The Private Mental Health Provider Cygnet Health Care Fined £1.53 Million Over Inpatient’s Tragic Death in London*.

In a landmark legal case, Cygnet Health Care, a private-sector mental health provider, has been hit with a £1.53 million fine after pleading guilty to charges brought by the Care Quality Commission (CQC). The charges revolve around the provider’s failure to ensure the safety and well-being of an inpatient at its Ealing hospital, ultimately resulting in the tragic death of a young woman who took her own life in July 2019.

This big fine marks a significant milestone, constituting the largest penalty ever imposed on a mental health service as a result of legal action initiated by the CQC. It follows a prior £1.5 million fine imposed on the Essex Partnership University NHS Foundation Trust in 2021 for breaches in care that led to 11 fatalities.

Cygnet Health Care, which is under the ownership of the US-based Universal Health Services, acknowledged its shortcomings in providing a secure ward environment that would minimize the risk of ligature use by patients. Additionally, they failed to ensure adequate patient monitoring in accordance with company protocols and neglected to adequately train staff in emergency resuscitation procedures.

A revelation by The Guardian in 2022 exposed serious deficiencies in the care provided to 11 inpatients at Cygnet facilities since 2012, as well as at other private mental health providers. In total, the NHS allocates approximately £2 billion annually to private hospitals for mental health services.

The CQC initiated legal proceedings following the case of a young woman admitted to Cygnet Hospital Ealing in November 2018, who tragically took her own life on the ward eight months later. The CQC highlighted that Cygnet Ealing was fully aware of the patient’s previous suicide attempt, which was nearly identical, yet they failed to adequately address the known environmental risks she faced. The CQC asserted that had Cygnet Health Care fulfilled its statutory obligations, the young woman would not have been exposed to such a significant risk.

Jane Ray, Deputy Director of Operations for CQC in London, expressed her disappointment, stating that individuals, especially those going through vulnerable periods in their lives, should expect safe and compassionate care. She emphasized that it was unacceptable for Cygnet Hospital Ealing to mismanage the young woman’s safety when she needed them the most. She welcomed Cygnet Health Care’s guilty plea but also criticized the provider for failing to learn from prior incidents that could potentially have prevented this tragic outcome.

During the court proceedings, the judge clarified that the case was not about prioritizing profit over safety.

If you’ve experienced the loss of a loved one due to inadequate mental health care, we might be able to assist you in pursuing a claim and guiding you through the inquest procedure.

Our skilled medical negligence solicitors will conduct a thorough investigation into the circumstances surrounding your loved one’s suicide, seeking to determine how and why it occurred.

We will strive to secure an acknowledgment of the mistreatment your loved one endured and obtain the compensation you rightfully deserve to address any financial charge you have encountered.

*Source: https://www.theguardian.com/society/2023/sep/22/private-mental-health-provider-fined-153m-over-in-patients-death

Nadia Persaud, the east London area coroner and the coroner who led the inquest about the suicide of Allison Aules, 12 in July 2022 has warned the health secretary that preventable child suicides are likely to increase unless the government provides more funding for mental health services.

Nadia Persaud told Steve Barclay that the suicide of Allison Aules highlighted the risk of similar deaths “unless action is taken”.

At the conclusion of the suicide Allison’s inquest, coroner Nadia Persaud highlighted a series of failures by North East London NHS foundation trust (NELFT) that contributed to her death. In her verdict, Persaud said: “Allison didn’t receive the mental health care which she should have received and I find that the absence of care contributed to her death.”

In a scathing report, Persaud has identified the under-resourcing of child and adolescent mental health services (CAMHS) as a significant contributing factor to the death of Allison. The report, which was addressed to Barclay, NHS England, and two royal colleges, expressed concerns about delays in Allison’s assessment by the mental health team due to the under-resourcing of CAMHS.

An inquest into Allison’s death found that the North East London NHS foundation trust (NELFT) was responsible for a series of failures that contributed to the tragedy. The delays and errors uncovered during the inquest, according to Persaud, shed light on wider concerns about funding and recruitment problems in mental health services.

Persaud’s report highlighted that the under-resourcing of CAMHS was not limited to the local trust responsible for Allison’s care but was a national issue of significant concern.

The inquest revealed that Allison’s situation deteriorated dramatically during the Covid lockdown. Her school referred her to NELFT in May 2021 due to concerns about self-harm, low mood, anxiety, and bed-wetting. However, she was not assessed for a period of nine months and never received face-to-face treatment.

Persaud’s report further stated that the delays experienced by Allison were unfortunately not uncommon within CAMHS teams across the country. She noted that there was a lack of evidence of any consultant psychiatrist taking charge of the team and highlighted difficulties in recruiting qualified psychiatrists.

The inquest also revealed that Allison was inappropriately discharged just weeks before her death, with input from a management team tasked with clearing a backlog of cases that had accumulated during the pandemic. The coroner criticized the poor funding of CAMHS, given that the region was facing 140 referrals of children and adolescents each week compared to only 10-12 in the 2010s.

Dr. Persaud expressed concern that if the ongoing under-resourcing of CAMHS services persists while demand continues to rise, similar future deaths may occur. The report called for immediate action to prevent such tragedies from happening again.

Barclay, along with the NHS, has been given until 25 October to respond to the report. Under the Coroners and Justice Act 2009, both entities must outline the actions taken and proposed to prevent similar deaths in the future, along with a timeline for implementation. If no action is proposed, an explanation must be provided.

The Department for Health and Social Care expressed condolences to Allison’s family and highlighted their commitment to investing in mental health services for children and young people. They mentioned an additional £2.3bn per year to be allocated to mental health services by 2024, which will allow an additional 345,000 children and young people to access NHS-funded mental health support. The government stated that they are carefully considering the coroner’s recommendations and will respond within the required timeframe.

If you’ve experienced the loss of a loved one due to inadequate mental health care, we might be able to assist you in pursuing a claim and guiding you through the inquest procedure.

Our skilled medical negligence solicitors will conduct a thorough investigation into the circumstances surrounding your loved one’s suicide, seeking to determine how and why it occurred.

We will strive to secure an acknowledgment of the mistreatment your loved one endured and obtain the compensation you rightfully deserve to address any financial charge you have encountered.