Another inquest for a death in a private mental hospital – why do we even have private hospitals?

 

On 11th June 2019 Brooke Martin, who was 19, was found suspended from a ligature point in her bedroom at Chadwick Lodge Hospital run by Elysium Healthcare. She had diagnoses of Autism and Emotionally Unstable Personality Disorder and had been detained under s.3 of the Mental Health Act. The inquest ended on 1st July 2021.

The solicitor for her family stated that the inquest had revealed “stark failures in risk assessment, information sharing and observation setting in a mental health hospital dealing with an exceptionally vulnerable patient group.”

The inquest heard that only 5 days before her death she had tried to hang herself, but this incident was not properly recorded or communicated with staff and there was no risk assessment or review of her observations. Earlier that evening Brooke was twice found by staff to have something that could be used as a ligature which she had concealed under her duvet. No action was taken as a result of this that could have protected her.

Elysium Healthcare admitted that had they taken appropriate action, Brooke would not have died.

Elysium Healthcare was founded in 2016 and is owned by BC Capital. They bought up several mental health hospitals, mainly from the Priory Group and Partnerships in Care.

For the year ended 2019 Elysium reported a turnover of over £74 million. This came predominantly from either NHS England or Clinical Commissioning Groups – in other words, public money that would otherwise have been spent on services within the NHS.

A couple of weeks ago I reported on the death of Peggy Copeman, who died in a private ambulance on the hard shoulder of a motorway, while being transferred from the Cygnet Hospital in Taunton, another private hospital. She was allowed to leave the hospital despite her being “the most poorly patient on the ward”.

Another major provider of private mental health beds is Priory Healthcare.

In 2017 the Priory Roehampton was rated “inadequate” by the CQC, and there had been little improvement when it was inspected a few months later.

Priory Healthcare also owns St John’s House in Suffolk. This is a specialist unit providing a low and medium secure environment for men and women with learning disabilities. They are all detained under the Mental Health Act.

In December 2020 it was placed in special measures, after a CQC inspection saw CCTV footage showing "a patient being dragged across the floor... a patient being pushed over and the seclusion room door trapping a patient's arm and making contact with a patient's head when closed". On five occasions staff were asleep when they should have been completing patient observations. There was low staffing, with a heavy dependency on agency workers, poor record-keeping and 204 instances of physical restraint in a six-week period.

A subsequent inspection in April 2021 discovered that many issues causing concern “remained unchanged”.  They again found staff were asleep when they should have been observing patients, including all three members of staff assigned to one patient. The CQC said "Our latest inspection found the overall quality of care had not improved and many of the issues we previously raised remained unchanged."

You might think that private psychiatric hospitals would offer levels of care superior to NHS hospitals, since isn’t that what you would expect if you were paying for care and treatment? But frequently the reverse is the case.

A Guardian report from 5th July 2021 revealed that there were 23,447 NHS mental health beds in 2010-11 but only 17,610 in 2020-21, a reduction of 5,837 (25%). This is in spite of the fact that there has been a 21% increase in people involved with mental health services since 2016,  and an increase of 53% of people being detained under the Mental Health Act, 13,437 in March 2016 to 20,494 in March this year. This has inevitably led to a huge increase in people being admitted to out of area beds – this being a euphemism for “private hospitals”. These beds are frequently over 100 miles away.

In March 2021 alone the NHS spent £11.5 million on funding out of area placements.

These private placements can be enormously expensive. As Keir Harding, who has long been a champion of improving servicers for people with personality disorder, has pointed out, a locked rehabilitation unit claiming to be a specialist personality disorder unit will charge around £250,000 a year per patient.

For over 10 years, the Conservative Government has tampered with the NHS and services for people with mental health needs, weakening or destroying effective community based services, cutting funding to local authorities, who are responsible for social care, and forcing the increased use of private hospitals.

You can reduce the numbers of psychiatric hospital beds, or you can cut back on community services, but if you do both, it won’t save money, it will simply put pressure on other public services, such as A&E departments, the courts, and the police and ambulance services. Most importantly it creates misery for people who are denied the care and treatment they need, forcing them into avoidable and traumatising situations.

One example of this is the now discredited Serenity Integrated Mentoring (SIM) scheme, which many areas have been introducing (without any significant evidence of efficacy) as a means of managing people with emotionally unstable personality disorder who appear to be disproportionately coming to the attention of A&E, police and ambulance services. Rather than offering a therapeutic approach to dealing with their distress, the outcome is often to criminalise people and if anything to increase their distress.

Private, for profit, hospitals should have no place in the effective provision of mental health services. The only solution is reinstating proper funding for health and social care. The new Health and Social Care Secretary, Sajid Javid, has an opportunity to rectify this. As MarkTrewin recently said in Community Care:

"We have a new Secretary of State who has the opportunity to put right some of the mistakes of the past. Let’s have a social care reform plan before the end of this year that is creative and radical, that includes mental health, younger people and autism and that is designed with people who use services to genuinely improve the lives of all those people with mental health issues currently struggling within the system, and the hard-working professionals who work with them."

The Peggy Copeman Inquest and what it says about Mental Health Services

 

This is a special post looking at the implications of the Peggy Copeman Inquest, which concluded on Friday, 25th June 2021.

Peggy Copeman died in a private ambulance on the hard shoulder of the M11 on the 16th December 2019, while being transferred between hospitals while detained under the Mental Health Act. This is what happened.

Peggy was 81 years old, and had been a resident in a care home in Norfolk. She had a long standing diagnosis of schizophrenia. A request for an assessment under the Mental Health Act was made when she appeared to be experiencing a significant deterioration in her health. She was refusing medication, food and drink and acting out against staff - actions described as "out of character". 

She was assessed on 11th December, but the Norfolk and Suffolk Mental Health Foundation Trust had no beds available, and arranged for her to be admitted to the Cygnet Hospital in Taunton, a private hospital 280 miles away.

The admission took place by private ambulance on 12th December.

While at the Cygnet hospital, she was diagnosed with a urinary tract infection and received treatment. On 15th December it was reported that she appeared dehydrated and was described as sunken, pallid, and having a dry mouth. There were concerns about her fluid intake. A nurse reported "She was the most poorly patient on the ward."

Nevertheless, the NSFT arranged for her to be transferred back to Norfolk when a bed became available a few days later, and a private ambulance service, Premier Rescue, provided transport on 16th December.

Despite her age, frailty, and physical ill health, a Ford Transit van with a crew of 3 was sent.

The driver said : "I was shocked at how old she was. I have not transported anyone of that age before. The patients we deal with are young and more spritely." He added that they had to "practically lift her in" to her seat.

After 2 hours, the transport stopped at a Motorway Services and Peggy was asked if she'd like a coffee. However, she only responded by groaning.

Undeterred, they continued on their way until the driver heard a noise "so loud I thought there was something caught under the car." He was told it was Peggy snoring. The other staff then noticed mucus coming out of her nose, and at this point they pulled onto the hard shoulder of the motorway, and Peggy then took her last breath.

It was reported that initially they contacted the Cygnet for advice and were told to ring 999. By the time an emergency ambulance arrived, Peggy was dead.

Dr Khalid Khan, a cardiology expert, said that in his view the ambulance staff had failed to recognise the Peggy was in respiratory or cardiac distress and she had "effectively died whilst sitting between them". He thought that they did not act promptly in calling emergency services in a "reasonable or timely matter". He concluded that her life may have been saved had a defibrillator been on board.

It was revealed that none of the ambulance staff had any medical training, with one member trained in CPR, and another shadowing.

The Coroner Jacqueline Lake, in a narrative statement concluded: "Peggy Copeman died from a fatal ventricular arrhythmia as a result of ischaemic heart disease. 

"Her death has been escalated by a short time by not being recognised and acted on whilst being transported on December 16 2019."

She said that evidence suggested Mrs Copeman would not have survived a hospital discharge but said that  the use of a defibrillator may have allowed her family to see her and "say their goodbyes and for her to die in an appropriate and dignified setting."

This tragic case highlights all that is wrong with the current state of mental health care.

All the services involved failed in their duties. The Cygnet Hospital failed to make a proper physical assessment of Peggy's ability to survive a journey of 280 miles. The private Premier Rescue Ambulance Service did not supply a suitable ambulance or properly trained staff.

But ultimately her death in such appalling circumstances could have been avoided if only the Norfolk and Suffolk Foundation Trust had had enough suitable beds to meet needs.

The NSFT has been in special measures since 2017, with little sign of any significant improvement. Several years ago it closed all the beds in King's Lynn for older people, meaning the only beds for older people in Norfolk are in Norwich, even though demand for beds has increased during that time. It has half the average number of beds for older people, despite it serving an area with an ageing population. In the year 2019-20 alone it spent £7 million on out of area beds.

However, the problem is much deeper and more intractable. This dire state of affairs has been made possible by the massive national cutbacks in funding for mental health services and the NHS in general, and the encouragement by stealth of privatisation in the NHS and the creation of an internal market through dividing the NHS into Trusts.

An example of this is the creation of regional ambulance trusts, who then contract with Clinical Commissioning Groups to provide services. These contracts can often be arbitrary and not reflect the actual needs. One example was that of the East of England Ambulance Trust, who would happily transport a patient detained under s.136 to a Place of Safety, but once that person had been assessed and a decision made to admit them to a hospital, that subsequent journey was not covered by their contract.

Having worked in statutory mental health for going on 40 years, I know that in the past local ambulance services would if necessary take a patient to a hospital anywhere in the country. The East of England Ambulance Trust, which covers Norfolk and Suffolk, will not transport patients outside the area covered by the Trust, meaning that AMHP services and the NSFT are reliant on private ambulance services to do this. Although all private ambulance services have to be approved by the CQC, those using them have little control over the quality of the service provided.

Private hospitals are another area where vast amounts of NHS money are spent, for often very poor services.

St Andrews Healthcare is a good example. It has, among other hospitals, a vast psychiatric hospital in Northampton with over 650 beds. Its annual report for 2019-20 states:

St Andrew's receives almost all of its income from NHS commissioners... Our single biggest source of such funding is NHS England... Our other main source of funding is the Clinical Commissioning Groups who commission our services for their patients with complex needs.

NHS England reported that it had directly purchased £294,796,282.22 of services from St Andrews Healthcare over the period January 2014 to July 2017. 

In February 2018 St Andrews Healthcare Northampton was rated by the CQC as “inadequate”.

Then there's Priory Healthcare. They are probably best known for providing drug and alcohol detox programmes for high profile celebrities, but it is one of the biggest private mental health care providers in the country. In 2017 it had an operating profit of £2 million.

In December 2020, the Priory Group was sold to a Dutch private equity company for £1.08 billion.

On 17.04.19. the Priory Group was fined £300,000 over the death of a 14-year-old girl, Amy el-Keria, in their hospital in Ticehurst, East Sussex, in 2012. Amy had a recent history of self-harm and suicide attempts and was found hanged in her room, a room that had been assessed by an untrained staff member to have “medium risks” with a number of ligature points, but this assessment had not been followed up. There was a catalogue of poor and negligent practice. Staff did not promptly call 999 or a doctor and were not trained in CPR. The hospital’s lift was too small to accommodate the ambulance service’s stretcher. Nobody from the hospital went with Amy in the ambulance.

Sounds a bit familiar, doesn't it?

I'd like to think that Peggy's death will lead to national changes to the provision of mental health care. But I doubt it.

What’s the point of private psychiatric hospitals?

Once upon a time, in a galaxy far far away…

Once upon a time (about 20 years ago) NHS psychiatric hospitals had enough beds for anyone who needed to be in hospital. Indeed, often, the local unit I admitted to would frequently have a 10% under occupancy rate. This meant that imaginative uses could be put to these beds, such as brief respite admissions or even allowing patients to contact the hospital themselves to ask for admission as part of a crisis care plan.

It was exceedingly rare for beds (other than some specialist beds such as eating disorder units) to have to be obtained from out of area, in which case, one or two moderately local private hospitals would be used. Patients would then be brought back into the locality NHS hospital within days.

Back then, private hospitals were almost exclusively used by private patients who were well off enough to have private health insurance.

I recall working with a patient back then who was admitted privately under s.2 . He was experiencing an acute psychotic episode.

His parents, who were extremely wealthy, arranged for him to see a private psychiatrist. This psychiatrist, who was also a locality NHS psychiatrist, assessed him and concluded he needed to be detained. As he also worked part-time for the private hospital, he arranged for admission there.

The patient appealed, and I provided a social circumstances report and attended his Mental Health Tribunal.

In preparation for this, I spoke to the psychiatrist who had seen him. He told me that he was referring him to our local CMHT psychiatrist, and would not continue to see him privately. This was because “I only see private patients if there’s nothing seriously wrong with them.”

I am using this story to illustrate the difference back then between NHS and private psychiatric hospitals: NHS hospitals admitted “proper” patients, while private hospitals concentrated on anyone who could afford to pay, whether there was anything significantly wrong with them or not.

I know this is an appalling generalisation, but there is at least an element of truth there.

But over the last 10 years in particular (is it a coincidence that this has been during the Coalition/Conservative period of austerity? I think not) all this has changed. As NHS hospital beds have been cut back and cut back, there has been a corresponding vast increase in the use of private hospitals by NHS Trusts, at enormous expense.

While there may be a case for seeking specialist beds in private hospitals, for example, for eating disorders, most of these private beds are simply for acute adult admissions.

The most recent statistics for detentions under the MHA give a breakdown of those detained in NHS psychiatric hospitals and those detained in independent hospitals. Independent hospitals are hospitals either run for profit, such as the Priory Group Hospitals, or operated by charitable trusts, such as St Andrews Healthcare.

On 31st March 2018 there was a total of 15,918 patients detained in hospital. Of these, 12,555 were in NHS hospitals, while 3,330, or 21%, were in independent hospitals.

Are independent hospitals any good?

One might expect private hospitals to be able to provide exceptional care, since they are privately funded (or are they? I’ll come to that).

It’s not necessarily been my experience.

One incident concerns an extremely unwell and psychotic patient who was admitted from the community under s.3 to a private hospital. She was there for about a week when I received a call from a nurse on the ward. She told me that the patient had absconded 3 days earlier, and wanted to know if, as she was no longer in hospital, she could be discharged from s.3. The hospital had made no effort to inform the police, or even bother to tell me as the care coordinator at the time.

Who funds private and independent hospitals?

St Andrews Healthcare’s annual report for 2016-17 states that NHS England is its biggest source of funding.  It says: “The Charity receives essentially all its income from NHS entities.”

NHS England reported that it has directly purchased £294,796,282.22 of services from St Andrews Healthcare over the period January 2014 to July 2017. 

In February 2018 St Andrews Healthcare Nottinghamshire was rated by the CQC as “inadequate”.

The National Health Executive reported:

Staff at the hospital did not adhere to the Mental Health Act Code of Practice when using seclusion, and staff allowed patients on one ward to vote on whether to end or continue other patients’ seclusions.

Inspectors identified several potential ligature anchor points, placing patients at risk with out of date risk assessments – contributing to the CQC’s assessment that “staff did not protect patients from avoidable harm or abuse.

Patients told the inspectors that, on some wards, staff ignored them and did not respond to basic requests, such as for going to the toilet and for food and medicine.

St Andrews Healthcare is not the only organisation providing psychiatric inpatient care that obtains large amounts of NHS money. In fact, it has been my experience that most private hospitals are very keen to take money from the NHS for patients.

One example is a private hospital that will only consider the admission of an NHS patient if it can be guaranteed that the patient will remain with them for at least a month. This seems to fly in the face of the principles of the MHA which stresses that detention should not last longer than absolutely necessary.

I am also aware of the case of a 15 year old child with a diagnosis of Obsessive Compulsive Disorder and Autism who was detained under s.2 in a general hospital because of problems over low weight. He was assessed by the eating disorders service who concluded that he did not have an eating disorder, but needed a specialist bed for his OCD and autism. Instead, he was placed in a private eating disorders specialist unit.

The unit requested detention under s.3 for treatment. His care coordinator, who was also an AMHP, assessed him with a 2nd s.12 doctor. They both concluded that the patient did indeed not have an eating disorder, and therefore treatment in an eating disorder specialist unit could not be justified. As he was agreeing to remain as an informal patient, the s.2 was allowed to lapse.

The unit continued to treat him for an eating disorder, and wilfully downplayed his actual mental health problems. But they were very reluctant to allow him to be moved on.

And one final anecdote. This concerns a 16 year old girl who was detained under s.2 in a private hospital. Her care coordinator arranged for her to live in special accommodation in her home area in order to attend 6th form college. Her community psychiatrist was fully on board with this. However, the hospital psychiatrist refused to discharge her from her section, so she lost her accommodation and could not start her course.

You’d be forgiven for thinking that the reasoning behind this refusal was more to do with financial considerations that the needs and welfare of the patient.

The Priory Group

The Priory Group is probably best known for providing drug and alcohol detox programmes for high profile celebrities, but it is one of the biggest private mental health care providers in the country. In 2017 it had an operating profit of £2million.

On 17.04.19. the Priory Group was fined £300,000 over the death of a 14-year-old girl, Amy el-Keria, in their hospital in Ticehurst, East Sussex, in November 2012. Amy had a recent history of self-harm and suicide attempts and was found hanged in her room, a room that had been assessed by an untrained staff member to have “medium risks” with a number of ligature points, but this assessment had not been followed up. There was a catalogue of poor and negligent practice. Staff did not promptly call 999 or a doctor and were not trained in CPR. The hospital’s lift was too small to accommodate the ambulance service’s stretcher. Nobody from the hospital went with Amy in the ambulance.

And if you’re thinking that the Priory Groups private patients might be treated with more respect, consider the recently reported case of PB v Priory Group Ltd [2018] MHLO 74. I am grateful to Matthew Seligman of Campbell-Taylor Solicitors (solicitors for the claimants) for summarising this truly disgraceful case.

As a private patient PB attended an outpatient appointment at the Priory Hospital (North London) in September 2018. In the first 15 minutes of the consultation she was told that she was being detained under s.5(2) MHA. She ran out of the room, but was prevented from leaving and was admitted to a ward.

Readers of this blog will probably now be exclaiming, “But s.5(2) only applies to inpatients! It can’t be imposed on someone merely visiting a hospital!”

You’re absolutely right.

To add insult to injury, the person’s husband, who had also attended the appointment, had to make an immediate down payment of £10,626 on his credit card, as the Priory charged £834 per day.

She was then detained in hospital for a total of 17 days. This included 72 hours under the illegal s.5(2), which was allowed to expire without assessment for s.2, meaning she was detained for a further 7 hours without any form of legal authority, until an application under s.2 was finally made. She was eventually discharged by the hospital psychiatrist on 17th October 2018.

To make things even worse, if that’s possible, the hospital then pursued the couple for outstanding fees of £3,000. I assume that they felt this was more than a step too far, because the patient and her husband then brought proceedings against the hospital, claiming damages for the whole period of the wife’s stay for unlawful detention and breaching her human rights under Article 5. The couple accepted an offer of £11,500 plus legal costs.

Despite these horror stories, I am not suggesting that all private psychiatric care is poor, and in fact I have a lot of experience of very good, humane, patient centred treatment from some private hospitals.

But I will question why the NHS is spending so much more on private psychiatric provision, when it does not even guarantee an acceptable level of care.

NHS psychiatric beds should be available for NHS patients when needed. The Government should be providing sufficient funds for the NHS to be able to ensure this.

Private psychiatric hospitals should only be required for patients who want to pay for their private care.