Whittington deaths probe pinpoints bed shortages
Independent investigation reveals ‘unexpected number of tragic incidents in a relatively short period of time’ connected to Archway hospital
01 June, 2018 — By Tom Foot
The Whittington Hospital
AN independent investigation has found that bed shortages and assessment delays were “contributory factors” in a cluster of deaths of Whittington patients.
Five people committed suicide or died following self-harm after attending the hospital’s A&E between October and December 2016.
Because of the “unexpected number of tragic incidents in a relatively short period of time” the NHS trust commissioned consultancy firm Verita to investigate independently.
Its report said that mental health patients were sometimes sectioned to an A&E overflow room waiting “for days” for a bed to become available.
The report added: “Bed availability is the major factor in very long delays for mental health patients as the length of time it takes to find a bed leads to mental health patients having to spend many hours, and sometimes days, in the department.
“Emergency departments are generally not good places for people with mental health problems, who would ideally be seen in calm, quiet environments.”
The report added: “It is clear that a rising number of people presenting at the emergency department and the shortage of mental health beds for them to go to will mean that long waits are likely to continue… Patients wanting a bed is a major bottleneck in the system.”
One of the patients, Dominic White, threw himself from a building hours after absconding from the hospital. His inquest heard that he had been sectioned in the A&E after telling staff he was “seeing demons”. He had tried to jump out of a window at home. He was waiting to be transferred to a privately-run secure mental hospital in Stevenage when he escaped, jumping to his death hours later.
In 2015, Camden and Islington Foundation Trust launched its own investigation into another “cluster of deaths”, where 17 mental health patients died in the seven months leading up to May 2014. The report found that management of available beds had heaped “unacceptable” stress on some of the patients.
The Verita report, discussed by Whittington board, said that there was an issue with A&E staff not “seeing themselves as jailors” of patients, adding: “While it is always an option to lock sectioned patients into a room, their [the staff] reluctance to do so is understandable.”
The closure of A&E at Chase Farm Hospital, in Enfield, led to a rise in admissions at the Whittington. There have also been cuts to mental health crisis and community teams since 2010.
The report said there was “compelling evidence” that practice has “improved greatly in the Whittington since these incidents occurred”.
Changes have already been made to A&E facilities and a new mental health unit is being built in Highgate.
A Whittington Health NHS Trust statement said: “Mental health patients who have such long waits in our emergency department are those who need a specialist mental health bed provided by another organisation.
“We are committed to keeping patients safe while they wait with us. This is why we have recently renovated our facilities for sectioned patients and will shortly be opening a new mental health suite, which will be staffed by a team from Camden and Islington Mental Health Trust.”
The Camden and Islington trust said: “At a time of increasing demand for mental health beds nationally, in the last year we have introduced an initiative which aims to more effectively manage bed use and ensure our service users do not stay in hospital longer than they need.”