'Harrowing' failings in NHS mental health treatment laid bare by ombudsman report

A mental health patient died from a drug overdose after being discharged by NHS staff due to missing one appointment.

David West’s death is one of several “harrowing” cases highlighted in a new report that documents “serious failings” in England’s mental health services.

Campaigners said the Parliamentary and Health Service Ombudsman (PHSO) report showed “the desperate need for reform” of “overstretched services”.

Mr West, 28, from Southampton, had a complex history of mental health problems including bipolar disorder.

He was discharged by Southern Health NHS Foundation Trust’s community health team after missing a single appointment. But he was not told of the decision, given a discharge plan, or offered access to a crisis service.

He died shortly after from a drugs overdose.

The ombudsman said the trust “should have done more to support” West and “opportunities were missed to treat his illness and limit his deterioration”.

In another case highlighted by the report, staff at another NHS trust left a woman in seclusion with no access to sanitary products after she suffered an acute mental health crisis.

She was forced to collect menstrual blood in a cup, causing her “distress and humiliation”, said the ombudsman.

The ombudsman also detailed the death of a woman who suffered a fatal reaction to antipsychotic drugs.

The report said that had doctors identified the condition she would likely have received the appropriate treatment and survived.

Another case highlighted involved a vulnerable young man with bipolar disorder and autism who was attacked by another patient in a residential home.

The PHSO, Rob Behrens, said the incident could have been avoided had a risk assessment been carried out by staff, some of whom were found to have worked double shifts.

He said the cases “starkly illustrate the human cost of service failures”.

He added: “These cases are not isolated examples. They are symptomatic of persistent problems we see time and again in our complaints casework and, moreover, they represent failings throughout the care pathway.

“Patients who use specialist mental health services are among the most vulnerable in our society. As a result, any serious failings on the part of the organisations providing these services can have catastrophic consequences for them.

The report states workforce shortages in the NHS mental health service are “jeopardising” patient care and safety.

It also warns plans to transform mental health services may fail unless there is action to address staff shortages.

Almost one in 10 posts in specialist mental health services in England are vacant.

The report states: “Patient care and safety is jeopardised by these workforce challenges.

“They show clinical staff ill-equipped with the skills to manage potentially violent situations, being expected to work double shifts leading to exhaustion, and clinicians having to treat conditions they have no experience of.”

Mr Behrens added: “This report shows the harrowing impact that failings in mental healthcare can have on patients and their families.

“Too many patients are not being treated with the dignity and respect they deserve and this is further compounded by poor complaint handling.”

Brian Dow, director of external affairs at the charity Rethink Mental Illness, said the report showed “overstretched services” were failing patients “time and time again”.

He added: “These findings underline the desperate need for reform and the sometimes devastating consequences of a struggling system.

“We do now have a blueprint for change but this will need drive and funding to achieve its aims, or we will continue to hear stories like these.”

Chief Executive of Southern Health, Nick Broughton, said: “I am extremely sorry for the mistakes that led to the death of David West after his involvement with Southern Health, and I fully accept our failure to look after him better.

"We have worked very closely with Richard West in reviewing the circumstances that led up to his son’s tragic death, identifying areas for improvement and developing changes, and his support has been invaluable.

"We believe that working with patients, families and carers who have lived experience of the services we provide is the only way to ensure we can truly meet the needs of the people we care for.

“We welcome the publication of this report and the additional scrutiny on mental health services nationally. We have made a number of significant improvements in Southern Health, but we are clear that there is still much to do, both locally and across the whole country.”

An NHS spokesperson added: “This important report starkly and rightly recognises the scale of the challenge facing mental health services.

"It should be read and acted on by every part of the mental health service as over the next few years services expand, including for eating disorders, crisis care and psychosis.

"This will mean increased access, closer to home, to earlier and more effective treatment for greater numbers of people than ever before.”