Acute Mental Health Units (Hansard, 22 April 2004)

§ Mr. Oliver Heald (North-East Hertfordshire) (Con)
I thank Mr. Speaker for allowing me to discuss this subject.
The concerns that I wish the Minister to address arise from the background to the tragic death of my young constituent, Tim Goff. Tim was 20 years old, a bright young man who had done well at Fearnhill school in Letchworth, in my constituency, and gone on to become a student at the university of East Anglia. At the beginning of September last year, Tim suffered his first serious episode of mental ill health, and was referred to the acute unit at Lister hospital in Stevenage. He was being kept under observation as a suicide risk. He died in the bathroom there, having hanged himself from a ligature point in the suspended ceiling. His parents were devastated. They are here today. I know that everyone will understand their sense of loss and their desire to ensure that this risk is dealt with to avoid such distress to other families. I hope that the Minister will join me in expressing condolences to the family.
After the tragedy, Peter and Susan Goff looked into the safety issue. They discovered that in 2001 both the Northern Ireland Adverse Incident Centre and the NHS in Scotland Property and Environment Forum had issued a clear warning to all trusts in their area of the danger of suicide posed by ligature points covered by suspended ceilings in psychiatric units. The information on which the notices were based appears to have come from NHS Estates, as indicated in the 2001 NIAIC report, which stated: Following a number of reports received by NHS Estates concerning suicides and attempted suicides by hanging where access to a point of ligature has been gained by the removal of ceiling tiles from a suspended ceiling, NIAIC issued Safety Notice … alerting … organisations of the … risks.
I understand that it is the statutory responsibility of the NHS Estates department to ensure that all alerts or warnings received from individual trusts or regions are passed on. I also understand that the warnings issued in Northern Ireland and Scotland were fully compliant with the procedure that requires information to be passed on to NHS Estates.
It has been confirmed to the Goffs that no warning was issued in England. Peter Goff has explained his feelings to me as follows: In September 2003 my son died as a result of an incident involving a ligature point behind a suspended ceiling in the bathroom of a psychiatric unit, while supposedly on observation as a potential suicide risk. Both his family as active carers and staff in the unit … who had a formal duty of care for him, assumed the physical environment in the bathroom posed 'no known hazard' when in fact NHS Estates had been fully aware of the risk posed by suspended ceilings for over 2 years … and had the responsibility for informing English Health Trusts.
He is particularly concerned that, despite representations, that still seems to be the case. On 1 March, the Goffs contacted me and wrote to NHS 525 Estates in Leeds. I wrote to NHS Estates in Leeds, too. The reply to me of 9 March from the head of engineering, Mr. Kerr, said: it is not appropriate for us to send you a copy of our response". However, Mr. and Mrs. Goff did receive a reply, dated 9 March, which they immediately passed to me. In it, Mr. Kerr says: Our guidance makes it clear that each individual body is responsible for carrying out its own risk assessment and deciding what action it needs to take in the light of that assessment to minimise and … eliminate risk. Each trust has a responsibility for ensuring a safe environment. He goes on to quote guidance on suspended ceilings in medium secure psychiatric units dated 1993, but the unit that we are concerned about is not a medium secure unit; it is an acute unit. He then indicates that guidance will be issued to the NHS "as quickly as possible".
Not unnaturally, the Goffs were not satisfied with that because the letter contains no explanation of how Scotland and Northern Ireland issued safety notices in 2001 but England did not. In further correspondence, Mr. Kerr of NHS Estates has had to admit that the 1993 document to which he referred is not an appropriate reference document in this context"; that the history was that, after receiving two reports of near misses, the Scottish authority issued a safety notice in June 2001 warning of the danger posed by ligature points under suspended ceilings; and that copies were sent to NHS Estates and to Northern Ireland. In Northern Ireland, they acted immediately, issued a notice and copied in NHS Estates, so NHS Estates was sent notices from Scotland and from Northern Ireland that were not acted on. Mr. Kerr's response is: Scottish Healthcare Supplies advise us that they forwarded a copy of their notice … to NHS Estates. A search of NHS Estates records has not identified receipt of the notice.
NHS Estates has no record of having received the NIAIC"—the Northern Ireland authority— safety notice". In a later phone call, Mr. Goff was told that the two documents must have been "lost in the post".
The questions for the Minister are as follows. Has a safety warning notice yet been issued to all trusts in England? How was it that the organisation responsible thought that a 1993 document about a different kind of unit covered the point? Is she satisfied with the procedures that are in place within NHS Estates to log all incoming post and to ensure that it is forwarded promptly to the official for action?
It seems that the Scottish and Northern Ireland notices would have been sent to the Medical Devices Agency of the NHS but that its procedure is that any notice that refers to a non-device matter is routinely destroyed. Is that a sensible policy? Would the Minister care to comment on that? Can she explain how the Scottish notice explains that it was following a number of reports received by NHS Estates that the Scottish notice was issued, whereas NHS Estates denies all knowledge of such incidents? Is she happy with the systems in place for the dissemination of best safety practice between acute mental health units in England? Will she instigate a full investigation into the 526 issuing of safety notices and the procedures to be adopted, so that we can ensure that these problems are addressed?
Finally, does the Minister understand that, for Mr. and Mrs. Goff, the key issue is to ensure as far as possible that others do not suffer such tragedy and that a first incident of serious mental ill health should not lead to a death?

§ The Minister of State, Department of Health (Ms Rosie Winterton)
I congratulate the hon. Member for North-East Hertfordshire (Mr. Heald) on securing the debate. He is absolutely right to raise in the House the tragic case of his constituent. I should like to offer my very sincere condolences to the family of Tim Goff who, as the hon. Gentleman mentioned today, died in hospital while an in-patient at Lister hospital in September last year. His family has my heartfelt sympathy.
As the hon. Gentleman said, Mr. Goff was admitted on 15 June last year as an informal mental health patient to the Lister hospital. On 6 September last year, tragically, he committed suicide. Let me emphasise that both the hospital and the Department of Health need to learn from serious incidents such as this.
It might be helpful if I set out the actions carried out by Hertfordshire partnership trust since this tragic incident. There is a detailed protocol to be followed in the event of a serious incident, which initially requires a detailed local clinical review into the circumstances of the incident. This was carried out by Hertfordshire partnership trust and was completed on 15 October 2003. It recommended a higher level in-depth inquiry, so a panel review has been set up.
The panel review, which is ongoing, includes an independent expert consultant psychiatrist, and has terms of reference that have been agreed between the trust and, I am assured, Tim Golfs parents. In particular the panel has been asked to identify lessons that could reduce any risk for patients in the care of the trust and to make recommendations about how that can be achieved.
I am aware also that an inquest has been opened into Mr. Golfs death and has been adjourned while the coroner investigates further. In addition, Hertfordshire partnership trust has responded by undertaking a review of its own observation policy within the trust services and intends to implement the recommendations. All recommendations coming out of the inquiry and the inquest will be carefully considered to ensure that lessons are learned.
The hon. Gentleman has referred to the issue regarding the alert notice sent out by Scotland and Northern Ireland in 2001 regarding suspended ceilings. This alert focused on suspended ceilings and ligature points and instructed chief executives to ensure that the alert was brought to the immediate attention of staff to take appropriate action to make safe unsupervised areas with such ceilings used by patients considered to be at high risk of suicide.
The hon. Gentleman is right that NHS Estates believes that it did not receive the alert. Thanks to the work of Mr. and Mrs. Goff and the hon. Gentleman, NHS Estates has now been made aware of the alert and, on 18 March, the relevant alert was sent to trusts in England.
527 Obviously, I want to make sure that best practice is disseminated between departments so that prompt action can be taken. I can assure the hon. Gentleman that as a result of this incident we are reviewing the protocol to ensure that everything is being done so that when there are such alerts they are communicated as quickly as possible. That will mean that many of the questions that he has raised—such as why the incident happened and why the alert was not sent out immediately—can be considered as part of the review of our protocols. In addition, as part of our consideration of how we can share best practice in the way that the hon. Gentleman discussed, NHS Estates will be part of a safety alert broadcast system throughout England, so that we can do everything that we can to promote safety throughout the health service.
As part of our wider commitment to ensuring patient safety, we created the National Patient Safety Agency in July 2001 to enable us to co-ordinate the entire country's efforts in reporting and, more importantly, in learning from mistakes and problems that affect patient safety. The system that we had until recently was effective in making sure that local inquiries were carried out and local lessons learned, but we want to have a robust system that can ensure that when local inquiries have reported, their reports are gathered together at central level. We can then examine those incidents and send information from them back to local areas, ensuring that lessons are learned from incidents such as this one. Instead of lessons perhaps remaining at local level, we can then ensure that there is proper national consideration of what has happened.
The National Patient Safety Agency has already identified patient safety in acute mental health settings as a priority area in its mental health programme. We will be launching a major initiative on that in May. Its aim will be to reduce the risk of suicide, self-harm, violence, aggression, racial harassment and abuse. I can assure the hon. Gentleman that as part of that initiative we will certainly look at what can be learned from the incident that he has brought to our attention.
The National Patient Safety Agency has also developed a national reporting and learning system to promote comprehensive national learning about safety incidents. That is part of the need that I mentioned earlier to provide a way of gathering information so that it can be put together centrally. We can then provide feedback on the services provided and identify the issues that need to be considered. Officials from the National Patient Safety Agency are meeting NHS Estates and other experts specifically to discuss ligature points.
To ensure safety, it is obviously vital that in-patient units where the most vulnerable in our society are cared for are safe, therapeutic and supportive. That of course includes doing everything that we can to reduce the risk of suicide. We in the Department of Health strongly support the national confidential inquiry report into suicide and homicide by people with mental illness. That inquiry and its recommendations are crucial to gaining a 528 better understanding of the circumstances surrounding suicide when people are under the care of our mental health services.
The National Institute for Mental Health in England recently published an audit toolkit to help local services to measure progress in implementing the recommendations of the inquiry report. We also recognise the importance of the physical environment in providing psychiatric in-patient care, and we are committed to a programme of modernisation, backed up by substantial investment, so that we can improve psychiatric wards and in-patient care.
However, there is no doubt that we need to do more to review the physical environment of in-patient settings, and to make the necessary changes in order to reduce access to the means of suicide, and to avoid tragedies such as the one we are debating today. I can assure the hon. Gentleman that we will continue to make this a priority by looking at the physical environment and at the improvements that we need to make within psychiatric in-patient settings.
It is very difficult to find the right words to give comfort in such tragic situations, but I hope that the hon. Gentleman and Mr. and Mrs. Goff in particular will accept that I am very aware of all that they have done to ensure that we in the Department of Health are aware of what happened and can learn lessons from it.

§ Mr. Heald
It is clear that a lot of activity is going on that, one hopes, will lead to results. One concern is that the logging of the post coming into NHS Estates from Northern Ireland and Scotland seems not to have been effective in ensuring that the documents from the two authorities made their way to the relevant official, and that the safety notice was then issued. Will the office procedures of NHS Estates be improved? Such a reassurance would give us some comfort that if an incident in another part of the United Kingdom gives rise to concern in future, NHS Estates will know about it and be on to it, and action will be taken.

§ Ms Winterton
The hon. Gentleman is right to say that we need to look at the system for logging such information. As I said, we intend to examine the protocols for exchanging information, which will include considering how notes are logged, and ensuring that they are not destroyed if a time lapse occurs. The matter is under review, and I undertake to write to the hon. Gentleman—who can in turn contact Mr. and Mrs. Goff—about the arrangements that we can set in train to ensure that such information is properly logged and passed on to the relevant person.
I repeat my tribute to the work undertaken by Mr. and Mrs. Goff to ensure that we learn lessons from what has happened. I can assure them and the hon. Gentleman that I undertake to do all that I can to support their work, so that, as the hon. Gentleman said, we can avoid such tragedies in future.