'Lessons learned' after elderly man's suicide on ward

Saturday 29 May 2021

Jersey's mental health service has said it has learned lessons and made important changes after an 87-year-old man in its care hanged himself.

Brian Harold Blampied - a retired wholesale confectioner, and former electrician - who was described as “lovely, kind and someone who would do anything for anyone”, but who suffered severe anxiety and depression in later life, died in his room at Clinique Pinel at St. Saviour’s Hospital in November 2018.

An inquest was held into his death on Friday, not only to establish a cause of death and the circumstances around it, but also to see if any lessons needed to be learned.

In submitted statements, Mr Blampied’s family said that Clinque Pinel had been “unpleasant, out-of-date, over-stretched and fraying at the edges.” 

After Mr Blampied’s death, Health commissioned an independent investigation, carried out by a team from the Essex Partnership University Trust, to see if anything had gone wrong and what should be remedied.

They found that:

• a ligature risk assessment of Mr Blampied’s room on Cedar Ward had not been carried out; 
• the observation time for his level of vulnerability should not have been set at regular intervals; 
• airway equipment to aid resuscitation should not have been removed; 
• the emergency alarm system was inadequate; 
• and the approach to patient care should be more multidisciplinary.

Clare Ryder, Lead Nurse for Mental Health, told the inquest that these failings had been addressed since this "tragic event". A new alarm system, for example, had been installed and airway equipment was in place.

Its absence at the time of Mr Blampied's death had been due to no one being trained to use it, but this had now changed, she said, and there was now a robust and regularly updated training programme.

There was also mandatory training in the use of ligature-removing equipment; refresher training on the filling in of daily care sheets; and observations were in a 15-minute window so vulnerable patients could not predict the specific time of the next visit.  

“Staff also now hold safety huddles on the ward three times a day,” she added. “This ensures that any factor that could impact patient safety, such as their mood earlier in the day or any clinical development, is shared, discussed and documented.

“The huddle gets the right people with the right skills in the right place to support the clinical needs of patients.”

Pictured: Mr Blampied was a resident at Clinique Pinel, which was described as "out-of-date" and "over-stretched" by his family.

The family of Mr Blampied, who had served as an electrician in the Royal Navy, before taking over the family's wholesale confectionery business, had earlier shared their concerns over why he had been allowed to wear an item of clothing - part of which he had used as a ligature - when he had previously shared suicidal thoughts and plans.

The inquest heard a statement from the consultant psychiatrist who had treated him on the ward that it was always a “tricky balance” between patient safety and the maintenance of their dignity.

Mental health, especially in old age, was dynamic, fluid and can change in minutes, the inquest heard. 

“Unfortunately, that is the tragedy of our profession,” consultant psychiatrist Dr Miguel Garcia said. “No matter how many years’ experience you have, it can still happen in front of you.”

Another concern of the family was that, while they were praising of the care Mr Blampied had received at Clinique Pinel, there seemed to be too few staff there. 

For example, when Mr Blampied was given permission to leave the hospital or go for a walk around its grounds, this was often curtailed by a lack of staff able to accompany him.

“I am sorry if that was your experience,” Dr Garcia, who is Associate Medical Director of Adult Mental Health Services, told the family. “We now have a dynamic staff management system that matches the number of staff to what is required in each ward. Staff ratios are very different now and reviewed in a different manner.

“I would like to ensure the family that we have learned and responded.”

Addressing criticism of the facilities at Clinique Pinel, Dr Garcia said: “Mental health services have been in the spotlight for some time, which has been beneficial in the sense that we have been listened to and secured the necessary funds to make changes.

“A new centre is being built at Clinique Pinel and a new mental health facility will be co-located with the new hospital at Overdale. This will be fresh start and remove the stigma and fear of going to St. Saviour’s Hospital.”