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Findings of a national review exposing multiple, system-wide failings over a man’s death after a decade spent in inpatient mental healthcare have uncovered uncomfortable criticisms of a flagship learning disability programme.
Clive Treacey, from Staffordshire, had a learning disability and was detained in NHS hospitals from 2007 to 2017.
The 47-year-old, who also had the rare epilepsy condition Lennox-Gastaut syndrome, died in January of that year at an independent facility in Nottingham.
The independent report, published this week, finds that Mr Treacey’s death was “potentially avoidable” and system failures in delivering his care and treatment “together placed him at a higher risk of sudden death”.
It features criticisms of the Transforming Care programme, launched after the Winterbourne View abuse scandal, with Staffordshire’s TCP lead quoted as saying she was trying to “work in a system that was simply not working”.
NHS England denied further criticisms that it created a “toxic environment” during its push to reduce the number of people with learning disabilities living in inpatient units, one of the fundamental tenets of the programme.
The organisation confirmed its policy was for CCGs to reduce the number of inpatient learning disability units, as many patients and families desire care delivered closer to home.
Work to do
Concerns over delays to lifesaving emergency surgery and pregnant women having to wait up to six hours for assessment have contributed to an ‘inadequate’ rating for two departments at Brighton’s Royal Sussex County Hospital.
The Care Quality Commission gave the rating to the surgery and maternity departments at the hospital, run by University Hospitals Sussex Foundation Trust, which has kept its overall “outstanding” rating.
The CQC issued the trust with a warning notice following its inspection in September and October. The notice required it to take action on staffing, training, governance, and culture to ensure the safe care and treatment of patients.
The CQC’s full report shows the ratings for surgery and maternity at the Royal Sussex County Hospital in Brighton have been cut from “good” to “inadequate”. Maternity services at Worthing Hospital and St Richard’s Hospitals have fallen from “outstanding” to “requires improvement” and, at the Princess Royal, Haywards Heath, from “good” to “requires improvement”.