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'Systemic failures' at Bethlem Royal Hospital in Beckenham
INVESTIGATIONS into serious incidents at the Bethlem Royal Hospital have identified “systemic failures” by staff.
The first independent review was commissioned by South London and Maudsley NHS Foundation Trust, which runs the mental health hospital in Beckenham, after four teenage boys absconded from the adolescent unit.
And the second was ordered after two separate but related incidents at the medium secure unit River House on the night of October 1 last year.
On the night patients from Norbury Ward besieged the nursing station in Spring Ward and made threats to kill and rape staff.
The review panel found there are excellent policies in place in the unit but these are not always carried out very well.
According to the report, the attitude and behaviour of some of the staff is counterproductive to safe clinical practice.
And when questioned some staff did not seem to know how to use the communication devices to summon help in an emergency.
The patients involved in the incident had been temporarily moved to Spring Ward while improvement works were carried out on their ward.
But the review found there was no documentary evidence to show staff had adequately assessed what effect this move would have on the patients.
The report said: “Linked together, these factors represent systemic failure which resulted in the destabilisation of the care environment which could have had catastrophic consequences.”
The Bill Yule Adolescent Unit, which was the subject of the first independent review, has been permanently closed ever since the teenagers escaped after removing a window then scrambling over a wooden fence on February 26 last year.
But despite its closure the review panel has made 14 recommendations about how the service should be improved if it was ever reinstated.
These include significantly improving staff induction and continuing a professional development training programme.
The panel said the Trust had been trying to improve the service but the adolescent building’s unit was not fit for purpose in terms of security and effective therapeutic space.
A SLAM spokeswoman said: “In the case of Bill Yule Adolescent Unit, the Trust immediately made arrangements to arrange transfer of the patients and suspended the service in early March 2012.
“Subsequently it was decided that the service would not be reopened.
“The River House incident led to immediate action and there was no injury to staff or patients.
"We welcome the independent review findings and have accepted the key recommendations.
"Work on plans to improve clinical and security arrangements in the unit has been underway for some time and we are confident that considerable improvements have been made that will reduce the likelihood of a recurrence.
“The new forensic service director Eleanor Davies and her team are conducting a top to bottom review of how the service is organised, including reviewing training and skills.
"The new arrangements will provide clearer lines of communication between frontline staff, senior clinicians and managers to help ensure the patient experience and environment is managed more effectively and consistently, now and in future.”
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