Safeguarding Review concerning Mid and South Essex NHS Foundation Trust makes recommendations for change
Care provided to three patients under Mid and South Essex NHS Foundation Trust has been closely scrutinised as part of a Thematic Safeguarding Adult Review published by Thurrock Safeguarding Adults in August 2023.
What is a Safeguarding Adult Review?
A Safeguarding Adult Review (“SAR”) concerns the process of considering the circumstances around the death or serious harm of an adult that has happened due to suspected or known abuse or neglect where it appears that agencies could have done more to prevent it.
In this case, Thurrock Safeguarding Adults Board SAR Panel considered the three cases referred to them and concluded that a review should take place to identify any common themes and provide recommendations to those involved. The review addressed the pathway from admittance to discharge for each patient, the Serious Incident process, the management of family concerns and the impact of Covid. The review is not one to apportion blame but is one to ensure lessons are learnt for the future, identification of what went wrong is made and to improve future practice.
The three patients within the report were on different wards on different sites but all fell under the responsibility of Mid and South Essex NHS Foundation Trust. Their attendances were between 2020 – 2021 and took place at a time where services were facing the additional pressures of dealing with the Covid pandemic.
The three patients appear from the SAR to have had challenging admissions which included a failure to record a patient’s food and drink intake when a patient was refusing to eat; a family being advised their family member was fit and well to be discharged yet upon collection he was found not to be medically fit for discharge, it was also found that there was a failure to communicate with a patient in a meaningful way. The report advises that two of the patients were subject to Serious Incident Investigation by the Trust however the third patient did not have a Serious Incident Investigation carried out. Further to this patient’s death when the case went to Inquest, the Coroner raised concerns in his conclusion that Trust staff had failed to provide basic nursing care to the patient for an extended period.
Conclusions drawn from the Safeguarding Review
The SAR noted a number of common themes which included patients being discharged with a need for further care however as the cases were at the height of the Covid-19 pandemic conclusions are not drawn against the entirety of the care pathway. Concerns were also raised by communication with families and the role of family engagement.
Amongst the recommendations given by the SAR were that the Trust’s Serious Incident Reporting needs to be in line with the new Patient Safety Incident Response Framework, the Trust should ensure that record keeping is up to standard and improvements in communication with both patients and family members is to be improved.
Care Quality Commission assessment
The Care Quality Commission recently assessed the Basildon University Hospital which falls under the umbrella of Mid and South Essex NHS Foundation Trust in early 2023. This was an unannounced focused inspection due to concerns they had received surrounding medical care and older people’s services. Their findings were that overall, the rating of the Trust was “inadequate”. With the areas of “Safe”, “Effective” and “Well-led” all being given the “inadequate” rating. Two of the patients that formed part of the SAR received their treatment at this hospital.
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You can find out more about the safeguarding review report and the recent CQC inspection below:
- Safeguarding Adult Reviews (SAR) | Thurrock SafeGuarding Adults (thurrocksab.org.uk)
- Basildon University Hospital – Care Quality Commission (cqc.org.uk)
- Thematic Safeguarding Adult Review (SAR)
The content of this page is a summary of the law in force at the date of publication and is not exhaustive, nor does it contain definitive advice. Specialist legal advice should be sought in relation to any queries that may arise.
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