AN investigation triggered by a 19-year-old’s suicide at the Wedgewood Unit in Bury St Edmunds and nine killings has revealed serious management failures in Suffolk mental health services.
The Suffolk Mental Health Partnership Trust (SMHPT) commissioned a report in December 2010 following the suicide on Southgate Ward in August. That followed five homicides in the county between May and August 2009 by people treated by SMHPT, including John McFarlane’s murder of 38-year-old Mary Griffiths, in front of her children in Bullrush Crescent, Bury. There were four more homicides since 2009.
The report team headed by Malcom Rae, a fellow of the Royal College of Nursing, revealed concerns about medical leadership, clinical oversight, management practice, and resistance to change.
They highlight system failures in communication and record keeping and delays in safety changes after serious incidents.
The report praises patient care and does not blame the deaths on poor management, though some are still being investigated. But the report emphasises management’s lack of clinical oversight, or governance.
The team says that despite interviews to appoint staff to lead, those people did not fully understand what was expected of them. The report says: “We were also concerned to receive comments from a consultant that, ‘The ward is a disaster zone’ and ‘One should be surprised that more incidents are not occurring’.”
It adds: “[One] consultant we interviewed, who in other ways was impressive, was not able to identify any clinical governance processes in the trust other than being involved in an SUI [serious untoward incident]. ”
Rae’s team highlighted that the trust’s action on SUIs was not to the East of England Strategic Health Authority’s standards. It says nine of the first 10 incidents reported in 2010 had not been investigated in the required 45 days.
When the Rae team visited Southgate Ward, they found not all points from which people could could hang themselves had been removed and demanded action.
Some consultants’ attitudes are strongly criticised.
The report says: “The impression we have... is that some members of the consultant group, who initially appeared ill organised and disengaged, are actually a very powerful force maintaining the status quo. They operate a parallel management structure which is unaccountable... and we presume to be driven by vested interests.”
The report says there was a consensus strong medical leadership was needed but when now-retired medical director Dr Michael Lowe tried to make changes, the consultants accused him of shortcomings.
Dr Lowe was exonerated and the Rae report says: “This was unprofessional and unacceptable behaviour from the senior medical team.”
The report’s recommendations call for more systematic approaches to communication, records, shift hand overs, training, medical oversight and investigating and acting on SUIs.
Irene Ryan, speaking on behalf of Mary’s family, said “We feel totally let down by Suffolk Mental Health Trust.
“The overall failing was that the leadership and governance at the trust was inadequate.
“We, Mary’s family, believe John McFarlane should have been sectioned, and if he had been sectioned we believe this may have prevented Mary’s death.
“We are awaiting the findings of this investigation, but nothing will ever compensate our family for the loss of our beloved Mary.”
SUFFOLK Mental Health’s new chief executive Aidan Thomas is positive the trust is putting its house in order.
Though he says patient care was good, he admits there were serious management problems.
He could not say if the trust was responsible for any of the killings because ‘the investigations haven’t come through yet’, but he added: “There was a review done because of the cluster of five homicides which produced a number of actions a year-and-a-half, two-years ago and there’s only limited evidence of those being put in place.”
He said the Rae report showed governance systems at the trust ‘weren’t as they should be’.
“We’ve changed some of that already,” he added.“The leadership in general nursing and medical weren’t doing all the things they should have been doing to make the trust as effective as it could be in learning from events.”
He stressed new deadlines for change would be met. “There are individuals responsible for making sure work is done and we’re being monitored by NHS Suffolk,” he said. “An awful lot has already been done. Some of that is about being positive and clear on what is expected of individuals.
“The majority of medical staff are really committed to doing the best they can. The tiny minority who weren’t doing as they should are coming on board.”
Mr Thomas is also chief executive of Norfolk and Waveney Mental Health Trust, which is expected to merge with Suffolk so he became the latter’s acting chief executive in March.
The trust has an action plan to address all Rae’s concerns under 20 main headings with deadlines between June 2011 and April 2012. They include:
n Redesigning governance (oversight) and accountability systems including creating a new governance team.
n Establishing a single action plan for homicides and SUIs.
n Increased frequency and monitoring of suicide prevention and training.
n Increasing the number of SUI investigators from four to 20.
n Alter the board level approach to improve visibility and commitment to governance.
n Develop a Trust-wide suicide action group.
Make it easier for matrons to get maintenance and changes to ward environments with a budget for that purpose.
n Make a suicide prevention survey risk assessing all premises and their fixtures and fittings.
n Create a records team and improve records equipment.
n Establish a nursing leadership group.
n Reduce the patient to staff ratio by having more staff or fewer beds.
n Use nationally approved auditing checklists.
n Clarify governance responsibilities and remind senior medical staff of them.
See the full report at www.smhp.nhs.uk