Keeping children and young people with mental health needs safe: the design of the paediatric ward

1.1 This interim report highlights the significant risks associated with caring for children and young people who exhibit certain high-risk behaviours when staying in a paediatric ward. The risks affect the safety and wellbeing of those with high-risk behaviours and of other patients, family members and staff on the paediatric ward.

1.2 The purpose of an HSIB interim report is to highlight urgent emergent safety risks to the healthcare system. While some of the risks highlighted in this interim report are known by the wider system, HSIB considers that the risks may not be fully understood or considered holistically.

1.3 The risks associated with caring for children and young people who exhibit certain high-risk behaviours when staying in a paediatric ward were identified as part of a HSIB national investigation. The national investigation is looking at the risk factors associated with the design of paediatric wards in acute hospitals caring for children and young people with mental health needs. The national investigation will continue and will be published in due course. The national investigation will have more in-depth analysis and exploration of some of the wider risks and issues mentioned in this interim report.

The findings presented in this interim report were identified through observational visits to acute paediatric wards, speaking with paediatric ward staff and directors and heads of children services at 18 acute hospitals across England (including district general hospitals and dedicated children’s hospitals serving a variety of population demographics), speaking with mental health experts and national organisations, and speaking with patients and families.

Background

2.1 The number of children and young people with mental health needs has risen since 2017. In 2022, 18% of children aged 7 to 16 years and 25.7% of young people aged 17 to 19 years had a probable mental disorder (NHS Digital, 2022). Paediatric (children’s) wards in acute hospitals are increasingly caring for children and young people who have mental health needs. Given the number and increase of children and young people with probable mental health needs, paediatric wards will have patients on their ward who may have physical and mental health care requirements. Paediatric wards are primarily designed for the care of children and young people who only have physical health needs and are not typically designed to help keep those with mental health needs safe.

2.2 The national investigation was launched after an incident was referred to HSIB involving a young person who visited an emergency department expressing suicidal thoughts. The young person was admitted to a paediatric ward in the acute hospital while awaiting a mental health assessment under the provisions of the Mental Health Act (1983). After being assessed, the young person was detained on the paediatric ward under section 2 of the Act. During their stay they had episodes of violence and aggression where they attempted to self-harm and to harm staff. They also left the paediatric ward without permission (absconded) on several occasions; on two of these occasions they took paracetamol tablets and needed medical treatment.

2.3 There is an ongoing transformation programme to improve mental health services for children and young people, as set out in the ‘NHS long term plan’ (NHS, 2019). NHS England has also published a framework to support staff at regional and system levels who care for children and young people with mental health needs in acute paediatric settings (including emergency departments and paediatric wards), see ‘Supporting children and young people (CYP) with mental health needs in acute paediatric settings: A framework for systems’. The framework provides recommendations around:

• providing greater support to children and young people with mental health needs who are admitted to a paediatric ward
• improving collaboration between health and social care services
• improving care pathways
• supporting the paediatric workforce to deliver high-quality care including access to training and education
• caring for children and young people with a learning disability or autistic sensory needs. This includes principles for adapting the acute hospital environment for children and young people with sensory needs and signposts the ‘It’s not Rocket Science’ report (NHS England, 2022).

3.1 Section 135 of the Mental Health Act (1983) states that a hospital is a ‘place of safety’ for people for whom there is reasonable cause to suspect they are suffering from mental disorder. A place of safety can be residential accommodation provided by a local social service authority, a hospital, an independent hospital or care home for mentally disordered people, or any other suitable place (Mental Health Act, 1983).

3.2 Children and young people who are suspected to have a mental health need who may be exhibiting high-risk behaviours often go to hospital emergency departments. High-risk behaviours include attempts to die by suicide, self-harm, attempts to leave the hospital without permission (abscond), and episodes of violence and aggression. The child or young person displaying high-risk behaviour may then be admitted to the hospital’s paediatric ward because they have a physical healthcare need and/or to provide them with a ‘place of safety’.

3.3 Acute hospitals told the investigation that children and young people with high-risk behaviours often had complex needs. For example, they could have a combination of mental health needs, neurodiversity (for example, autism and attention deficit hyperactivity disorder), and/or complex social situations influencing their high-risk behaviour. Their complex needs combined with pressures across the health and social care system (NHS England, 2022) meant it could be difficult to find and arrange suitable follow-on care in either a mental health inpatient setting, social care placement or with appropriate community wrap-around care. The investigation was told about some of the health and social care pressures including a national shortage of inpatient mental health beds and limited social care placements for children with learning difficulties and/or neurodiversity. Acute hospitals told the investigation they had children and young people with high-risk behaviours staying on the paediatric ward for several days, weeks or periods ranging up to 9 months. This was because the paediatric ward was viewed as the most clinically appropriate place or the safest place for the child or young person to stay and/or there was no suitable alternative.

3.4 The Care Quality Commission has published a brief guide on the care of children and young people in unsuitable hospital settings (BG068). It states that:

3.5 Acute hospitals told the investigation that paediatric wards were able to offer some children and young people with mental health needs, who may also have a physical healthcare need, or those awaiting an appropriate social care placement, a safe short-term environment to stay in. However, the investigation was told and observed that there were significant challenges in caring for children and young people who were exhibiting high-risk behaviours.

3.6 Paediatric wards are primarily designed to care for patients who only have physical healthcare needs. The wards contain many self-harm and ligature risks (points that could be used to attach something that could be used for self-harm or suicide). Staf, patients and families commented that paediatric wards were crowded, busy and noisy, and were unsuitable for children and young people experiencing a mental health crisis and/or who have sensory needs. 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.

3.7 Thirteen out of 18 acute hospitals the investigation spoke with stated that for children and young people with high-risk behaviours the paediatric ward was “not safe” and was not a suitable environment, particularly if the child or young person did not have a physical healthcare need. The remaining 5 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. The investigation continues to engage with more hospitals as the national investigation progresses.

3.8 The investigation found that the limitations in the ability of the paediatric ward to provide a suitable and safe environment for children and young people with high-risk behaviours had a negative impact on the safety and wellbeing of those children and young people, but also that of other patients, families and staff on the paediatric ward. Safety and wellbeing risks to children and young people with high-risk behaviours

3.9 The investigation found that children and young people with mental health needs and/or high-risk behaviours had limited to no specialist mental health care and therapeutic engagement while on the paediatric ward. Therapeutic engagement is supporting the child/young person to become and remain actively involved in their care, treatment and support. Mental health nurses who spoke with the investigation reported that effective therapeutic engagement was key in supporting children and young people with mental health needs and/or high-risk behaviours.

3.10 There were also limitations in the therapeutic environment, which meant that the wellbeing of children and young people being cared for on paediatric wards could deteriorate and high-risk behaviours could increase. Offering a therapeutic environment can help support recovery, foster enhanced therapeutic relationships, contribute to feelings of safety and control and reduce the likelihood of negative behaviours such as violence and aggression (Barnicot et al, 2017; Bowers et al. 2006; Jovanović et al, 2019; Van der Schaaf et al, 2013).

3.11 The investigation was told and observed that staff would sometimes place a child or young person who was exhibiting high-risk behaviour into more secure, enhanced observation areas with restricted access and exit. There may also be a security or police presence to help manage escalated behaviour. 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 (Barnicot et al, 2017; Van der Schaaf et al, 2013).

3.12 The investigation found there was variation in the adaptations being made to the paediatric ward. Paediatric ward staff told the investigation that they had limited guidance on how the paediatric ward should be adapted to support children and young people with high-risk behaviours. The adaptations to paediatric wards will be explored further as part of the national investigation.

3.13 The investigation was told that restrictive practices were being used to protect children or young people from harming themselves or others in the paediatric ward environment. The restrictive practices included physical restraint and sedation. While some acute hospitals told the investigation that they tried to use restraint as a last resort, some raised concerns about the number of times these practices were having to be used.

3.14 The investigation analysed a 3-month period of one hospital’s paediatric ward security incident reports. There were over 70 security reports related to children or young people with high-risk behaviours, most of which involved the use of some form of physical restraint. In just over half of the security incidents reported, the child or young person had been sedated, sometimes requiring multiple attempts (up to 7) for the sedation to become effective.

3.15 The investigation spoke with subject matter advisors, who stated these restrictive practices also had the potential to either create trauma in a young person’s life or could bring back past trauma they had experienced. Additionally, when using restraint on a child or young person, there is a risk they can be physically harmed. As such, the actions taken to mitigate the risks of the environment and harm to themselves and others, could be causing physical and psychological harm to children or young people with high-risk behaviours.

Safety and wellbeing risks to other patients and families

3.16 Many of the paediatric ward staff interviewed said they were concerned about the negative psychological impact that caring for children and young people with high-risk behaviours was having on other patients and family members on the paediatric ward. The paediatric ward cares for very young babies, infants and toddlers, and older children who may have additional needs and chronic health problems who may be on the ward long-term. The investigation observed and was told that vulnerable and unwell children and babies were situated next to or near a young person who was trying to harm themselves and/or whose behaviour could be violent and aggressive. Other patients and families were witnessing children and young people screaming, swearing and/or being restrained in public areas.

3.17 Paediatric ward staff told the investigation that families had voiced concerns over the incidents they were witnessing or concerns for their child’s safety. Concerns were also raised about the potential for another patient or family member to be physically assaulted. One acute hospital had a serious incident of this nature, and another told the investigation that a parent had discharged their unwell child early because they were concerned for the child’s safety.

3.18 The challenge of trying to balance the physical healthcare needs of patients on the paediatric ward with caring for a child or young person with high-risk behaviours was also raised. The investigation was told and observed that during periods of escalated high-risk behaviour it could take most, if not all, of the paediatric ward nursing team to help de-escalate and manage the situation. This meant that for periods of time, paediatric ward nurses were not able to offer other patients sufficient levels of observation and nursing care.

Safety and wellbeing risks to staff

3.19 Paediatric ward staff spoke of initiatives by NHS England and their trusts to change the culture towards parity of esteem – that is, the need to give equal value to mental health and physical health. Paediatric ward staff wanted to support children and young people with high-risk behaviours 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. While some staff had completed some training, they felt it did not offer them the level of skills and competence needed to manage the complexity and high-risk behaviours that some children and young people were exhibiting.

3.20 The investigation was told about many incidents of staff being physically assaulted by a child or young person with high-risk behaviours. Paediatric ward staff told the investigation they were experiencing significant stress about the events they had witnessed and felt anxious about coming to work. Some of the acute hospitals the investigation spoke with had seen increases in staff sickness levels and some paediatric wards were struggling to recruit and retain staff and described that their workforce was “collapsing”. As a result, some paediatric wards told the investigation they were unable to maintain recommended safe staffing ratios.

3.21 Acute hospitals also stated that their safe staffing models were based on caring for children and young people with physical health needs and did not consider the resource required to care for those with high-risk behaviours. Staff spoke of the significant impact on their workload owing to issues in staffing and managing events where a situation involving a child or young person with high-risk behaviour had escalated. HSIB’s third interim bulletin examining the harm caused by delays in transferring patients to the right place of care (Healthcare Safety investigation Branch, 2023) highlights the strong links between patient safety and staff wellbeing.

Risk management

3.22 As highlighted in the background section of this report, there is ongoing work as part of a national transformation programme to improve mental health services for children and young people, as set out in the ‘NHS long term plan’ (NHS, 2019). NHS England has also published a framework to support staff at regional and system levels who care for children and young people with mental health needs in acute paediatric settings (NHS England, 2022).

3.23 The investigation is aware of other ongoing work on issues highlighted in this report such as reducing restraint (NHS, 2019) including guidance around paediatric restrictive practices for patients with eating disorders (https://ngt-restrictive-practice.nhs.uk/). The investigation was informed by NHS England there is work to roll out crisis and home treatment teams, increase training to staff (see https://www.e-lfh.org.uk/programmes/ cypmh_in_acute_settings/) and testing innovations to help support paediatric ward staff and/or provide alternative suitable places of care for children and young people with mental health needs (NHS England, 2022).

3.24 The investigation was also informed by the Royal College of Nursing that work is underway to update documentation for staffing in paediatric wards. However, while work is ongoing and/or yet to be implemented, the risks to children and young people with high-risk behaviours described in this report remain.

3.25 The investigation asked hospital staff how the risks associated with children and young people with high-risk behaviours were escalated and shared with the wider health and social care system. Acute hospitals told the investigation that they had regular meetings with wider stakeholders such as the local children and young people’s mental health service, social care, safeguarding and their integrated care board (which is responsible for arranging the provision of health services in their geographical area).

3.26 However, many of the acute hospitals felt that the management of the risks associated with caring for children and young people with high-risk behaviours was predominantly placed on them. Staff told the investigation that the discussions with wider stakeholders tended to focus on finding an appropriate placement for a particular child or young person and did not always consider the full spectrum of risks (the holistic risks) associated with caring for children and young people with high-risk behaviours on the paediatric ward. For example, the safety and wellbeing risks associated with the paediatric ward environment, the safety and wellbeing risks to other patients and families, and the risks to staff, were not always fully considered.

3.27 A small number of hospitals reported feeling more supported by the wider system where their integrated care board and/or children and young people’s mental health service was helping to manage the risk. Some hospitals had also embedded specialist mental health nurses into their paediatric workforce. Increased integration and coordination of care with the wider system and embedding mental health experts into the paediatric ward team was reported to be beneficial. The investigation was told it resulted in shorter stays for children and young people with mental health needs on the paediatric ward.

3.28 The investigation also heard an example of how one hospital had managed to put in place a bespoke package of care for a child who had been on their paediatric ward for 9 months. Specialist psychiatric care and support was brought to the paediatric ward and adjustments were made to the environment. The investigation was told that the bespoke package of care reduced the child’s distress, they engaged with the care plan and their incidents of violence and aggression reduced significantly. This initiative was enabled with collaboration between clinical and mental health teams.

3.29 The investigation has found there is variability in how the risks associated with caring for children and young people with high-risk behaviours on the paediatric ward are managed. The investigation has been told about the significant risks paediatric wards are facing when trying to care for children and young people with high-risk behaviours across most hospitals the investigation has engaged with. HSIB calls for immediate action to be taken to reduce the risks associated with caring for children and young people with high-risk behaviours as low as possible acknowledging this is a complex issue and there are pressures across the health and care system.

HSIB suggests the following action for Integrated Care Boards

HSIB makes the following safety observation

Local-level learning

4.1 The national investigation will continue to explore the design of paediatric wards for supporting children and young people with mental health needs and the adaptations being made. The national investigation will also continue to explore how risks relating to the care of children and young people with mental health needs on the acute paediatric ward are managed.

4.2 HSIB welcomes further information that may be relevant from any source and will report any significant developments as the national investigation progresses.

Barnicot, K., Insua-Summerhayes, B., et al. (2017) Staff and patient experiences of decision-making about continuous observation in psychiatric hospitals, Social Psychiatry and Psychiatric Epidemiology, 52(4), pp. 473–483. doi: 10.1007/s00127-017-1338-4

Bowers, L., Whittington, R., et al. (2006) The City-128 study of observation and outcomes on acute psychiatric wards. Report to the NHS SDO Programme. doi:10.1186/1471-244X-7-S1-S122

Healthcare Safety Investigation Branch (2023) Interim bulletin 3. Harm caused by delays in transferring patients to the right place of care. Available at https://www.hssib.org.uk/patient-safety-investigations/harm-caused-by-delays-in-transferring-patients-to-the-right-place-of-care/interim-bulletin-3/ (Accessed 30 July 2024).

Jovanović, N., Campbell, J., et al. (2019) How to design psychiatric facilities to foster positive social interaction – a systematic review, European Psychiatry, 60, pp. 49-62. doi: 10.1016/j.eurpsy.2019.04.005

Mental Health Act (1983) Available at https:// www.legislation.gov.uk/ukpga/1983/20/contents (Accessed 16 March 2023).

NHS (2019) The NHS long term plan. Available at https://www.longtermplan.nhs.uk/publication/ nhs-long-term-plan/ (Accessed 17 April 2023).

NHS Digital (2022) Mental health of children and young people in England 2022 – wave 3 follow up to the 2017 survey. Available at https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-young-people-in-england/2022-follow-up-to-the-2017-survey# (Accessed 12 April 2023).

NHS England (2022) Supporting children and young people (CYP) with mental health needs in acute paediatric settings. A framework for systems. Available at https://www.england.nhs.uk/wp-content/uploads/2022/11/B2041-i-Supporting-children-and-young-people-with-mental-health-needs-framework.pdf?utm_source=The%20King%27s%20Fund%20newsletters%20%28main%20account%29&utm_medium=email&utm_campaign=13591352_NEWSL_HM (Accessed 24 November 2022).

Van der Schaaf, P.S., Dusseldorp, E., et al. (2013) Impact of the physical environment of psychiatric wards on the use of seclusion, The British Journal of Psychiatry, 202(2), pp. 142-149. doi: 10.1192/bjp.bp.112.118422