Bradgate Mental Health Unit: 'Promised changes' not made
The parents of a woman who died while in the care of a mental health unit have criticised managers after further failings were identified by inspectors.
Sally Ann Vye died after going missing from the Bradgate Mental Health Unit in Leicester last year.
In July, the Care Quality Commission (CQC) identified a number of continuing problems with patient care.
Leicestershire Partnership NHS Trust said it was working hard to resolve the issues.
The unit has seen 10 suicides since 2010. Inquests have highlighted repeated failings by staff.
During the latest inspection, it was found that some problems were caused because staff had not completed risk assessments.
In one case, the details of a patient with a history of alcohol misuse "who appeared to have had a drink" were not included in the risk assessment.
This meant the patient was able to continue on unescorted leave.'Dark few weeks'
Bradgate patient deaths
- Dione Brennan, 25, was being treated at the Bradgate Mental Health Unit when she fell from a Leicester multi-storey car park in May 2012.
- Kirsty Brookes, 19, was found hanged in a wooded area near a busy road in Leicester after escaping from the unit by climbing over an 8ft security fence.
- Sally Ann Vye, 39, from Melton Mowbray died at Beachy Head, Sussex in June 2012 after leaving the Bradgate Unit.
- Gagandip Singh Sandhu, 55, was a patient at Bradgate, and should have been accompanied while off the ward. He was found hanging from a tree in a park in 2011.
- Michael Coltman, 48, died at the Bradgate unit after hanging himself with a sheet.
The CQC report also found some paperwork which had been completed was unreadable because of the handwriting.
Following a public meeting with the trust on Thursday to discuss progress, Marilyn and Ron Vye said: "We were very disappointed that it was necessary to come.
"Changes that had been promised to have been brought about at the unit at Sally's inquest still haven't taken place."
The inquest into her death found that despite the known existence of a "real and immediate risk" to Miss Vye's life from self-harm, she was able to go missing.
She remained undetected for nearly eight hours due to not being properly observed in accordance with her needs, the coroner said.
Ms Vye, 39, died at Beachy Head, Sussex after leaving the Bradgate Unit.
The trust's acting chief executive Sue Noyes admitted "it had been a dark few weeks" following the inspection.
However, she said: "What I can assure people of is the commitment of the trust board, the executive team and all the staff to rectify this."
She added: "We fully accept the CQC findings, recognise the severity of this situation and are being transparent in all aspects of its response.
"This latest CQC visit reinforces that, while several wards have maintained good performance, this performance has not been consistently maintained across all wards at the unit."
The trust said it had already implemented a number of improvements following the CQC inspection, including reviewing in depth how each individual's needs and risks are assessed and documented.
It was also announced that Leicestershire Partnership NHS Trust was shelving plans for foundation status, which would have enabled the trust to control its own finances.
Zuffar Haq, from the Leicester Patients' Panel, said: "We do not have any foundation trust status hospitals in Leicestershire and it is a huge problem.
"We have a system that isn't working well and things need to improve - patients need to get a better service."