(10 months, 3 weeks ago)
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The Secretary of State for Health and Social Care (Victoria Atkins)
I have requested that the Care Quality Commission (CQC) conduct a special review of mental health services in Nottinghamshire under section 48 of the Health and Social Care Act 2008.
Like many of my Parliamentary colleagues, I was appalled by the horrendous and tragic killings of Barnaby Webber, Grace O’Malley-Kumar and Ian Coates in Nottingham in June 2023. I would like to place on record my deepest sympathies and condolences to the families of Barnaby, Grace and Ian.
The CQC special review will focus on reviewing the care provided by Nottinghamshire Healthcare NHS Foundation Trust and identifying where things may have gone wrong. This will give the families much-needed answers and will help identify how to improve the standard of mental health care in Nottinghamshire.
Any concerns regarding patient safety, quality of care, or public safety will be reported by the CQC, who will consider carefully the available relevant evidence, including witness and other oral evidence made public during the criminal trial of Valdo Calocane.
It is essential we move quickly to get the answers we need. This is why I am asking the CQC to conclude their investigation by the end of March at the very latest.
This special review will proceed alongside the Trust’s own internal investigation and NHS England’s Independent Mental Health Homicide Review, which is standard practice in these cases. I expect all parties to share information to avoid duplication and make sure that we receive as full a picture as possible. The CQC review will focus on this case and on wider issues in mental health care provision in Nottinghamshire, including at Highbury Hospital and Rampton Hospital.
I would also like to take this opportunity to update the House on the next steps of the Health Services Safety Investigations Body (HSSIB) investigation into mental health inpatient settings, which my predecessor announced in June 2023, in response to a number of tragic incidents that had taken place across the country.
Since June, the HSSIB, and its predecessor, the Healthcare Safety Investigation Branch (HSIB), has undertaken significant preparatory work, including holding over 30 meetings as part of the process of determining the scope of the investigation, and have reviewed the research evidence on safety.
The terms of reference for the investigation have today been published on the HSSIB website at https://www.hssib.org.uk/patient-safety-investigations/. There will be four investigations, which will focus on the themes of:
Learning from inpatient mental health deaths, and near misses, to improve patient safety.
The provision of safe care during transition from children and young person to adult inpatient mental health services.
Impact of out of area placements on the safety of mental health patients.
Creating the conditions for staff to deliver safe and therapeutic care (the workforce, relationships, and environments).
The investigations will identify risks to the safety of patients, and the HSSIB will seek to address those risks by making recommendations to facilitate the improvement of systems and practices in the provision of mental health care in England. This will include consideration of patient and staff safety with regard to allegations of sexual assault and rape. The investigations will conclude by the end of 2024.
Patient voice will be integral to the HSSIB’s investigation and report. They have been in touch with patients and families who have experienced poor care, as well as their parliamentary representatives, and are working with patient advocates and the charitable sector to arrange focus groups to support these investigations.
The HSSIB can also be contacted directly by any patient, carer or family member who wants to share their experiences of the mental healthcare they or their loved ones have received by emailing enquiries@ hssib.org.uk. I would strongly encourage all Members to highlight this opportunity to their constituents who may feel they would like to engage with this process and have their voices heard.
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