- South London and Maudsley Mental Health FT and NHS Professionals have launched investigation into two nurses and a healthcare assistant
- Follows death of Alex Blake, a patient who died of an overdose whilst he was an inpatient
- Coroner who said nurses, who were looking after Alex, either did not carry out observations or lied to court
- Trust investigation also found staff had “copied and pasted” risk assessment documents for the patient, leading to inaccurate information
A trust and the NHS’ staffing agency have launched an investigation after a coroner found two nurses and a healthcare assistant may have lied about carrying out patient observations.
Alex Blake died from an overdose in June 2018 while he was staying on one of South London and Maudsley Foundation Trust’s wards.
In his prevention of future deaths report, the senior coroner for South London Andrew Harris said he suspected the staff – who were employed by SLAM through the NHS Professionals agency – either did not perform any observations on Mr Blake at all, or provided false evidence to the trust and court.
According to the report, the two nurses and healthcare assistant gave conflicting evidence about their observations of Mr Blake during the night. One of the nurses, for example, reported Mr Blake was asleep and breathing regularly at 5.52am. However, at this point Mr Blake was already dead.
The coroner, also said: ”Given the serious professional and legal implications of the evidence of the nurses each is referred to the Nursing & Midwifery Council.”
The trust’s own route cause analysis investigation into Mr Blake’s death, seen by HSJ, has revealed staff on the ward were also found to have “copied and pasted” his risk assessments, leading to inaccuracies; not followed protocol regarding observations; and failed to consider his history of drug abuse.
In a letter to Mr Blake’s mother Linda Blake, also seen by HSJ, the trust’s director of nursing said the trust had since removed one of the two NHS Professionals’ nurses from clinical duties, who had become a permanent employee, pending the outcome of an investigation.
NHS England and Improvement recently sent a letter to all mental health trusts, urging them to ensure national guidance on risk assessments for mental health patients were being met and that risk assessment tools should not be used in isolation. This letter was prompted by a report into the care failings relating to two young men who died while patients at a unit run by North Essex University Partnership FT.
Mr Blake was admitted to SLAM’s community ward, from a medium secure unit, in May 2018. On 24 June, he was found dead on the ward.
According to the report, he admitted to staff he had taken and bought class A drugs during unescorted leave from the unit. Despite his admission, he was still allowed unescorted leave on the day of his death.
Vanessa Smith, interim director of nursing at SLAM, said: “On behalf of the trust I would like to offer my sincere condolences to the family and friends of Mr Alex Blake.
“We are working closely with NHS Professionals who are investigating the incident. Pending the outcome of the investigation we will take steps to review our policies and procedures if necessary.”
Speaking with HSJ, Linda Blake, Alex Blake’s mother, said: “At the inquest the night staff [allegedly] lied under oath and did not carry out the appropriate checks. Neither were the night staff told that Alex had admitted taking Class A drugs, nor did the day staff implement more frequent checks on Alex.
“I am not saying that out in the community, he would not have overdosed, but the point is he should not have overdosed in hospital when being held on a Section 3 for his and others safety. Alex had a right to life which he was denied.”
HSJ Transforming Mental Health Summit
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Patient Safety Congress
The Patient Safety Congress, taking place on 13-14 July 2020, brings together more than 1,000 people with the shared aim of transforming patient safety. It draws together contributions from patient speakers, safety experts from healthcare and other safety critcal industries, and frontline innovators, to challenge and drive forward on patient safety. You will be part of influential conversations with those responsible for driving the new national strategy on patient safety and take away real solutions that you can adopt to improve outcomes where you work.
Prevention of future deaths report, information provided to HSJ
September and October 2019