Elise Sebastian, 16, of Southminster, near Maldon, was found collapsed in her bedroom. Unfortunately, this tragic scenario was just one distressing incident that happened at the St Aubyn Centre in Colchester in April 2021. Two days later, she died in the hospital, leading to an inquest that started this week. Family members of Erika her first day of the inquest. They are leading the charge on the current Lampard public inquiry into mental health deaths.
The inquest uncovered a shocking truth — Elise was supposed to have one-to-one care. The alert system linked to her bedroom had been silenced, allowing her to languish for 28 minutes before responders arrived. As staff shortages at the facility put all patients at risk of lapses in their safety and standard of care, this lapse was serious. The inquest noted that Elise was “a young person with her own hopes and dreams,” underscoring the tragedy of her untimely death.
Brian O’Donnell, the former clinical lead at the St Aubyn Centre, who gave compelling testimony on staffing issues, was a key witness during the hearings. He warned that chronic staff shortages and a lack of budget flexibility within the NHS made it impossible to provide safe care to patients. O’Donnell issued a personal statement expressing his concerns, saying. He argued against the idea of having staff diagnose up to 15 patients in under a minute each.
“Looking back, it’s unbelievable that we used to do that,” – Brian O’Donnell
O’Donnell spoke out against the practice of “pre-populating” observation sheets with check-in times, which ruined the whole point of randomizing who was looked in on. In his complaint, he alleged that patient safety was at risk due to patients left unattended for extended periods. He did this on at least three other occasions to the Care Quality Commission.
In addition, he noted that he had written 56 letters to individual staff members regarding the importance of accurately recording observations. O’Donnell emphasized that the reliance on agency and bank staff to cover for shortages was “a risky strategy,” stating that even the best temporary staff do not have the familiarity with the ward that regular staff possess.
“Even the best agency or bank staff don’t know the ward like we do,” – Brian O’Donnell
The St Aubyn Centre is still heavily criticised for its continued reliance on agency and bank staff. O’Donnell illustrated how this continues to be the case even up to today. He voiced concern with management’s fixation on minimum staffing levels for observations, noting that it spreads the staff too thin.
“The trust do look at the bare minimum that you need to cover observations – it really stretches staff,” – Brian O’Donnell
O’Donnell’s testimony further illustrated the increasing pressure being put on healthcare workers, who often already work under dangerous and crushing workloads. He pointed out the impact of all this, the emotional stress it causes to their employees.
“I’ve seen huge pressure on people – I’ve seen people in tears before,” – Brian O’Donnell
The Lampard inquiry into mental health deaths will also be watching closely inquest. Its aim is to address the systemic problems that underpin the crisis in mental health care across the NHS. The heartbreaking story of Elise Sebastian reminds us all why we must do more to ensure adequate staffing in our healthcare facilities. Let’s make sure we’re raising the floor of patient care nationwide.
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