A number of patient deaths sparked inspectors to visit an NHS trust.

East London NHS Foundation Trust (ELFT) provides mental and physical healthcare services for adults and children in east London and in Luton and Bedfordshire.

Across these regions, the trust also provides inpatient services delivering 24-hour care and treatment for patients who are experiencing an acute mental health episode.

The Care Quality Commission (CQC) says it became aware of a number of self-harm related deaths and serious incidents for ELFT patients who were detained under the Mental Health Act (MHA).

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Between January 2019 and January 2023 there were six deaths and two serious incidents for MHA detained patients from self-harm, CQC said.

The inspection of ELFT's acute wards for adults of working age and psychiatric intensive care units took place in February.

CQC said the aim was to see how the trust implemented improvements to care, minimised the repetition of poor practice and whether learning from serious incidents has been fully completed.

Inspectors visited 12 wards across City and Hackney, Newham and Tower Hamlets and in Luton and Bedfordshire and the report of their findings has now been published.

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The inspection did not re-rate the service, which remains 'outstanding' overall.

Jane Ray, deputy director of operations in London, said leaders have taken "quick and thorough action" to learn from the "tragic incidents" that had previously occurred in the service.

She said: "We saw leaders had identified repeating problems with staff observation of people whose distress could pose risks to themselves or others.

"In response, they sought the views of staff and people using the service to find innovative solutions.

"They also worked with experts at City University to understand current research and good practice in this area.

"We’ll continue to monitor the trust, including through future inspections, to support it to deliver the best possible care."

Inspectors found that people were supported to share their opinions of the service and they found staff to be friendly and competent.

The service introduced high-visibility jackets for staff doing observations, so that colleagues knew not to distract them.

They also introduced a folder relay system, inspectors wrote, which made sure the observation folder was never allowed to be put down - only handed to another colleague.

Online training was created to teach staff about learning from serious incidents that could protect people in future.

Inspectors said leaders also introduced a new process to give people's loved ones immediate support if an unexpected death occurred.

However, the report noted that leaders did not always support staff to improve their practice by supervising them.

Not all staff had completed mandatory training such as restrictive practice and basic first aid.

Leaders did not always keep action plans updated, inspectors found, which meant that learning about what did or didn't work to improve people's safety was not always shared.

An ELFT spokesperson said: “Patient care and safety remain the absolute priority for the East London NHS Foundation Trust. 

"We really value feedback from the CQC and are currently in the process of putting a plan in place to address areas of improvement identified in the report.” 

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