent safety improvements after two deaths on acute ward

Katherine Johnston (10 March, 2021)

'Four months later it is just awful for relatives to still not know what happened' - Harriet Harman, Camberwell and Peckham MP

40550The Maudsley Hospital in Denmark Hill

The care regulator has warned the South London and Maudsley NHS Trust that urgent improvements must be made in a ward where two patients died within two months last year.

In total there were three serious incidents in the Jim Birley Unit at the Maudsley Hospital’s Denmark Hill site, recently relocated from Lewisham, between September and October 2020.

Inspectors from the Care Quality Commission (CQC) assessed the acute mental health ward, which cares for eighteen working-age female adults, in December.

Worrying safety lapses included ‘significant gaps’ in recording patients’ physical health checks – an issue identified as far back as May 2019 by the CQC.

Staff also highlighted they needed more training in managing patients’ physical health needs and helping those with substance misuse and addiction.

Inspectors also found evidence the administration of medicine was not always fully recorded, there were not enough staff with current training in basic and immediate life support, some patients lacked up to date risk assessment and care plans at the time of all three serious incidents – again first highlighted in 2019.

Many of the problems are attributed to a “period of instability” in staffing when the ward moved sites and reopened with an all-new team with nursing vacancies and lack of manager.

Both the trust and CQC have emphasised that staffing concerns and safety improvements have already been made including ‘improvements’ to night checks and handover of care.

Some feedback, including from patients, highlighted that staff were supportive and approachable.

But the question of how three such serious, devastating incidents could have happened in just two months remains largely unanswered.

Furthermore, despite the CQC’s report outlining that inspectors had visited the unit, much of its investigations were conducted remotely, including over video calls and by telephone.

The report, published on March 5, details: “We found significant gaps in the recording of vital signs and physical health checks in the 20 patient records we inspected.

“At the previous inspection in July 2019, this was an area we noted the trust should improve.

“Staff told us that electronic recording of physical health observations were not always saved when there were issues with WiFi on the ward.

“The paper records used during these times still included significant gaps, and were not recorded on the National Early Warning Score (NEWS) charts which make it clear when staff should seek medical advice.

“Staff were also often not recording when they had attempted to check vital signs or physical health but patients have refused.

“It was therefore not clear if staff were meeting the trust policy for physical health monitoring.”

Camberwell and Peckham MP Harriet Harman said lessons needed to be learned “sooner rather than later” and highlighted the agonising wait for bereaved families who remain in the dark about what caused their loved ones deaths.

“Two deaths on one ward in such a short space of time sounds the alarm,” she told the News, saying that she was in contact with the trust’s chair and leadership team about what improvements had already been made. But as yet there are no formal findings on how the tragedies took place.

“The legal process and NHS protocols have to be followed,” she added, “but four months later it is just awful for relatives to still not know what happened.”

When asked if she believed the regular would take effective action, and quick enough, she said: “I believe there has to be a very strict balance between the hospital and CQC having an ongoing relationship and working together to make improvements, and being a fierce independent regulator that holds unannounced visits.”

She said she hoped the regulator would now refocus on in person visits – and not just remotely.


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