WEST LONDON MENTAL HEALTH NHS TRUST UNDER INVESTIGATION

The Healthcare Commission has launched an investigation into
services provided by West London Mental Health NHS Trust. The investigation
follows concerns from different sources about how the trust handles serious
incidents, including incidents involving self-harm.

It will examine whether the trust takes appropriate action to address the
root causes of incidents in order to prevent similar events reoccuring and
improve services to patients. As part of preliminary work, the Commission’s
investigations team made unannounced visits at several trust sites on
February 13.

Based on this information, the Commission considers that an investigation
is needed to make sure that there are adequate systems and processes in
place to protect the safety of service users. The investigation will focus
on the period from April 2005 to present. It will look at how the trust
responded to safety incidents in this period and whether it took appropriate
action to prevent similar incidents from reoccurring.

This will include an examination of:
<li>The procedures and processes in place to protect the safety of
patients
<li>How the trust conducts its own investigations into incidents and
‘near misses’, including the time taken to complete them and how the
outcomes are communicated
<li>How the trust learns from incidents to improve services
<li>The number and types of incidents in the specified time period
<li>The systems that allow senior leaders at the trust to assure
themselves that the mental health services provided are safe and of
good quality.</li>

The Commission will also look at any other issues that may arise in the
course of its investigation. More detail is provided in the terms of
reference, also published today.

West London Mental Health NHS Trust employs 3,800 staff across 32 sites and
provides care for up to 18,000 patients at any one time. It provides a full
range of local mental health services for children, adults and older people
living in the boroughs of Ealing, Hounslow, Hammersmith and Fulham. The
trust also provides specialist and forensic mental health services. The
trust is responsible for high security services at Broadmoor Hospital but
these are not the main focus of the investigation.

Nigel Ellis, the Commission’s Head of Investigations, said: “Clearly, there
are particularly challenging safety issues that have to be managed at
mental health trusts. It is crucial that every trust monitors and manages
risks in order to protect the safety of patients. This investigation will
look into how this is done at West London Mental Health NHS Trust.

“We are not saying the services provided by the trust are unsafe. If we
believed they were unsafe we would take immediate action. But we have a
duty to patients to be certain that all necessary systems are in place to
manage risks.

“We are pleased to have the full cooperation of the trust in our work and
will report back fully and publicly in due course, making recommendations
to improve services if necessary.

As part of its investigation, the Commission will interview service users,
their families as well as staff members. People who think they might have
relevant information to contribute to the investigation can phone the
Healthcare Commission on 0845 601 3012.