FOI request
In the not too distant past, this particular organisation was successfully prosecuted by the Care Quality Commission, for at least two avoidable (suicides) deaths.
Have you not been informed of this, as it would appear that patient safety comes under your remit?
Because it appears that no disciplinary action was commenced, let alone firm action taken, e.g. formal warnings, dismissal etc. I have submitted Freedom of Information requests to TEWV Mental Health Trust (judging by their failure to acknowledge my request - for obvious reasons! - I can only presume they've been swallowed up by the Bermuda Triangle), General Medical Council and the Nursing and Midwifery Council, to ascertain as to why nothing has been done.
Shouldn't your organisation be doing something?
Decision
a) In the not too distant past, this particular organisation was successfully prosecuted by the Care Quality Commission, for at least two avoidable (suicides) deaths.
Have you not been informed of this, as it would appear that patient safety comes under your remit?
HSSIB are aware of the cases you refer to at Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV). Within our report entitled ‘Mental Health Inpatient: Creating conditions for learning from deaths in mental health inpatient services and when patients die within 30 days of discharge’, we refer to TEWV and their system-wide independent investigation into concerns and issues raised relating to the safety and quality of CAMHS provision.
b) Because it appears that no disciplinary action was commenced, let alone firm action taken, e.g. formal warnings, dismissal etc. I have submitted Freedom of Information requests to TEWV Mental Health Trust (judging by their failure to acknowledge my request - for obvious reasons! - I can only presume they've been swallowed up by the Bermuda Triangle), General Medical Council and the Nursing and Midwifery Council, to ascertain as to why nothing has been done.
Shouldn't your organisation be doing something?
HSSIB’s core role is to carry out independent patient safety investigations that do not find blame or apportion liability with any individuals or organisations. Our job is to understand why patients may have been harmed or be at risk of harm. Our investigations take a system perspective and aim to reduce the likelihood of patient safety incidents from happening. We share learning and support patient safety improvements across the whole healthcare system in England.
We have investigated many aspects within the provision of mental health care including:
- Creating conditions for learning from deaths and near misses in inpatient and community mental health services: Assessment of suicide risk and safety planning
- Mental health inpatient settings: Creating conditions for the delivery of safe and therapeutic care to adults
- Mental health inpatient settings: Out of area placements
- Mental health inpatient settings: Supporting safe care during transition from inpatient children and young people’s mental health services to adult mental health services
- Mental health inpatient settings: Creating conditions for learning from deaths in mental health inpatient services and when patients die within 30 days of discharge
- Care delivery within community mental health teams
- Transition from child and adolescent mental health services to adult mental health services
- Provision of mental health care to patients presenting at the emergency department