Woodbourne Priory Hospital in Edgbaston admits mental health patients to the wrong wards

High-risk patients with mental health issues were admitted to the wrong wards at a Birmingham hospital it was revealed - as inspectors rated it ‘inadequate’.

Woodbourne Priory Hospital in Edgbaston provides care and treatment to children, young people and adults with mental health conditions, including those whose rights are restricted under the Mental Health Act.

But following a visit in May 2022 it has now been given the lowest rating by the Care and Quality Commission (CQC) after inspectors found safety concerns. From August 2022 the service is also currently under a separate investigation by the CQC for a ‘historic event’.

Their report found that ‘high-risk’ patients had been transferred from a strict ward to a ward with more freedom, despite the safety concerns of other patients not being properly assessed. It also found that the service was failing to properly identify and record risks. The hospital has seven wards including ‘acute wards’ for adults and psychiatric intensive care units, child and adolescent mental health wards and specialist mental health eating disorder services.

What did the report say?

The report said: “Staff did not always know about any risks to each patient or act to prevent or reduce risks. Staff had failed to identify and respond to any changes in risks to, or posed by, patients.

“On Aspen ward, we reviewed five incidents and found that risk assessments and care plans had been updated in only two cases, one within 24 hours of the incident and one within 48 hours. All three incidents without updates referenced verbal aggression to staff and additionally in one case damage to property and use of seclusion. This posed a risk that staff working with patients were not fully aware of the risks that the patients may pose to themselves and others, or how to mitigate against such risks.”

After being warned by the CQC that their service could be suspended, Woodbourne Priory was given 24 hours to introduce a new review system.

Inspectors say the service now has a system in place to record incidents by the next day. Staff had completed thorough risk assessments of the outside garden and courtyard areas of the seven wards, and removed or reduced any risks they identified which included ‘risk of ligature points where patients could potentially hang themselves’.

Patients are now prevented from escaping the hospital with high fences and vandal paint, after previous incidents of patients leaving the facility by climbing over them.

Hospital statement

A hospital spokesman said: “Patient safety remains our overriding priority and we acted swiftly and responsively to all concerns raised with us.

“We are confident in the additional, comprehensive work undertaken to implement new patient safety processes and enhance existing ones. Daily staff meetings are held to share learnings, fully embed safety processes and mitigate risk.

“Further measures around handovers and admissions, patient risk reviews, and assessments – audited by clinical experts – are all evident. Environmental changes in the garden area of Beech Ward are complete, with a fence height of no less than 3.2m and anti-climb roller bars attached at the top.

“The CQC conducted a further inspection in August in response to historic concerns, unrelated in any way to any recent incident, and we have been advised that our current rating has been suspended until their inspection process is complete. We will continue to ensure that Woodbourne provides the highest level of care and a positive environment for everyone we support. Priory undergoes regular scrutiny of its services by external agencies including the NHS, and the overwhelming majority of Priory sites are rated ‘good’ or better by UK independent regulators.”

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