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Swift fixes made to mental health service after Ellis death

Swift fixes made to mental health service after Ellis death

Friday 11 October 2019

Swift fixes made to mental health service after Ellis death

Friday 11 October 2019

Improvements recommended in an expert report advising on how to better the island's mental health service have been mostly competed, according to HSC, just six months after its release.

The report, released today to the public, was written by UK Consultant Psychiatrist Geraldine O'Sullivan after the death of Lauren Ellis, a 22-year-old who ligatured herself while she was an inpatient on the Crevichon Ward.

Immediately after the death, Health & Social Care commissioned the report to try to get to the bottom of how the death could have happened. 

That death led to a Royal Court trial, as two of the nurses on the ward were tried for manslaughter by gross negligence, but eventually found not guilty.

However, both nurses had admitted they were not doing their job properly, which raised questions about the quality of care at the Crevichon Ward. 

court entrance

Pictured: Lauren Ellis ligatured herself while in a room on the Crevichon Ward, in a period of time of nearly two hours when two on-duty nurses failed to do their 15-minute observation checks. The nurses were sat in the nursing station on their phones, with one of them having their feet on the desk. 

In her report, Dr O'Sullivan said she had found Guernsey had a ‘good service’ that is ‘well resourced’ and delivered in a ‘state of the art environment’.  She was ‘impressed by the commitment and dedication of the clinical and managerial staff.’

But she also identified eight areas which needed, or had room for, improvement. 

  1. The understand of Emotionally Unstable Personality Disorder
  2. Creating Ligature free environments 
  3. Better capacity legislation
  4. More integrated working across teams in adult mental health
  5. Better acute inpatient provision
  6. Governance in the mental heath team
  7. 'Assurance'
  8. A full review of mental health services

These areas were expanded upon when Dr O'Suillvan was giving evidence in Court. She spoke about how there was an endemic attitude among nursing staffs to not do their 15-minute observation checks. They felt they were pointless, so didn't do them, she said. Furthermore, she said she felt there was not a strong system of leadership among the mental health nurses.


Pictured: The Oberlands Centre. 

She did have a great deal of praise for the service as well, however. In her findings, Dr O'Sullivan said: "My impression is that the AMH service is well resourced with a number of teams providing inpatient, outpatient and community care to the population. There is a well-resourced support and counselling system in place for staff undergoing formal processes. These include automatic referral to Occupational health, counselling, pastoral oversight and off-island treatment if required.

"There is excellent work already underway on improving the systems and processes around admissions to Crevichon ward. These include but are not exclusive to the following important areas:

  • The admission process is being improved to ensure that there is a joint medical and nursing assessment of risk and care planning to manage clinical risk.

  • Policies are being reviewed updated and/or developed stop this includes the observation policy and consideration of the levels of observation.

  • The handover process has been clarified in writing.

  • There is now a robust induction process that is based on a competency based framework.

  • Resuscitation training/simulation.

  • An important area of development centres on nursing leadership and development within the ward to ensure that nurses are aware and capable of adopting accountability and responsibility in accordance with their roles."

HSC said 'the majority' of the actions that resulted from the review were completed within six months. Further steps had also been taken to ensure ongoing improvements. 

Juliet Beal

Pictured: Professor Juliet Beal. 

Chief Nurse, Professor Juliet Beal, said: "After the tragic death of Ms Ellis in 2017, it was right that we looked at what could be done to prevent anything similar happening.  We have been working hard to bring in improvements to adult mental health services, and that work continues.  But I am pleased Dr O’Sullivan found a good standard of care is being provided.  I would particularly agree with her assessment of the dedication of our staff.

"As Dr O’Sullivan’s report reflects, this area of healthcare works with the most high-risk patients and it is not possible to mitigate completely against all possible risks.

"It is important that HSC is constantly aware of new developments and research and therefore it is a process of continuous improvement to ensure that policies remain up to date and staff are correctly trained."

Pictured top: The Crevichon Ward is part of the Oberlands Centre. 

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