PERFORMANCE: The trust rated the risk of an “inability to manage suicide risk on inpatient wards” as 16 out of a possible 25
The rating system applies scores by multiplying likelihood and severity of incident scores, which range from one to five.
The trust’s May papers also gave itself a risk rating of 16 for “failure to meet medium secure standards” and 15 for “ligature risks in inpatient settings”.
The trust’s risk-rating policy describes a “likelihood” measure of four as something where “It is only a question of time before significant impact or harm occurs.”
The risk-rating document said a score of four applies when: “Practices and processes are limited and/ or ineffective [and] resources are not always available when required.”
It can also apply where an incident or “near miss” has already occured and “Practices and processes have been checked, have been found to be limited and are considered unlikely to prevent situation from recurring. [Or where] audit and/ or incident investigation routinely finds root cause of incident(s) to be shortcomings in practices and processes.”
A red-rated score of 15 was also recorded for WLMHT’s “Systematic failure leading to homicide”.
A spokesman for the trust said: “The ratings used in our risk reports are determined partly by likelihood but also by the relative impact of such events if they actually occurred. The risk register process is a vital tool which supports us to manage and monitor risks so that patients, staff and the wider public remain safe.
“The events have the potential for high impact and therefore carry an appropriately high rating. It does not follow that these events are therefore likely to happen. However the high rating ensures that the board is aware of these potential risks and, crucially, of the numerous actions that are in place to reduce and manage these.
“Some of the key risks, which relate to suicide on wards, ligature risks and compliance with standards for medium security, are all rated high because of challenges we face due to ageing buildings. It is for this reason that we plan to redevelop our secure services on the St Bernard’s site in Ealing, and have in place a range of training, policies and procedures to manage these risks, as well as a programme of smaller scale local environmental improvements.
“The ratings do not mean that disaster is imminent, but show we have acknowledged the risks and potential consequences and have measures in place to manage them as much as possible and to monitor each area closely.”
In July 2009 the CQC made nine recommendations to WLMHT after a year-long investigation of quality standards the Trust.
A statement from the regulator released with its July 2010 report said: “The original report highlighted delays in investigating incidents and a failure to learn from common themes documented in action plans.
“This was followed up by an inspection completed in March of this year, involving interviews with people who used services, staff and board members, and a review of documented evidence. This inspection found that the trust had made improvements in the assessment of physical health care, the reporting, investigating and communication of risks, the provision of primary care services and cleanliness of wards.”
But it found continuning issues with “care planning, improving communication between staff and people who use services and demonstrating that lessons learnt are shared across the whole trust”.