The Care Quality Commission (CQC) has today published the second part of its special review into patient safety concerns of mental health services at Nottinghamshire Healthcare NHS Foundation Trust, following the deaths of Ian Coates, Grace O’Malley-Kumar and Barnaby Webber in 2023.
The report makes several important recommendations outlining how mental health services can improve the care they provide.
Responding to the review, Dr Lade Smith CBE, President of the Royal College of Psychiatrists said:
“The circumstances under which this review has taken place are incredibly tragic. We were all deeply saddened and shocked by the terrible incident that took place in Nottingham last year. Our thoughts and heartfelt sympathies are with the bereaved families and all those who have been affected by this terrible event.
“The CQC’s review raises multiple areas of concern regarding the provision of mental health care at Nottinghamshire Healthcare NHS Foundation Trust. The Royal College of Psychiatrists is committed to working with NHS England to support the implementation of the recommendations at both a local and national level.
“Mental health services have been chronically underfunded for years and are struggling to meet rising demand without the resources they need. Effective treatments for severe mental illnesses are available, but when services are chronically overstretched it’s harder to provide the very best of care. Change is needed both in terms of investment and in the way we deliver mental health services.
“Evidence suggests that people with severe mental illness who receive continuous care from the same psychiatrist and mental health team – both in hospital and in their local community - engage better with services, and therefore have better outcomes and are less likely to relapse. Continuity of care can also help reduce risk when people become very unwell.
“Positive therapeutic relationships support patients to work with their clinicians to agree the best care plan for them. This means patients will be far more likely to continue using mental health services, engage with and adhere to their treatment regime. That is why it is important we see the use of Advance Choice Documents (ACDs) brought into law as part of broader reforms to the Mental Health Act.
“ACDs provide patients with the opportunity, when they are well, to express how they would like to be cared for at times of mental health crisis, which is when things are at their worst. They have been shown to improve engagement and treatment outcomes.
“Patients must not be discouraged from seeking support, and services should strive to include loved ones in the treatment process where possible.
“Ultimately, we must remember the lives that have been lost in this tragic incident and use the lessons learned to change the way services are offered and the resources we have to deliver them.”
For further information, please contact:
- Email: press@rcpsych.ac.uk
- Twitter: @rcpsych
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