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A mental health trust in Essex, which previously admitted failures of care relating to the deaths of 11 inpatients, has been told to make safety improvements.
The health watchdog, the Care Quality Commission (CQC), carried out surprise inspections of the Linden Centre in Chelmsford, following the death of Jayden Booroff, a patient who had escaped from the mental health unit.
23 year old Jayden was was sectioned and admitted there in October 2020 while suffering with psychosis.
Just four days after he arrived, he escaped, and less than two hours after fleeing, his body was found by British Transport Police near Chelmsford Train Station.
That's your job, you've got one job to do, and that's to keep patients safe, these are vulnerable patients. He was put in there because he was vulnerable and deemed not to be able to keep himself safe. And, I trusted them, I put his life in their hands.
Six days after Jayden's death, inspectors visited the Linden Centre, which is run by the Essex Partnership University NHS Foundation Trust (EPUT).
It carried out unnanounced focused inspections of Finchingfield Ward, the trust's 17 bed inpatient mental health ward which provides care and treatment for men experiencing acute mental health difficulties.
Some staff did not follow the required actions to maintain patient safety. For example, garden areas required staff to observe patients due to environmental risks.
Inspectors witnessed an incident on CCTV which showed observing staff were not present and this contributed to an incident of a patient leaving the site.
Staff did not keep accurate records of patient care and managers did not check the quality and accuracy of notes.
Staff failed to correctly record patient's mental health act status and they did not always make entries to records in a timely way.
CQC says it will monitor the Trust's progress
The trust responded quickly to concerns raised during feedback from the inspection and provided assurance on how they intended to address issues. The trust took immediate actions to address some safety concerns, including the removal of garden shelters and increasing security measures.
"Patients gave positive feedback about the ward staff and the hospital environment. The trust ensured there was support available to patients and staff following incidents, this included access to senior leaders and psychologists."
Stuart Dunn also went on to say, the Trust's progress in addressing the issues would be monitored:
We have reported our findings to the trust leadership, which knows what it must do to bring about further improvements and ensure it maintains any already made. We will return to check on the trust's progress.
Latest criticism for troubled mental health unit
Jayden's death and the intervention of inspectors ordering Essex Partnership University Trust to make improvements is the latest development in almost twenty years of controversy surrounding the Linden Centre.
For almost a decade mum, Melanie Leahy, has been campaigning for justice for her son Matthew, who was found dead on the unit in 2012.
She is now leading a call for a statutory public inquiry into Essex mental health services, backed by more than 60 families, including Jayden Booroff's.
In November last year, the Trust admitted health and safety failings in relation to the deaths of 11 of its inpatients, between 2004 and 2015. One of those was Matthew.
Two week after that, Nadine Dorries, Mid-Bedfordshire MP and Health Minister announced an independent inquiry into the Linden Centre spanning from 2000 to 2020. Although, this is not the statutory public inquiry the families are still pushing for.
Statement from Essex Partnership University Trust
EPUT was formed in 2017 when the South Essex Partnership Trust and the North Essex Partnership Trust merged.
Since, the Trust says it has spent more than £2.4 million improving safety.
Regarding the findings of the Care Quality Commission's inspections in October and November last year, EPUT says it took immediate action to remedy safety concerns raised by the inspections which included making physical changes to the ward environment, ensuring staff are able to follow procedures correctly, and providing leadership support.
Chief Executive of EPUT, Paul Scott, said: “Safety is an absolute priority and we have taken immediate action to make the physical environment safer and improve practices to ensure that staff are supported to provide consistent, safe, high quality care.
There is still more to do, and we have accelerated work to improve the safety of services, including investing in digital innovations that will support staff to monitor patients’ safety and wellbeing.
The Trust also said it is rolling out a new technology to help better observe its patients. It uses secure optical sensors to remotely monitor patients’ pulse and breathing rates, and alerts staff if they display activity or behaviour that may present a risk to their safety.
Essex mental health services timeline
- 2008: Ben Morris found dead at Linden Centre.
- 2012: Matthew Leahy found dead at Linden Centre.
- 2015: Richard Wade found dead at Linden Centre.
- 2016: Police launch investigation into deaths of 25 patients (including Ben, Matthew & Richard) from 2000 to 2016, who had died under the care of North Essex Partnership Trust.
- 2016: Healthcare regulator at the time, the Health and Safety Executive, begins an investigation into how safety and environmental risks to patients were being managed at the Linden Centre, and six other sites run by the North Essex Trust. The investigation covers 2004 - 2015 and relates to 11 inpatient deaths (including Ben, Matthew & Richard).
- 2017: South and North Essex Partnership Trust merge to form the Essex Partnership University Trust.
- 2018: Police drop criminal manslaughter investigation against the Trust, saying there’s no corporate manslaughter charge to answer.
- 2019: Melanie Leahy gathers 105,580 signatures to secure a parliamentary debate, into her call for a public inquiry into the death of her son Matthew at The Linden Centre.
- 2020, January: The results of an investigation by the health ombudsman into the deaths of two patients at Linden Centre, one who was Matthew, are published. It reveals serious failings relating to their deaths.
- 2020, August: March and memorial held in Chelmsford calling for a statutory public inquiry into all deaths of mental health patients in Essex. Families are now uniting with legal representation.
- 2020, September: The Health and Safety Executive announces it will be prosecuting the Trust for historic health and safety failing.
- 2020, 23rd October: Jayden Booroof absconds from the Linden Centre and is found dead by British Transport Police in Chelmsford. Six days later the health watchdog, the Care Quality Commission carries out surprise inspections of the Linden Centre.
- 2020, 12th November: EPUT pleads guilty to the Health and Safety Executive's prosecution at Chelmsford Magistrates' Court. The Trust admits its predecessor, the North Essex Trust, breached health and safety rules relating to the management of fixed ligature points on its units and 11 inpatient deaths, between 2004 and 2015.
- 2020, 30th November: At a parliamentary debate of Melanie Leahy’s petition, Health Minister Nadine Dorries MP announces an independent inquiry into ‘all tragic events’ at the Linden Centre 2000 - 2020. Expected to start in February 2021 and last two years.
- 2021, January: Care Quality Commission publishes results of unannounced inspections of the Linden Centre it carried out in October & November 2020, sparked by Jayden’s absconsion. The CQC tells the Trust to make improvements to its wards for men of working age and psychiatric intensive care units
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