The Care Quality Commission (CQC) has today published its findings following an inspection of West London Mental Health NHS Trust in November 2016. It found that 9 out of the 11 service areas examined required improvement, and rated the Trust as “Requires Improvement” overall.
Standards appear to have fallen since the last inspection which was carried out in 2015, when 5 out of the 11 areas examined were rated as “good”.
I act for the family of Peter Docherty, who was under the care of the trust when he died in January 2015 and to them these findings have come as a great disappointment, given the evidence given by the trust at the inquest recently held into his death.
The inquest was held in January 2017, and the coroner, Miss Ormonde-Walsh concluded that there were a number of serious failings in the care provided to him which may have contributed to his death. Mr Docherty was killed by a train at Ealing Broadway station having been allowed to go home from hospital, despite having been admitted as a high risk patient.
At the inquest, a trust representative stated that since Mr Docherty’s death, numerous changes had been made to improve patient safety. It would appear that these changes have not gone far enough.
The report notes that the trust had undergone a period of strategic change, and that they were in the process of transforming their adult services to reduce the number of people needing inpatient beds. This involved increasing services in the community. However, the CQC is critical of the fact that for patients treated in the community, effective links were not always established with GPs and other professionals providing support.
The report comes hot on the heels of a recent BBC Panorama investigation into mental health services, which highlighted a sharp rise in the number of unexpected deaths of patients due to medical negligence under the care of NHS mental health trusts nationally. Their investigation focused on care provided at the Norfolk and Suffolk NHS Foundation Trust, and found that the increase of unexpected deaths there coincided with the trust cutting nearly a quarter of its inpatient psychiatric beds. In light of this, the strategic decision taken at West London would appear questionable.
It is shocking that the majority of NHS mental health trusts in England are rated by the CQC as “requires improvement”. The pressures on the system are immense, with cuts in funding and an increase in the number of people seeking help. It appears that a lot more needs to be done to ensure that vulnerable patients such as Peter Docherty are provided with the treatment and care they require, and to avoid future deaths.