NHSE pressure led to ‘toxic environment’, report into patient’s death told

An independent review into the death of Clive Treacey, who had the rare epilepsy condition Lennox-Gastaut syndrome, raises questions over the implementation of the Transforming Care programme. TCP was launched in 2015 in response to the abuse of patients at Winterbourne View.

Mr Treacey died in January 2017 at the independent Cedar Vale hospital in Nottingham. The hospital was then owned by Danshell Group which was embroiled in the Whorlton Hall scandal one year later. 

Mr Treacey had a learning disability and spent almost a decade, from 2007 to 2017, under section in mental health units.

The investigation into his death was commissioned by NHS Midlands in line with learning disability mortality review principles.

Staffordshire’s TCP lead is quoted in the report as telling Mr Treacey’s family she was “trying to work in a system that was simply not working”.

The report stated: “We heard that the pressure from NHS England nationally placed on the [Clinical Commissioning Group] and TCP team at the time to reduce the number of inpatients quickly had led to what was described as a ’toxic environment’.”

Reducing the number of people with learning disabilities and/or autism held within inpatient units has been the core success measure of Transforming Care since its launch. Inpatient units had seen a number of care scandals, such as that at Winterbourne View, with Edel Harris, chief executive of the learning disability charity Mencap, describing them as “modern day asylums” last year.

NHSE confirmed its policy was for CCGs to reduce the number of inpatient learning disability units, as many patients and families desire care delivered closer to home. However, it denied this had created a “toxic environment”.

System-wide failures

The report into Mr Treacey’s death finds that it was “potentially avoidable”.

It claims there were “multiple, system-wide failures in delivering his care and treatment that together placed him at a higher risk of sudden death”.

The review’s independent chair Beverley Dawkins wrote there were “the same fatal flaws in a system that has been responsible for many other deaths”.

In the report, she stated the recently published adult safeguarding review of the deaths of Joanna Bailey, Nicholas Briant and Ben King at Cawston Park in Norfolk “sharply echoes many of the findings in this review”.

Ms Dawkins added: “It was a system that failed Clive … there really are no words to describe the devastating consequences for Clive and his family and their experience of a broken system that literally swept him away.”

Structural failings highlighted include commissioners and regulators responsible for assessing Mr Treacey’s care appearing to lack specialist expertise and clear standards on good epilepsy care.

And despite responsibility for oversight and care coordination of Mr Treacey’s case being principally led by health commissioners, his family felt they “relinquished and passed on responsibility to inpatient providers”.

The review found detailed records indicating “very little oversight or involvement” from Stafford and Surrounds CCG in Mr Treacey’s care prior to Transforming Care’s introduction.

Staff described structural challenges created by Transforming Care. Commissioning lay with CCGs and the TCP teams only managed assessment and care coordination.

The review found it “effectively separated commissioners from working with families to co-design service specifications” and from “critical procurement stages”.

Greater multidisciplinary scrutiny of Mr Treacey’s needs could have allowed him to leave hospital and detention, the review found, but there were “critical missed opportunities” to discharge him.

It added there was “ineffective oversight and accountability” for the quality of Mr Treacey’s care overall that “failed to address experiences of poor care” and led to a prolonged detention of nearly 10 years.

The review’s recommendations include the following:

• Local commissioners should actively assure themselves that care providers are delivering epilepsy care to NICE standards. Regional NHSE/I learning disability and autism programmes should undertake a capacity and training needs audit to review capacity and skills of staff to commission safe care.

• Diagnostic overshadowing (attributing Mr Treacey’s behaviour to his epilepsy condition over mental health issues) resulted in missed opportunities to investigate serious health conditions. Health Education England, the Academy of Medical Royal Colleges, trusts, GPs and independent providers should provide training.

• NHSE/I’s national learning disability and autism programme should review existing quality standards for the commissioning of care and the capacity of local teams to deliver safe care.

• Commissioners should ensure individuals have a named care coordinator with statutory responsibility for consistently maintaining contact with them and their family.

A spokesperson for the NHS in the Midlands added: “We are already working with key partners to improve how people with a learning disability are cared for.

”The number of people cared for in an inpatient setting has reduced by nearly a third since 2016 and we will carefully consider the recommendations in this report as we continue to support people in their own communities.”

It is understood all Midlands systems have developed three-year plans to improve care and treatment.

A national review, confirmed by NHSE mental health director Claire Murdoch after the Cawston Park deaths, is under way to check the safety and wellbeing of all mental health inpatients with a learning disability or autism.