Two NHS trusts have accepted failings which contributed to the killing of two patients on a hospital medical ward in 2015, and set out the actions they have taken since.
In a detailed statement responding to HSJ’s questions about the events, Leeds Teaching Hospitals Trust offered “sincere apologies” to the families of Ken Godward and Roger Lamb, who were beaten with a walking stick by Harry Bosomworth. He had been diagnosed with paranoid schizophrenia, and was staying on their ward while in St James’s Hospital for acute care in February 2015, in an incident revealed today for the first time by HSJ.
Both Leeds Teaching Hospitals and Leeds and Yorkshire Partnership Foundation Trust said they were cooperating with an ongoing NHS England-commissioned serious incident review. The review has been subject to substantial delays, and a whistleblower with knowledge of the situation, and families of the victims, have raised concerns with HSJ that the incident is being covered up.
LYPFT chief executive Sara Munro said the two trusts were working together to deliver “necessary improvements”. She added: “This was a rare and very tragic incident and we can only reiterate our condolences to the families who have been affected.
“We have engaged fully with the further review commissioned by NHS England and once they report their findings, we will take any further action deemed necessary to maximise the learning from this case.”
An earlier report commissioned by the two trusts and completed in March 2016 revealed multiple missed opportunities in Mr Bosomworth’s care, including his mental health taking “second place” to physical care.
Asked whether it accepted the criticisms and findings of the investigation, Leeds Teaching Hospital Trust said: “Yes we do and we would like to reiterate our sincere apologies to all the families involved. We understand that this has been an extremely difficult and upsetting time for everyone involved and we have taken this tragic incident very seriously.
“We continue to work closely with [LYPFT] to improve the care of patients with mental health needs in our hospitals and to protect patients from harm. This includes improving team working; strengthening communication of patient information between the two trusts and ensuring the supervisory needs of all patients are assessed and addressed consistently.”
The trust said the care of patients with mental health needs in acute hospital settings was a problem nationally. The statement said: “We increasingly care for vulnerable patients with challenging behaviours in our hospitals and we recognise that the ward environment is not always ideal for their mental health needs. This is an issue nationally across the NHS.”
Asked if it had co-operated fully with NHS England’s investigation, LTH said: “Yes. The trust has fully engaged in the process with NHS England.”
LTH said lots of changes had been made as a result of the fatal attacks, which it said had led to the number of reported incidents reducing significantly.
- Integrating clinical records to share details about individual patients between staff at the two trusts.
- Development of a new standard operating model between the two trusts to ensure staff have access to consultant psychiatric opinions.
- A new risk assessment tool to help staff to determine on admission the level of observation and supervision patients require to maintain their safety and the safety of others on the ward. The tool is also used to reassess the patients throughout their admission.
- A joint forum between both trusts meeting monthly to consider the care of patients with mental health needs in the hospitals. This includes a review of incidents and the actions taken.
- There has been a full review of liaison psychiatry services to provide cover during the day, night and at weekends. This includes a specialist mental health practitioner based on the St James’s site. This role is a first point of contact for staff who have concerns about a patient with mental health needs and provides urgent assessment and advice, supporting nursing and medical staff on wards.
- The appointment of a lead nurse for older adults at Leeds Teaching Hospital Trust to address how services are provided to meet the needs of “this growing group of patients.”
The trust accepted that during a meeting with Mr Lamb’s family, LTH medical director Yvette Oade and Craig Brigg, director of quality, had discussed “concerns that we were unable to resolve”, and added: “It was highlighted that the remaining questions the family had were likely to be answered through the coronial inquest process.”
The trust did not answer whether it considered this to be appropriate.
A spokesman for NHS England’s north of England team, which has been coordinating the review, said the independent investigator was now working with all organisations and families. He added: “Whilst we strive to complete the investigation process as quickly as possible the process is not a straightforward one and primacy must be given to establishing the lessons which can be learned by organisations in order to improve care for patients.”
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Exclusive: Two patients attacked and killed on acute hospital ward
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Trust apologises after fatal ward attack on patients