The hon. Gentleman makes an excellent point. We need to get to the bottom of why there has been continual failure not only at Bootham, but in the general delivery of clinical services.
The board member’s revelation was shocking and demonstrated that the current system allows for interests other than that of patient safety to be put first. Leeds and York did not invest in mental health in York, which was noted by staff and patients alike, and let the service be deemed unsafe by the CQC not once but twice, and then a third time, following a third inspection, which I will come on to later. It is also clear that the other bodies involved were not able to accelerate the inactivity. It is not that nothing was happening; discussions were ongoing, and the CQC and the Department of Health knew that a plan was slowly being drawn up by the CCG-led Bootham Park hospital programme board to address the CQC report’s findings, but “slippage” was evident. However, it is clear that frustrations existed between the bodies and blame for inaction was passed from one to the other. People hid behind jurisdictions and clear leadership was lacking once again, which is why there must be external oversight.
How can we have a health system in which there is scope for other interests, lack of focus, delay, lack of enforcement and blame, and in which CQC findings are not managed as a priority? We are back to poor governance and poor frameworks, which is what this debate is really all about. Leeds and York lost the contract to provide mental health services for the Vale of York CCG to TEWV. The trust appealed the decision to Monitor last June. Leeds and York then ran a highly public and politicised campaign that showed it was not interested in improving patient safety at Bootham, only in contractual matters, as I witnessed when I met with its chair. Monitor rejected the appeal and TEWV became the new provider. However, TEWV understandably wanted to inspect the plans for the building from which it would be delivering its services. I stress that the Bootham Park hospital upgrade could only ever be a temporary step, as I outlined in my maiden speech on
The CQC made an unannounced inspection on 9 and
The third inspection found a worsening situation. In addition to the safety risks already identified, staffing levels were worse and unsafe, record-keeping was poor, the water was found to be at a scalding temperature, and the kitchen, lounge and activity rooms gave access to an urn, electrical wires, scissors and knitting needles. A long-standing leaky toilet was leaking urine and foul water to the ward below and there was a risk of Legionella. There were other poor maintenance issues—as the CQC’s inspectors were assessing Bootham, a piece of masonry fell from the ceiling.
The CQC reported more than two weeks later, on Friday
The Leeds and York trust chief executive said on that same day that if the Vale of York CCG at the eleventh hour did not transfer over the service at the end of the month and let Leeds and York continue to provide it, it could keep the hospital open as it would not have to re-register. He said it was important that that was achieved for months until repairs were addressed. Even as patients were being cast out of their beds and out of our city, contractual issues were being placed above patient safety. The hospital was given five days—including a weekend—to close.
The CQC fulfilled its registration remit, but that meant that the building’s registration was placed above the unsafe environment that sudden closure and relocation would place service users in. That highlights how process was the factor that closed the hospital. Patients were put at risk. There was no scope for review of the decision, no one to assess the balance of risks and transitioning arrangements and no one to agree more time despite the clinicians, patients, families and their MP all highlighting the risks.
Let me mention some of those risks: the closure of the place of safety, section 136 suite, so people in a crisis have to travel at least to Harrogate for an assessment and then on again for a bed for their own safety; the closure of acute beds, with in-patients moved as far away as Middlesbrough, creating a huge risk and insecurity; patients moved away from their support networks and families to strange environments; and the moving of 400 people engaged in out-patients’ services to new locations. I heard how one service user’s condition became so exacerbated on hearing about their move that they became seriously ill, and that is not the only story.
I have heard from a parent how their child totally withdrew—from food and from them—because he was very frightened, and they were fearful for him. I have since supported frightened service users and family members. Out-patients who were suddenly discharged were confused and one senior clinician said it would be a miracle if someone does not die.
The situation continues. We have the place of safety back and we hope that out-patients will also be back in the near future. The acute in-patients’ service will be placed in temporary accommodation from the summer, all being well. However, serious risks resulted from the decision and the deterioration of service users’ mental health occurred. Safety was put after process, with some of the most vulnerable service users placed in an unsafe situation. There was no one in the NHS under the 2012 Act who had the authority to weigh up the balance of risk and decide, when greater risk to the lives of service users could occur with the sudden move, that an alternative call could be made, such as properly planned transition. No intervention was made, not even by the Minister—in other words, no one has overarching responsibility for patient safety in the NHS. That was confirmed by all the bodies. This must change immediately.
The reason I am so vexed is that four months have passed and nothing has been done about the system. Lives remain at risk, were such events to happen elsewhere. My constituents ask me, and I ask myself: is it because we are in the north? Is it because it is mental health? Or is it because the Government are too proud to admit that their Act has created that risk, as before 2012 there was someone who made such decisions?
I know that the circumstances at Bootham Park are exceptional and I trust that this will not happen again, but it could. The lives of my constituents were put at risk, and harm to their health occurred. The system failed them. That is why I and my constituents are focused on the need for a fully independent strategic investigation. Through my work and the health overview and scrutiny committee’s processes and now their operational local review, issues have come to the surface, but an independent review must occur. Lessons must be learnt of the failures in the way that health bodies relate to one another, and the problems that there are with governance. My constituents deserve to have answers.
Serious risks to patients were created in the NHS, and that cannot be ignored. No one died, but do we always have to wait until it is too late for someone before problems are taken seriously and situations are investigated? Agreement to an independent investigation is overdue.
In closing, I want to thank the service users and their families and carers for their continual pressure to get answers as to what happened to their services. They have been extraordinary in these very difficult times and deserve a confirmation that their concerns about the system will be addressed. I again invite the Minister to meet them. I also want to praise the outstanding efforts of all the staff involved in trying to support this unnecessary crisis, and in particular Martin Barkley for providing the leadership as the chief executive of TEWV. After 40 years of working in mental health, Martin is standing down, but I trust that his legacy will be a new, state-of-the-art mental health facility on the Bootham site for York by 2019.
Minister, four months is too long to wait to meet, too long to wait to undertake an independent review of the situation, and too long for my constituents to get the answers they deserve. Lives were put at risk and harm occurred. I trust that we can move the situation forward today.