A young girl with an unhappy look on her face lies on her side in a hospital bed, hugging her teddy.

Safer mental health environment needed in paediatric wards

23 May 2024

Our latest report has called for improvements and changes in the design of paediatric wards to ensure they provide a therapeutic environment.

This is to support the safety and wellbeing of children and young people presenting with mental health, learning, cognitive, communication and/or behavioural difficulties. It is also to ensure the safety of other patients, their families and staff working on the wards.

Variation in design

In the report, and in a previous interim report, we emphasise that acute paediatric wards are traditionally designed for the treatment of physical conditions and not ‘typically designed to keep those with mental health conditions safe.’ However, the report cites that between 2021 and 2022, nearly 40,000 admissions of children aged 5-18 to an acute inpatient ward were for mental health conditions. Our investigation highlights that the paediatric wards have features which were particularly challenging for children and young people with mental health needs, such as being noisy, busy, and brightly lit.

Whilst some NHS trusts provide rooms and spaces for those children and young people with mental health needs, HSSIB identified that there is variation in how these rooms are designed across England, and also that there is limited national guidance to support consistency in how rooms should be best adapted. The report also reveals that adaptations tend to be focused on physical safety features, and that there is little or no consideration of therapeutic elements. Rooms are often stripped of anything that could be deemed a risk, for example window blinds or a shower curtain rail. Whilst this is done to protect patients, rooms can often appear ‘stark’ which can prove distressing for children and young people who may have to stay in the room for a prolonged period of time.

Safety concern

Speaking with patients, NHS staff, mental health experts, and looking at relevant research evidence, HSSIB concluded that the lack of a therapeutic environment is a safety concern because it can create a ‘restrictive environment’ which can lead to conflict situations. This includes increased aggression, physical and verbal abuse, rule breaking, medication refusal and self-harm. In the previous interim report, there were also examples of patients having to be sedated or restrained when behaviour escalates, other sick and vulnerable patients and their families feeling concerned for their safety during incidents and paediatric staff being physically assaulted.

Mental health experts told the investigation about the importance of creating an environment that reduces stress and anxiety and where the child or young person feels emotionally safe. One patient HSSIB spoke to shared their experience of their room being stripped of items - they “felt that they had no hope” and that they had thought “this is what my life has come to, this empty room, I have no human contact” and that “it’s a form of torture”.

The report states that a therapeutic environment balances patient safety, privacy and dignity. This includes everything from single patient rooms with private bathrooms to stress-reducing positive distractions – access to outdoor spaces, nature, art, exposure to daylight to having activities to participate in and facilitating calming and effective staff engagement.

The report references where some of the elements have been seen – with examples from some trusts of ‘mental health boxes’ containing comfort/stress reducing items and therapeutic spaces focused on music therapy and arts. HSSIB also visited a new mental health inpatient facility for children and young people, and saw the plans of a new children’s hospital which both demonstrated how design could encompass both physically safe and therapeutic features.

Our investigation did identify that there are differing views across healthcare on whether paediatric ward is the right place of care and that these differing views could be a barrier to improvements. The report acknowledges that there is a common perception that the ward “was not the right place” and that the overall NHS strategic direction is that most children and young people with mental health needs should be supported in the community, avoiding hospital and inpatient admissions where possible. However, it also states that the high levels of children who present with both physical and mental health difficulties, as well as the high incidence of neurodivergence, means that there will remain a significant proportion of children and young people on the acute paediatric ward presenting with mental health, learning, cognitive, communication and/or behavioural difficulties.

Safety recommendations

We have made three safety recommendations aimed at improving the design and adaptations that are being made to paediatric wards.

They have asked NHS England to look at developing national guidance on how acute paediatric wards could be adapted with particular focus on creating a therapeutic environment. The second recommendation is to update paediatric ward building guidance, to ensure children and young people with mental health needs are supported. The third is for the Care Quality Commission to ensure that the risks associated with the adaptations to paediatrics wards have ways to be escalated and managed.

Patient story illustrating risks seen in the wider investigation

Leah, a young person with a history of trauma had been taken to the local emergency department by her social worker as she was expressing suicidal thoughts.

Leah was admitted and detained on a ward whilst awaiting a mental health assessment (under the provisions of the Mental Health Act (1983)). During her stay she had episodes of violence and aggression where she attempted to self-harm and to harm staff. They attempted to keep her safe by removing most of the items (clinical and non-clinical) from her room and by using physical restraint techniques and sedation.

Leah absconded on several occasions. On two of the occasions she needed medical treatment for an overdose of paracetamol. In analysing her case, HSSIB found that adaptations to the ward were made when children and young people’s behaviour escalated, and that staff had little support, training, or guidance on how best to manage and adapt the ward environment. Leah told the investigation that she felt that there is a lack of privacy and dignity in the hospital environment for children and young people in mental health crisis.

Saskia Fursland
Saskia Fursland, Senior Safety Investigator at HSSIB.

Investigator’s view

Saskia Fursland, Senior Safety Investigator at HSSIB, says: “Caring for children and young people with mental health conditions is complex. Whilst having a therapeutic environment during a hospital stay may just be one piece of the puzzle, it is a crucial one. As we saw in Leah’s case, other patient stories and staff experiences, an overly restrictive and overly stimulating space can lead to feelings of irritation, anxiety, fear and sadness, could be factor in incidents of physical aggression and violence and, in the worst cases, increases the risk of self-harm and suicide.

“Parity of esteem and better integration of children’s mental and physical health care is a national priority with many programmes of improvement work underway. However, the design of the paediatric ward is a patient safety risk that has not been previously explored. Our report is an important piece of evidence showing that the environment could be deemed to be physically safe but does not provide the emotional safety truly needed for those who are most vulnerable.

“During our investigation we saw that NHS staff are doing the best they can to provide compassionate care in pressured circumstances to children and young people with mental health needs. They need to be supported by national and regional systems that bring consistency and best practice to ward design and adaptations, with an emphasis on therapeutic elements. It is clear that there are opportunities for improvement and innovations that could be harnessed. Children and young people could be admitted to a paediatric ward for any reason, and they should be in safe environment that is designed to support all of their physical, mental, emotional and social needs.”

Read the report

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