Review into Greater Manchester Mental Health Trust found patients were denied 'basic human rights'

A review into the care given by one of the country's largest mental health providers in the country has found that staff were unkind and abusive towards patients, and that leaders contributed to "a culture of fear and intimidation".

The review into the Greater Manchester Mental Health Trust (GMMH) was commissioned by NHS England in November 2022 after a host of failings to vulnerable patients came to light at the Edenfield Centre in Prestwich.

The report's final findings were published on 31 January 2024, and found that patient care across the trust has "at times been poor" and that patients have been "denied basic dignity and their human rights".

It found that there were repeated missed opportunities to act on the concerns raised at the Edenfield Centre by patients and their families.

The report said: "A large part of what was exposed... was due to the lack of value placed on the patient's voice in GMMH, as well as a frequent disregard for the experiences of families and carers.

"It is clear that patients and their loved ones had raised, on various occasions, serious concerns about the care provided at Edenfield and elsewhere in the Trust, and that this had not aways been taken seriously."

The report also looked into how staff's concerns were ignored by leadership.

It said: "Staff throughout the organisation and at all levels gave us examples of how the clinical voice and quality of care suffered directly as a result of this.

"Several leaders [were] identified by staff as displaying these behaviours remain in senior and influential posts; our review found that some of these individuals do not appear to understand how their behaviours might have contributed to the problems at GMMH."

The lengthy new report details the reasons why the abuse at Edenfield Centre was allowed to proliferate, as well as the wider problems causing havoc across the trust.

It said: "We found a service that had all the hallmarks of a closed culture, including an absence of psychological safety, incivility between staff, poor leadership, and a lack of teamworking."

The report was critical of the trust's leadership, with some 'senior and influential' leaders still in post despite contributing to a culture of 'fear and intimidation'.

The report said: "At Edenfield it was not uncommon for a single qualified nurse to have to assume responsibility for three wards.

"We heard of newly qualified nurses taking on leadership roles that they were ill equipped to deal with, often with little practical support or supervision.

"We heard of high levels of turnover across all disciplines, but especially among consultant psychiatrists. These workforce pressures likely had a significant impact on the safety, experience and effectiveness of the care provided."

After reports in the media, the trust was ordered to improve by health watchdogs the Care Quality Commission (CQC), and thrust into police and independent investigations.

The overall rating for the trust itself now stands at 'inadequate', as of a new CQC report carried out in 2023.

Jan Ditheridge, Chief Executive at Greater Manchester Mental Health NHS Foundation Trust, said: “We are truly sorry for the events described in the report.

"We worked openly and constructively with Professor Shanley and the team during their time at GMMH last year, we take the findings seriously and accept the recommendations.  

“We cannot change the past, but we are committed to a much-improved future – one in which all service users and carers feel safe and supported, and our people are able to do their best work.   

“Our improvement plan sets out a range of actions that are addressing the issues raised in this report. Many of these actions have been completed but we know there is more to do to ensure all of our communities get high quality and safe care all of the time.  

“Service users are already safer, staff are more supported, leadership and governance is stronger, and our culture is getting better.

“We are working with the review team, partners, and colleagues to fully implement the recommendations ensuring our service users and their carers are central to everything we do.”

A spokesperson for NHS England North West said: “We welcome the publication of the Independent Review and are grateful to Professor Shanley and his team for this report, as well as the patients, families and carers, and staff, who engaged with the review, for the thorough work it represents, and the clear focus on learning from the issues that led to it being commissioned.

“NHS England is committed to the delivery of high-quality care for all patients and commissioned this independent review to look into all the issues and allegations raised by patients, their families and carers and in the media, and took immediate action to carry out a rapid review to prioritise support and take steps to protect patients and improve patient safety.

“This involved helping the Edenfield Unit to reduce the number of patients it was caring for while improvements were implemented through our recovery support programme and the allocation of an improvement director.

“We now owe it to every patient cared for by the trust and the staff working for them and across the NHS, to ensure the review’s recommendations are implemented, and sustained and genuine improvements are made in the care being delivered to patients."

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