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Alarm at under-reporting of serious incidents at two mental health units


The Tyrone and Fermanagh Hospital

The Tyrone and Fermanagh Hospital

The Grangewood unit in Londonderry

The Grangewood unit in Londonderry

The Tyrone and Fermanagh Hospital

A Northern Ireland health trust has been heavily criticised by a watchdog body after it identified failings in the way adverse incidents and 'near misses' were recorded at two acute mental health facilities.

The Western Health and Social Care Trust said it would take on board the findings of a report by the Regulation and Quality Improvement Authority (RQIA) into services at the Tyrone and Fermanagh Hospital in Omagh and Grangewood in Londonderry.

On Monday the RQIA issued a notice of improvement to the trust, requiring it to undertake an urgent review of the information in its Datix system and to take action to address and mitigate specific patients risks.

The move came after the RQIA said its concerns about the recording of adverse incidents, some dating back as far as 2016, had not been properly addressed.

Meetings between the regulatory body and trust senior officials were held following unannounced inspections of Tyrone and Fermanagh's Beech Ward in September of 2016, and the Carrick and Evish wards of Grangewood in September 2017.

Inspectors had found evidence of under-reporting of serious adverse incidents (SAIs), as well as a failure to debrief and learn from such incidents.

Despite receiving assurances from senior trust officials at meetings after that inspection, that procedures would be reviewed and robust mechanisms implemented, a further multi-disciplinary inspection across the Western Trust's acute inpatient wards in June of this year - which included the Lime and Elm wards in Tyrone and Fermanagh - identified concerns with regard to the recognition and management of SAIs and near misses.

"We identified incidents which had been incorrectly categorised in the trust's Datix system and thus had not been appropriately escalated within the trust", the RQIA report stated.

"We discussed our concerns with senior trust representatives at a meeting on July 10, 2019. We received limited assurance regarding the actions in progress by the trust with respect to recognition and management of adverse incidents and near misses."

After receiving additional information following that high-level meeting, the RQIA ruled that the system for identifying and managing adverse incidents and near misses across the Directorate of Adult Mental Health and Disability Services in the Western Trust was "not sufficiently robust".

Sinn Fein's spokesperson for mental health, Orlaithi Flynn MLA, said she will be seeking a meeting with the trust to discuss the RQIA's concerns.

"It is deeply concerning that the regulator has found the Western Health and Social Care Trust to be failing to meet the minimum standards for ensuring the safe and appropriate management of risk within mental health and learning disability services," she continued.

"The under-reporting of incidents and not escalating incidents as appropriate will cause some distress to patients, their families and carers.

"It is vital that systems are in place to support a culture of learning that ensures patients receive the highest possible standards of care.

"Unfortunately, it appears this has not been the case within the Western Trust mental health and learning disability services with regards to learning from previous adverse incidents."

Meanwhile, advocacy group NI Patient Voice said it was "unacceptable" that the RQIA should need to "repeatedly flag" such issues to a health trust.

"Some of the issues raised by the RQIA, following inspections of the Tyrone and Fermanagh and Grangewood hospitals, were highlighted in 2016 and 2017," said group spokesperson Aidan Hanna.

"It is unacceptable that it takes the RQIA to have to keep reminding a health trust to look at how they manage and record potentially life-threatening incidents. Where is the accountability here?"

A spokesman for the RQIA confirmed it had issued the improvement notice to the Western Trust.

"This action has been taken with a view to improving the quality and safety of care across the Directorate of Adult Mental Health and Disability Services in the trust. RQIA requires the trust to achieve compliance with this notice by October 22, 2019," he added.

Meanwhile, a Western Health and Social Care Trust spokesperson said: "The trust is working with RQIA to address the recommendations. The trust is fully committed to continuously improving how we recognise and report risks within our services, capture trends and patterns and use this information to improve the services we provide.

"Looking at how we record, report, review and evaluate incidents and their trends is fundamental to providing high-quality care going forward.

"As a trust we are committed to listening and learning so we can improve our practices... we will use the findings of the independent inspections and take the learning on board to develop an improvement plan to address the issues of incident reporting for adult mental health and disability services in the trust area."

Belfast Telegraph