• Commissioners backtrack on previous refusal to review death of patient with learning disabilities
  • Pleas from the family of Clive Treacy, who died in 2017, were previously denied
  • Comes after HSJ passed on further appeals from the family to NHS England, along with details of alleged failings in his care

Commissioners have backtracked on a previous refusal to review the death of a patient with learning disabilities.

The family of Clive Treacy, who died in 2017, have now been told his case will be reviewed under the national learning disabilities mortality review programme, after their pleas were previously declined.

Mr Treacy died 12 weeks before the LeDer programme began, which the family was told made him ineligible for a review. This was communicated by an NHS England officer in 2019, they said.

But earlier this month, HSJ passed on further appeals from Mr Treacy’s family to NHS England, as well as details of alleged failings in his care over five years. A spokesman has now replied: “We agree that Clive’s family should have the option of a LeDer review.”

HSJ has asked NHS England to clarify which organsiation made the decisions over the review, after a spokesman suggested it was made locally.

The Care Quality Commission has also confirmed it is considering whether failures in his care meet its threshold for prosecution.

Multiple warnings

The family of Mr Treacy, who had a history of complex mental health, learning disability needs and epilepsy, say there were multiple failings in his care at two privately run units between 2012 and 2017.

He had previously been under the care of South Staffordshire and Shropshire Foundation Trust. But in 2012, the trust and Staffordshire Primary Care Trust transferred him to St Andrew’s Healthcare’s acquired brain injury unit in Northampton.

According to emails seen by HSJ, in June 2012, just after his admission to St Andrew’s, a nurse at SSSFT told the PCT about concerns over cleanliness, the use of seclusion in his care and an apparent lack of skills by staff who had to meet Mr Treacy’s epilepsy needs.

His family also raised a number of formal concerns about his care, which the PCT acknowledged.

But, the CQC said it did not receive any concerns about his care until 2016, when SSSFT warned of a “lack of leadership” within St Andrew’s and “an inconsistent, impersonalised and often negative approach” to Mr Treacy’s care.

In an email to the CQC in March 2016, the trust’s transforming care lead, Karen Plummer, said there was an emphasis on “generic, restrictive practices” and added: “I have previously reported my concerns to the clinical team along with the hospital manager; whilst it is clear that some steps have been taken to address my concerns, I am not reassured that the environment is safe.”

According to meeting minutes from SSSFT’s transforming care team in 2016, staff at St Andrew’s had reportedly been restricting Mr Treacy’s sleep apnoea machine, which he needed at all times, as a “punitive measure” to get him to leave his room.

Mr Treacy was transferred to Ceder Vale Hospital in June 2016, after suffering a fractured ankle, and his family have also raised concerns over his care for the six months until he died following a seizure in January 2017. A coroner later ruled he died from natural causes.

A St Andrew’s Healthcare spokesman said: “Our Neuropsychiatry Service was inspected by the CQC in May 2017, and was rated ‘good’ in every category. It also commended us for having clear vision and values, allowing us to deliver the best possible care for our patients.”

Meanwhile, in April 2012, an independent report carried out by the National Development Team for Inclusion, seen by HSJ, warned commissioners and local authorities in Staffordshire ”shortcomings” in the region’s learning disability services were “almost identical” to those which led to the Winterbourne View scandal.

It added: “Unless these shortcomings are addressed, people who challenge and have complex needs will continue to be sent out of area and/or the local health and social care system and the risk of a repetition of abuse — this time involving people from Staffordshire and Stoke on Trent — will continue.”

Updated after NHS England suggested the decision over the review was made locally.

In a later statement to HSJ, a spokeswoman for St Andrew’s Healthcare said: “The suggestion that the sleep apnoea machine was withheld as a “punitive measure” is untrue. We have evidence to support our decision regarding the use of the machine, which were made in line with the NICE guidelines at the time and following consultation and liaison with experts from the general hospital.

“Such machines are only used to maintain positive air pressure when asleep, and not at “at all times”. Therefore this is not something that would be used in the day time, unless the person was sleeping for long periods.”

This article was updated on 28 January after St Andrews Healthcare provided a statement on the use of Clive Treacy’s sleep apnoea machine.