Safety Repairs Slammed After Two More Hangings At Mental Health Unit

Published on: 21 Oct, 2020
Updated on: 24 Oct, 2020

Abraham Cowley Unit at St Peter’s, Chertsey run by Surrey and Borders Partnership NHS Foundation Trust. Photo: Surrey Advertiser.

By Julie Armstrong

local democracy reporter

The mental health unit co-located with St Peter’s Hospital, Chertsey, is making urgent safety improvements six months after two male patients hanged themselves in Clare ward within four weeks.

On April 15, this year a man took his life by fixing a ligature to ward fittings in the Abraham Cowley Unit (ACU) at Chertsey, which admits male adults from Elmbridge, Epsom and Ewell. Twenty-five days later, a second patient killed himself in a similar way.

Tragically, ACU ligature points have been used in other suicides. Two years earlier, Guildford electrician Bruce Simpson, 53, hanged himself in a bedroom. In 2015, Barry Gunner, a 43-year-old artist from Godalming, killed himself using a ligature on Clare ward.

Each time, a trust spokesperson said they were doing all they could to prevent something similar happening again.

Last October, an inquest jury listed four trust failures that led to Mr Simpson’s death:

A failure to place Mr Simpson under constant observation;
Having placed him on 15-minute intermittent observations, the Trust failed to observe him accordingly;
A failure by the trust to have an adequate and effective plan in relation to Mr Simpson’s risk of suicide, pending completion of his care plan and risk assessment; and
A failure by the trust to put Mr Simpson in a safe location, by placing him in a bedroom which contained a ligature point.

In June this year, Care Quality Commission (CQC) inspectors found the Surrey and Borders Partnership (SABP) NHS Trust had still not addressed the risks or set a date to do so.

Their report reads: “Effective controls to manage ligature risks remained in discussion with no real time scales for completion of remedial action.”

The CQC also found learning had not been shared with the other two mental health wards in the unit, Blake and Anderson. There was no formal training for staff in management of ligature risks.

Kevin Cleary, CQC’s deputy chief inspector for hospital inspection, said: “We told the trust it must make urgent improvements. The trust needs to ensure systems are in place to keep people safe, that it can mitigate risks to people’s safety.”

The SABP said they were “fixing and replacing parts of the physical environment” and “much of this work is already completed”, but they would not say when or if the fittings used as ligature points had been removed or replaced.

A remote monitor was installed this month to provide staff with patients’ vital signs 24/7. Other technology that automatically alerts staff to detected safety concerns was to be operating by the end of the month.

Surrey Cllr Jeff Harris (Con, Tadworth, Walton & Kingswood), who sits on the adults and health select committee, said: “When the CQC investigated, it would appear the response was, ‘We’ve been aware of this risk for some time’. My experience is that if you identify a ligature point anywhere, you eradicate it.”

In 2018, the council formed a mental health task group in response to concerns of watchdog Healthwatch about the ACU.

But Kate Scribbins, Healthwatch Surrey chief executive, warned Covid restrictions meant they were unable to use their “Enter and view” powers to access healthcare providers.

Dr Helen Rostill, director of innovation and development at SABP, said: “The ward has been closed, people have been transferred to other facilities and there are building works underway, so all of those risks are being eradicated and there are no patients being exposed.

“The work is to fit safety hinges which have a specialist sensor function to prevent ligature use.”

Work is due to be finished on the first ward by the end of November and on the other two by May next year.

An SABP spokesman said: “Work that could be done immediately was of course done immediately. We agreed a planned programme, which we shared with the CQC.

“More substantial work that is extremely disruptive is now under way following finding alternative inpatient beds, balancing our need to do the works with people’s safety and their experience.”

SABP chief executive Fiona Edwards said staff had been heartbroken by what had happened this year. She added: “The Abraham Cowley Unit is quite outdated and the physical environment is not what we would now expect of a modern mental health unit.

“In the next four years we plan to rebuild the unit to take advantage of new technology and thinking on therapeutic environments.”

Ultimately, the plan is to replace all dormitories and replace them with individual en suite rooms.

The county council’s adults and health select committee expressed disappointment that the improvements are scheduled for four years and asked the ACU to make improvements “with the utmost speed and no further delays”.

Cllr Nick Darby

Cllr Nick Darby (Residents’ Association and Independent group leader, Dittons), chair of the mental health task group, said: “There have been inordinate delays that need to be put right.”

He said “little or no progress had been made” since councillors were told of plans for improvement in 2018.

Karl Atreides, chair of the Independent Mental Health Network, said everything had to be reviewed and decided again after the architectural firm was suddenly dismissed in 2019.

For anyone wishing mental health support, the Samaritans helpline is on 116 123 and Surrey mental health crisis is on 0800 915 4644. Both are available 24 hours a day.