The CQC stated it was assured by investigations and learning undertaken by East London Foundation Trust – the provider of mental health services in the county – following the four deaths between December 2016 and July 2017.
Two weeks ago, the Gazette reported inquests for two patients from the all-male Ash Ward in Luton, who died within four days of each other.
Luke Wheeler, 30, of Dunstable, was killed running near Junction 11 of the M1 on June 21, 2017. Clinton Comb, 47, of Houghton Regis, died on June 25, 2017, after setting himself on fire.
CQC noted that the Ash Ward had now reduced the number of its beds from 27 to 19, allowing staff to have better oversight of patients.
Nevertheless, wards elsewhere continued to have bed numbers in excess of Royal College of Psychiatrists’ guidance and CQC found the following issues that required improvement:
n Staff did not always make the appropriate checks on the physical health of patients after rapid tranquilisation. This may put the health of patients at risk.
n Staff were not consistently reporting breaches of security. This meant there may have been lost opportunities to make safety improvements.
n Staff did not keep adequate records on cleaning and maintaining equipment. Staff take-up of basic life support and immediate life support training was below 75%.
Dr Paul Lelliott, CQC’s deputy chief inspector and lead for mental heath, said: “It’s good to see that the Trust has learnt from serious incidents and made some improvements in the quality of care at East London NHS Foundation Trust’s acute wards for adults of working age and PICUs in Luton and Bedfordshire.
“However, I would like to see care for patients improve further, when we next inspect this service. I was though pleased to see that patients reported that staff involved them in planning their care and treatment.”
South West Beds MP Andrew Selous represents the constituency for both Mr Wheeler and Mr Comb. Commenting on the CQC’s findings, he said: “The four unexpected deaths were all individual tragedies and my heart goes out to the families concerned.
“I have spoken to the CQC about their recent inspection of Ash Ward to reassure myself that lessons really have been learned.
“It is absolutely right that every part of the NHS is really serious about zero suicide outcomes. I particularly hope that more people will consider a career in mental health to help drive standards higher.”
East London Foundation Trust conducted its own serious incident reviews following the deaths of both Mr Wheeler and Mr Comb and identified a number of care delivery issues, which the Trust stated have since been acted upon with improved working practices in place.
Dr Navina Evans, chief executive of ELFT, added: “The loss of life of any patient is a tragedy and my heart goes out to the family and friends of those individuals. We have been focussed on learning lessons following these incidents and are encouraged that our progress has been recognised by inspectors. We will continue to work to improve how care is provided and to embed improvements across our services.”