Child Health

Acute wards ‘unsafe’ for children with complex needs | Nursing Times

Paediatric wards are “unsafe” and “inappropriate” for children with severe mental health needs due to an overstretched workforce and under-resourcing, investigators have warned.

The Healthcare Safety Investigation Branch (HSIB), which investigates patient safety and welfare, this week published an interim report titled Keeping young children and young people with mental health needs safe.

“In some paediatric wards it was also relatively easy for a child or young person to leave without permission”

Healthcare Safety Investigation Branch

It was based on studies of 18 acute hospitals in England aimed at finding out how safe it is to place children exhibiting “high-risk behaviours” into standard paediatric wards.

HSIB includes suicide attempts, self-harm, absconding, and violence or aggression as examples of high-risk behaviours.

Current practice allows for children exhibiting these behaviours to be put into a paediatric ward either as a place of safety, or because they also have a physical healthcare need.

However, 13 of the 18 hospitals told HSIB the paediatric wards were “not safe” for a child or young person with high-risk behaviours, and nor were they “suitable”.

HSIB identified that paediatric wards contained “many self-harm and [suicide] risks”, due to their layout, and that they were “crowded, busy and noisy”.

This, investigators concluded, meant they were unsuitable for a child or young person at risk of hurting themselves, or who is in mental distress.

As well as posing a threat to the children themselves, investigators noted that this would also negatively impact the safety of other patients, families and ward staff.

The report reads: “In some paediatric wards it was also relatively easy for a child or young person to leave without permission or engage in other high-risk activities because the ward layout meant that lines of sight could be limited.

“The remaining five acute hospitals spoke of the challenges in caring for children and young people with high-risk behaviours.

“These hospitals tried to make the environment as safe as possible but felt that more could be done.”

Mental health nurses involved with the investigation told HSIB they also felt a paediatric ward was unsuitable for a child with high-risk behaviours, in large part because of a lack of therapeutic or specialist mental health staff.

Staff would often place children with high-risk behaviours in more secure areas where they had limited access to exits, sometimes with security or police presence.

The report noted: “Staff were trying to ensure the child or young person with high-risk behaviours remained safe, but in doing so made the child’s/young person’s therapeutic environment on the paediatric ward worse.

“Most items deemed as a risk were stripped from the child’s/young person’s room, including the bed.

“Research has shown that ward design with an overly strong emphasis on patient safety can prove to be restrictive and can lead to negative behaviours, can disempower patients, and increases the risk of self-harm behaviours.”

In turn, HSIB concluded, these “limitations” in therapeutic contact and spaces for the children meant they had a greater risk of deteriorating.

HSIB’s report further found that there was no lack of willingness for try and accommodate for these children, but wards lacked the resources.

“Paediatric ward staff wanted to support children and young people with high-risk behaviours,” it said.

“But felt frustrated that they did not have the right training, resource, support from psychiatric liaison services or environment in which to best meet their needs.”

As a result of this under-resourcing, HSIB reported “many” incidents of staff being physically assaulted by a child with high-risk behaviours, and that this had a significant impact on ward staff coming to work.

Paediatric wards, staff told HSIB, are having their workforce “collapsing”, in part due to the stresses placed on them.

Responding to the report, Saffron Cordery, deputy chief executive of NHS Providers, said the long-awaited NHS workforce plan must come soon to address the matter of safe care for vulnerable young people.

“Services for children and young people have come under increasing pressure over the last few years”

Saffron Cordery

Ms Cordery said: “Overstretched services are seeing many more young people, often with more complex needs, particularly as a result of the pandemic.

“We welcome that HSIB has highlighted efforts by several hospitals to make environments as safe as possible and to work with others in the system, but the findings are concerning and underline the need for mental health services to have the same support as those for physical health

“We need to see urgently from the government a fully costed, fully funded workforce plan for the NHS to tackle severe staff shortages and to recruit and retain people to work in mental health services, to meet the challenges and growing demand they face.”

HSIB’s primary recommendation from the report was that integrated care boards should “facilitate a system-wide response” to help reduce safety and wellbeing risks to children with high-risk behaviours in paediatric wards.

It also recommended that NHS organisations should escalate “systemic risks” regarding this group of young people to integrated care boards, and that acute hospitals should review their practices following the report.

Ms Cordery added that capital and staffing investments were needed to allow the right changes to take place.

She said: “Services for children and young people have come under increasing pressure over the last few years.

“We need a sustained focus on investment in capital, resources and staff with the right skills, expertise and support to boost capacity in hospitals and ensure that patients with the most severe needs are cared for in first-class, therapeutic, safe and appropriate environments.

“We also need much more care in the community and earlier intervention and prevention services for children and young people.”

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