Ashford and St. Peter’s NHS Foundation Trust takes up a lot
of my time; you wouldn’t think I’d want to take on any more. You would be
right.
However there is another scandal in the grounds of St.
Peter’s Hospital, Chertsey although it doesn’t involve the Trust.
The Abraham Cowley Unit is a complex run by ‘The Surrey and
Borders Partnership NHS Foundation Trust’ which treats mentally ill people
including those detained for their own safety under the Mental Health Acts.
Patients there are normal people suffering from illnesses that require
monitoring and management. Some of them need to be held in a secure environment
for a time.
Most patients live normal lives but may need to stay as inpatients
every so often. At those times, the hospital should be caring for them and
providing them with a place of safety until they are well enough to leave.
No one wants a return to the days when such places were
frightening gothic prisons and yet; a place of safety needs to be safe.
The Abraham Cowley Unit is not safe.
I visited the Unit a number of times in the 2000’s, visiting
clients (when I was working). I also visited many other similar units and was
often surprised by how poor the supervision and security was.
These inquest reports confirm that the Unit has been failing
for a number of years.
The recent inquest of Simon Tree has resulted in The Coroner
issuing a legally binding notice under paragraph 7, Schedule 5, of the Coroners
and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations)
Regulations 2013. Notices like this are made to trusts where unsafe practices
have resulted in a death and where a Coroner has identified unsafe practices
which are like to result in further similar deaths, if nothing is done. It
requires the Trust to respond to the Coroner about how it intends to avoid
similar deaths in future.
The evidence given by staff is not what it should be;
Paranoid
schizophrenic Simon Tree had threatened to jump in river two days before death,
inquest hears;
Get Surrey
23 January 2015
By Matt Strudwick
A coroner
said he would be issuing a prevention of future death report to a mental health
unit after four subsequent patients also absconded.
Simon Tree
went missing from a mental health unit before drowning in the River Thames.
A man with
paranoid schizophrenia threatened to "jump into a river" just two days
before his body was found in the Thames, an inquest has heard. Simon Tree, 49 -
formerly known as Gary Randall - was found dead by a canoeist near homes at
Sunbury Court Island on February 18 2012.
A five-day
inquest held at the coroner’s court in Woking this week was told Mr Tree was
having treatment in the Abraham Cowley Unit (ACU), based at St Peter’s Hospital
in Chertsey.
He was
there voluntarily after setting fire to his Stanwell home in a failed suicide
attempt a month earlier.
Mr Tree,
who was diagnosed with depression at the age of 18, had been taken back to the
unit by police on the evening of February 16, after he was found drunk and
walking towards the river by a couple in Thames Street, Sunbury.
He had been
reported missing by the ACU at 4.38pm.
PC Claire
Phillips told the inquest how, when she and two colleagues returned him to the
Blake Ward at the ACU, she felt charge nurse Stephen Livesley had not taken the
situation seriously enough.
“I stated
Simon said he wanted to jump into the river and, I wouldn’t say he was dismissive,
but he said ‘they always say that when they’re drunk, it’ll be different in the
morning’,” she said.
“I didn’t
challenge the comment, but was surprised because he was so blasé about it.”
'High risk'
Mr Livesley
said he had no recollection of the conversation, but had told colleagues Mr
Tree should be reassessed the next morning by doctors when he had sobered up.
“It was the
first I heard in terms of Simon wanting to put himself into a river,” he told
the inquest. “First I knew Simon had any attempt to take his own life or may
have had.”
The inquest
heard Mr Tree was allowed off the ward by nurse Steven Hope at 8.20am the
following morning, onto the main corridor for breakfast, where patients could
gain access to the delivery area.
Mr Livesley
said the area was used as the main entrance at the time, due to maintenance
work at the front entrance, and the door was "insecure" and had "occasionally
not closed fully".
At around
midday, staff nurse Cecil Nhlangano raised the alarm that Mr Tree was missing
after colleagues could not find him in the facility for an assessment.
It took
staff until 7.40pm to report him missing to the police as they had thought he
may have gone shopping.
“I
disclosed with the ward manager, also, to try to come up with a plan,” said Mr
Nhlangano.“What we concluded was to give him a chance to come back as he might
have gone shopping.
“Those were
some of the reasons as he had requested to do some shopping for clothes
[earlier in the week].”
Coroner
Simon Wickens asked why the "intervening event" [of Mr Tree being
found drunk near the river] had not come into the discussions.
“You knew
this issue where he was going to take his own life and you knew he had gone
missing from the ward,” he said.
“At midday,
is he not, in your mind, a high risk, given those events?”
But Mr
Nhlangano said the risk had been minimised due to his return to the ward and
him no longer being intoxicated.
Mr Tree was
not found until 5pm the following day, when firefighters pulled his body out of
the river.
His father,
William Randall, said; “At Christmas 2011, he said he felt like jumping off
Staines Bridge but had shuddered at the thought of it. “The last time I saw,
Simon was on Blake Ward on February 15, when I brought him in some more socks.”
A post-mortem
examination concluded he had died from drowning, with toxicology results
showing small traces of prescribed drugs Citalopram and Risperidone, which were
being used to treat his depression and schizophrenia.
Giving a
narrative verdict on Friday morning, Mr Wickens said he would be issuing a
prevention of future death report to the unit after four subsequent patients
absconded in the past year - "four too many", as he described it.
"In
one incident the camera covering the air lock was moved to a blind spot to assist
a patient to leave," he said.
"I
propose to make a prevention of death report to the unit to take steps to address
those issues and closer monitoring of those exiting the building."
I’m not surprised that the Coroner was angry about the four
recent absconders from the Unit but the situation was worse than that.
This next report is again from ‘Get Surrey’ and it concerns
another recent inquest which also deals with a death from 2012 (why does it
take so long?).
This is negligence plain and simple. There was no assessment
of her mental state on her return to hospital and how on earth did she get hold
of a knife in a place of safety?;
Mental health
unit failings contributed to Katherine Bonaventura death, inquest jury decides.
Get Surrey.
14 January
2015
By Becca
Taylor
The
28-year-old, who was a diagnosed schizophrenic, stabbed herself in the chest
but an inquest jury said there was not enough evidence to establish if she had intended
to cause her death. Failings in procedure at a mental health unit in Chertsey
"more than minimally" contributed to the death of a promising
musician from Godalming, an inquest jury has ruled.
Katherine
Bonaventura, who lived in Warramill Road, died in December 2012 from a
haemorrhage after a stab wound to the chest, sustained while she was a detained
patient in the Abraham Cowley unit based at St Peter's Hospital.
Miss
Bonaventura had returned to the unit following overnight leave with her mother
Patricia on December 7 2012.
She
returned just after 11am and her registered clinician Dr Sheetal Sirohi had
plans to see her for an assessment at around 2pm that same day.
Miss
Bonaventura was found in a corridor at the unit shortly after 2pm, with a knife
in her chest.
Paramedics
attended and she was transferred to the trauma unit at St Peter’s, but was
pronounced dead at 4.22pm. She was 28-years-old.
A jury at
the inquest ruled she died as a result of her own actions, but that there was
not enough evidence to establish whether she had intended to cause her death.
The jury
also ruled that the unit had failed to elicit information when Miss Bonaventura
returned that day, and that they failed to "sufficiently and
immediately" assess her mental state.
'I'm going
to hell'
Miss
Bonaventura was diagnosed with schizophrenia in 2009, and over the following
four years had various periods in hospital, both voluntarily and under section
three of the Mental Health Act.
The night
before her death, Miss Bonaventura had been celebrating her mother’s birthday
at a restaurant with friends.
Mrs
Bonaventura said she had tried to express concerns to staff at the ward when
they returned that her daughter had been drinking heavily, which was at odds
with the anti-psychotic medication she was on, but that she felt the concerns
were dismissed.
Giving his
evidence, Sunil Boo Jharut, charge nurse at the unit, said he had no
recollection of Mrs Bonaventura expressing any concerns about the leave, and
that no formal note had been made of any handover.
After the
alarm was raised, Dr Sirohi cradled Miss Bonaventura as she lost consciousness.
Her last
words were "I’m so sorry. I’m going to hell. Let me go".
Staff said
Miss Bonaventura’s presentation seemed to be improving, though her mother said
that just two days before she was granted the overnight leave there had been
concerns she was having suicidal thoughts.
'Sad
incident'
Assistant
coroner Alison Hewitt confirmed that she had it in mind to write a report, or a
letter, to the Surrey and Borders Partnership NHS Foundation Trust (SABP),
which runs the Abraham Cowley unit, to make her suggestions as to improvements
that could be made following the jury’s verdict.
Jo Young,
director of quality at SABP, said: “We extend our heartfelt and sincere
condolences to Miss Bonaventura’s family for their sad loss.
“Maintaining
the safety of people who use our services is a vital part of our work, and
across the organisation we are embedding all that we’ve learnt from this sad
incident.
“Recommendations
were made as a result of our internal review and these are being fulfilled to
ensure we improve our practices.
"These
have included clearer guidance for staff in relation to searching a person,
their rooms and personal belongings, more detailed risk management plans, staff
documenting feedback from carers, family, friends when a person returns from
leave, and managing any identified risks appropriately.”
I’m very concerned that for the second time staff had no
recollection of what happened and there appear to be no written records of what
happened.
It’s a shame that a different coroner was dealing with this
inquest; a combined report would have been better.
This next article (also from ‘Get Surrey’) last year was
meant to be reassuring but it isn’t. It was written after the two deaths in
2012 but before the inquest’s this year.
You would think there were no problems;
Security
levels improving at the Abraham Cowley Unit
Get Surrey
3 May
2014
By Russell
Butt
The
director of mental health services at the Surrey and Borders Partnership NHS
Foundation Trust has said the numbers of patients wandering off at the ACU has
steadily reduced.
Security
levels at a mental health unit in Chertsey are said to be improving, despite
two worrying incidents in April.
The Abraham
Cowley Unit (ACU), based in the grounds of St Peter's Hospital, has had issues
in the past with patients going missing, although most return unharmed.
In one
recent incident a patient was talked down from a bridge over the M25 in Green
Lane, Chertsey, by a passer-by. Just two days later, another patient was coaxed
down from a roof of in the hospital grounds, prompting concerns over security
at the unit.
However,
Andy Erskine, director of mental health services at the Surrey and Borders
Partnership NHS Foundation Trust, which runs the ACU, said that despite these
two incidents, the numbers of patients wandering off had steadily reduced
during the past three years, even though more people were using the service.
He said:
"With four wards for people with acute mental ill-health, the Abraham
Cowley Unit in Chertsey is our largest in-patient site in the county.
"Our
first priority is to keep people safe while they are with us and we are
continually reviewing and improving the way we work.
"The
number of people going AWOL (absent without leave) across our inpatient
services, and especially at the ACU, has dropped significantly in recent years.
In 2009-10
the number of AWOLs from the ACU was 80, in 2011-12 it was 48 and in 2012-13 it
was 10."
Mr Erskine
said the overall AWOL figure for the trust as a whole was 43 for 2012-13.
He added:
"This is a real success considering that more people than ever are staying
at the ACU since a new ward opened in 2012. This reflects a concerted effort
from us to improve security levels.
"We
have invested in improvements such as secure card entry doors, as well as
giving patients more opportunities to talk about their feelings so people
understand why they should remain in our care.
"Some
people are able to leave to see family or friends as part of their recovery and
if they are late returning, then this has to be logged as an AWOL.
We would
not expect a zero rate of AWOLs, although we are, of course, determined to keep
this to a minimum to protect patient safety as much as possible.
"This
means that if people are AWOL, we review what happened and try to improve our
services."
The problem? We know from the Coroner that as of this year it
is still a problem and in 2014 there were two very serious incidents that
resulted in this rather complacent interview.
More worrying is that the Trust seems to think that 2012
(with only 10 absconders) was a good year; one of them died.
I’ll be watching Abraham Cowley closely from now on to see
how many more incidents happen!
Neil Harris
(a don’t stop till you drop production)
