"Improvements needed" to prevent suicide by mental health patients in Coventry and Warwickshire

Health chiefs are not doing enough to prevent suicide by mental health patients in the district



The Care Quality Commission (CQC) says Coventry and Warwickshire Partnership Trust (CWPT) needs to make improvements after an inspection found concerns raised during previous checks had not been dealt with.

Locally the trust runs The Caludon Centre at University Hospital Coventry, Parkside House and Swanswell Point along with some 19 other sites.

Inspectors rated the overall service as ‘requiring improvement’ after they again found ‘ligature risks’ – places where patients could hang themselves – on mental health wards. The same risks were flagged up during an inspection in 2016, which trust bosses were told to correct but had failed to do so.

Following the most recent inspection the service was rated as ‘requiring improvement’ in safety, effectiveness, and responsiveness, but received a ‘good’ rating in the caring category.

Inspectors reported long waiting times for children and young people needing mental health services and those waiting to be diagnosed with autism.

They were also ‘seriously concerned’ 600 children and young people across Coventry and Warwickshire were waiting to have the urgency of their cases decided by mental health teams.

Inspectors added staff had not all been provided with specialist training to work on wards with older people and dementia patients, and staff were not monitoring patients’ physical and mental health closely enough. Many had also not been trained in the Mental Health Act, which covers the care and treatment of patients.

An acquaintance of mine has tried to take his own life twice in the last few months. It was plain to all and sundry he shouldn't have been discharged from hospital after the first attempt. I believe it then took a further 6 or 7 weeks to get him into a day care centre, but this last week even though under day care he tried again. The mental health system is broken.

Back in the 80s I worked at a secure asylum for a few weeks. It was an eye opener, but at least the facilities were there to help. Care in the community has been a failure, mainly because there is so little community support these days.

I can predict a surge in demand for these services too when so-called "Universal Credit" is rolled out across Coventry.

Failures led to death of mum-of-five died at Coventry mental health unit



A husband is calling for lessons to be learned after his wife died at Coventry's Caludon Centre.

Teresa Doherty, 43, was found in the bathroom of her room at by a member of staff at the mental health unit about an hour after she had last been seen in February 2016.

Teresa, originally from Ireland but moved to Nuneaton in 2014, was found to have asphyxiated.

An inquest concluded Teresa “died as a result of her own deliberate act” but it was not known “whether she intended that act to cause her death.”

Following the mum-of-five’s death her family instructed expert medical negligence lawyers at Irwin Mitchell to investigate her care under Coventry and Warwickshire Partnership NHS Trust, which runs the centre.

An NHS investigation found, four days before her death, staff had relaxed Teresa’s 15-minute observations to every hour.

The independent investigation also found that there was inadequate ongoing assessment and monitoring of Teresa’s mental health state during her stay, and no documented evidence of one-to-one support or planned therapeutic interventions.

Despite telling doctors "she wouldn’t think twice about ending her life" the day before her death, her observation period was not amended.

An inquest has now heard evidence of how Teresa spent her last few days, which included her revealing to doctors how she was hearing voices and that she did not want to hurt anymore.

Nonetheless, Teresa was kept under the same level of observations and was provided with no therapy or counselling sessions, the hearing was told.

Bina Patel, assistant coroner who sat with an 11-person jury recorded a narrative verdict, concluding Teresa “died as a result of her own deliberate act” but it was not known “whether she intended that act to cause her death.”