Coventry mental health hospital rated inadequate after two people die

Care on the ward where the deaths occurred 'was not safe'



A Coventry mental health hospital has been rated inadequate after two people died on one of its wards.

A number of other serious issues were raised in the report published today (November 1), which is from the July inspection at the Cygnet Hospital in Hillfields.

The report found the two deaths on the same ward - Dunsmore - were linked to a failure by staff to carry out patient engagement and observations correctly.

As well as the deaths, another patient almost died from self-harm, in which it was found there were high levels of patients harming themselves on the same ward.

Wards at the female only hospital were not clean with dirty fridges and soiled furnitures. The seclusion room on one ward was also found to be foul smelling, had bodily fluids on the outside of the toilet and drinks stains on the walls and ceiling.

Inspectors also found out of date medicines and missing entries in records to show whether checks had been carried out on the emergency resuscitation equipment.

A summary of the report's findings said that particular problems arose due to other patients who posed a risk. It was also said there was a lack of one-to-one support.

When asking if the services were 'safe', the report found care on both the Dunsmore and Middlemarch wards were not and this was to do with lack of permanent staff, areas that weren't clean and other patients having to look after each other.

The Dunsmore ward did not have a good track record on safety, inspectors found.

There had been two deaths on the ward, one which could have been avoided and another patient almost died from self-harm.

Both deaths and the near miss were linked to a failure by staff to carry out patient engagement and observations correctly. There were high levels of patients harming themselves on the ward.

Staff assessed risks to patients and themselves well but struggled to anticipate, de-escalate and manage challenging behaviour because there were not enough regular staff to build relationships with patients.

Mental health ward was closed after deaths linked to failures by staff

A ward at a failing mental health hospital was closed after a damning report found that two deaths were linked to failures by staff.

A report into the Cygnet Hospital published by the CQC in November found that two patient deaths on the Dunsmore Ward were linked to failures by staff to carry out patient engagement and observations correctly.

Now it has been revealed that the ward was closed after enforcement action was taken by the CQC.

Admissions were also capped on the other wards at the hospital at the same time.

Cygnet Hospital, in the Hillfields area of Coventry , was rated inadequate after a visit from the CQC in July.

When the report was published in November, a spokesman said that ‘significant steps’ were undertaken as soon as concerns were raised and that a ‘comprehensive action plan’ agreed with the CQC had been implemented.

Cygnet Hospital added then that restrictions on three wards had already been lifted, and there had been major improvements underway in co-ordination with the CQC to re-open a further ward.

The CQC took immediate enforcement action and placed conditions on the provider’s registration after the inspection in July.

This included closing Dunsmore Ward and capping admissions on other wards.

The initial report was published in November – but this didn’t state what enforcement action had been taken.

This was confirmed when a new version of the report was published on December 24.

The delay is because the CQC only publishes information about enforcement action once any representations and appeals processes are complete.

Cygnet hospital to close temporarily for "transformation" of service

A Coventry mental health hospital is closing down temporarily – with a view to reopening to provide a new and better service.

It comes after major staffing concerns were raised by the CQC following a new inspection of the troubled Cygnet Hospital in Hillfields.

The service was rated inadequate by the CQC in a report published in November.

It came after two deaths on the Dunsmore ward, which were linked by inspectors to a failure of staff to carry out patient engagement and observations correctly.

Inspectors once again visited the hospital in an unannounced inspection. The service was not given a new rating because it was a focused inspection to check specific concerns that patients and relatives had raised with the CQC.

But now, hospital bosses have confirmed that the service will be “changed”. This means that all patients are being transferred out of Cygnet Hospital.