A heartbreaking incident unfolded at Birch Hill Hospital in Rochdale, where a long-term patient tragically lost his life after seven crucial checks were missed by a nurse assistant.Lee Doherty, 46, from Manchester, had been under the Mental Health Act for a decade. On July 15, 2022, his life came to a sudden end at Prospect Place, Birch Hill Hospital, managed by Pennine Care NHS Foundation Trust. The inquest into Mr. Doherty’s death is still ongoing at Rochdale Coroners’ Court, with Senior Coroner Joanne Kearsley presiding.
Gaps in Care Highlighted During Inquest
Jurors learned that Mr. Doherty was supposed to receive 15-minute observations. However, there were multiple instances where these checks were overlooked. Logs sometimes didn’t match the CCTV footage, raising serious concerns about record-keeping practices.
During a session on November 29, Coroner Kearsley questioned Ieuan Thomas-Cole, the associate director at Prospect Place. “You became aware of the issues around the falsifying of records?” she asked.
Thomas-Cole confirmed, “Correct.” The coroner pressed further, highlighting discrepancies between documented observations and actual events captured on CCTV. “There’s clear evidence that it happened, but there’s clear evidence that it happened by nearly every member of staff,” Kearsley noted.
Staffing Shortages and Break Patterns Contributed to Oversights
It emerged that Prospect Place had a culture where staff often took extended breaks at the beginning or end of their shifts. This practice led to periods where staffing levels dipped below the required minimum, compromising patient care.
Rosemary Thompson, a nursing assistant on duty when Mr. Doherty died, admitted missing seven checks between 1:40 PM and 3:20 PM on July 15. “I actually didn’t know that I was supposed to be doing the observations,” she confessed. Thompson was occupied with activities in the lounge, neglecting her monitoring duties.
When questioned about the rushed completion of records, Thompson revealed, “I panicked. I picked up the observations and started writing them down quickly.” This pattern wasn’t isolated; other staff members had also missed their checks, indicating a broader issue within the facility.
Impact of Shift Patterns on Patient Safety
The court was shown the shift schedules: day shifts from 7:30 AM to 7:30 PM with two nurses and four nursing assistants, and night shifts from 7:30 PM to 7:30 AM with two nurses and two nursing assistants. Thompson explained that taking long breaks at the start or end of shifts was standard practice.
- Day Shift: 2 nurses, 4 nursing assistants
- Night Shift: 2 nurses, 2 nursing assistants
This arrangement often resulted in minimal staffing during critical times, undermining the quality of patient care.
Changes Implemented Post-Tragedy
In response to Mr. Doherty’s death, Prospect Place has altered its break policies. Staff can no longer take extended breaks at shift beginnings or ends. Additionally, a new measure requires the nurse in charge to countersign observation logs to ensure their accuracy.
Thomas-Cole mentioned, “The nurse in charge is mandated to countersign the observations to make sure that they have happened.” However, Coroner Kearsley raised concerns about the timing of these signatures. “If I lie on that document, then go to the nurse in charge and tick that box, she has no way of knowing. Is that fair?” she questioned. Thomas-Cole affirmed, “Yes.”
Broader Implications for Mental Health Care
This case sheds light on systemic issues within mental health facilities, emphasizing the need for stricter oversight and better staffing practices to prevent such tragedies in the future. Ensuring that patients receive consistent and reliable care is paramount to their safety and well-being.
