Trust ‘reviewing hundreds of patients’ after failings discovered

Frances Wellburn, 56, was under the care of Tees, Esk and Wear Valley Foundation Trust’s community mental health team in York, which before the coronavirus pandemic had categorised her as “medium risk”.

This meant she should have had regular contact from the service, but an internal serious incident report into her death, seen by HSJ, found no contact was made with her for three months.

In June 2020 she required admission to an inpatient unit for three weeks, but she deteriorated again after being discharged and took her own life in August.

Her family have said Ms Wellburn was making a “good recovery” from episodes of psychosis prior to the pandemic, but the lack of support in the spring of last year had contributed to a major deterioration in her condition.

According to sister, Rebecca Wellburn, the trust’s director of nursing Elizabeth Moody confirmed in a meeting with the family that a wider review had now been launched into the care of hundreds of patients under its York-based community services.

The trust would not confirm this wider review to HSJ, but said: “In terms of reviews, we are committed to providing high-quality care across our services and we routinely undertake thematic reviews in order to enhance our organisational learning.”

Rebecca Wellburn added: “The community mental health team just stopped contacting my sister in February 2020 and then when lockdown happened in March, they made no contact with her to review the support she needed, despite her being on strong medication.

“They did a risk assessment of everyone on their caseload at this time, but this seems to have been a paper exercise and despite Frances being assessed as an amber risk absolutely no contact was made with her either virtually or face-to-face.

“So she was dealing with everything stopping and no support… It’s difficult enough to deal with her death, but the fact there was such a careless attitude to supporting her makes it feel even worse.

“There was resistance to communicating with me, even though family members will often be the people who can see a crisis happening early.

“Several times when I phoned the crisis team, they told me they couldn’t tell me anything because of data protection, not even whether they had seen my sister. I understand data protection but it surely shouldn’t override action needed to keep someone safe when they are in crisis”

The serious incident report into Ms Wellburn’s case said: “Familiar operational systems were abruptly overturned [during the pandemic], and teams were chartering unknown territory, often without clear and tested guidance.”

However, while it said the outbreak of covid “should have been an opportunity to re-engage with Ms Wellburn”, it concluded the pandemic “could not be viewed as being a major influence on events” as there had been pre-existing issues with the service.

Another key failing identified within the internal investigation was the lack of communication with Ms Wellburn’s family throughout her care, and specifically following her discharge in June.

It also found an earlier episode of psychosis in 2019 was not dealt with appropriately, due to clinicians falsely believing she was too old for early intervention in psychosis services.

While these services historically had a cut-off age of 35, in 2016 this was changed by NHS England to be available to all ages.

It is understood the Healthcare Safety Investigation Branch is considering opening an investigation into the case, although the regulator said it could not yet comment on the referral it had received.

A separate review into TEWV’s talking therapy services, sparked by a series of unexpected deaths, recently cited several shortcomings, including a lack of contact or reassessment for patients on waiting lists.

The trust also faces an ongoing review into inpatient deaths at West Lane Hospital in Middlesbrough in 2019.