By Ashley Young And Charlotte Webster-
Mental health trust leaders ignored staff concerns and reports over the safety of services at a hospital over many years before abuse was uncovered there in 2022, according to a damning review.
The programme showed appalling levels of abuse, humiliation and bullying of patients at the Edenfield Centre in Prestwich, which is
part of Greater Manchester Mental Health NHS Foundation Trust (GMMH).
Workers who raised concerns about issues such as unsafe staffing levels at the Edenfield Centre were ignored, creating a “toxic” culture that enabled the abuse exposed by BBC Panorama to take place, the inquiry said.
These issues extended beyond the forensic service hospital itself to the wider Greater Manchester Mental Health NHS Foundation Trust (GMMH), of which it is a part, according to the independent review into the trust commissioned by NHS England in the wake of the abuse scandal.
The review, chaired by former NHS trust chief executive and mental health nurse Oliver Shanley, also concluded that the lack of value placed on patients’ and families’ voices was a significant contributory factor behind what the BBC uncovered.
In 2022, Panorama sent an undercover reporter into Edenfield, a low and medium-secure mental health hospital for people transferred from the criminal justice system or with behaviours deemed to put themselves or others at risk.
The programme showed what the review described as “appalling levels of abuse, humiliation and bullying” from staff towards patients.
It sparked a police investigation, which is ongoing, the suspension – and ultimately, dismissal – of some staff and the closure of the centre to new admissions.
The Care Quality Commission also downgraded GMMH from requires improvement to inadequate overall in 2023, and NHS England placed it in the bottom rung of its recovery support programme, for health bodies with the most serious performance issues.
The Shanley review stressed the highly challenging context of forensic services, where patients are admitted against their will due to the serious risk they pose to themselves or others, in locked services away from loved ones.
While working in these environments had the potential to be “damaging and destructive”, this was exacerbated at Edenfield by “unsafe staffing levels” dating back years.
The review found that staff regularly working 13 hour shifts over 48 hours a week.
It also discovered that it was not uncommon in Edenfield for a single nurse to hold responsibility for three wards, newly qualified nurses were sometimes the only registered member of staff on a ward and unregistered staff were left unsupported and unsupervised on shift.
Staff also had to move wards during shift to maintain minimal coverage. Consultants told the review that, as a result, nurses often did not know the patients on their wards well or were not able to attend clinical meetings.
“This had a serious impact upon patient care with, on occasion, poor adherence to their care plans,” the report said.
Recruitment and retention problems “depleted the service of forensic nursing experience”. As a result, staff supervision rates at Edenfield had dropped markedly over the past three years, while few practitioners reported a positive view of supervision or on-the-job support.
The staffing situation had a significantly adverse impact on patient care with the review hearing “numerous accounts” of care tasks not being “safely and reliably completed”.
Patients told the review that bank and agency night staff were not responsive to routine requests and often told patients not to bother them or ask someone else.
The review also found no evidence that the trust had responded to a 2018 report commissioned by the trust finding that forensic staff were struggling with stress and overload and not feeling able to speak up.
Instead, Edenfield staff who raised concerns about unsafe staffing and care were “ignored” and, in some cases “reprimanded”, the review found.
The report said that “a great many staff, of all professions and levels, were highly distressed when telling their stories”, with several saying the review was the first opportunity they had had to talk about their experience of working at Edenfield.
“Reporting of concerns (such as unsafe nurse staffing levels) was actively discouraged and was described by numerous people as being ‘career limiting’, with staff having an “almost unanimous lack of faith” that anything would change as a result.