This investigation was launched by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.
Paediatric wards in acute hospitals are increasingly caring for children and young people (CYP) who have mental health needs. Paediatric wards are primarily designed to accommodate children with physical health needs and are not specifically designed to help keep children and young people with mental health needs safe.
This national investigation looks at the risk factors associated with the design of paediatric wards in acute hospitals for children and young people with mental health needs.
The national investigation will:
The reference event involves a young person who presented at the emergency department expressing suicidal thoughts. The young person was admitted to a paediatric ward in the acute hospital whilst awaiting a mental health act assessment. The young person was then detained under section 2 of the Mental Health Act for self-harm.
The young person absconded (fled) from the paediatric ward on several occasions. On two occasions they took paracetamol tablets during their absence. Each time the young person absconded they were located by the police and brought back to the paediatric ward. On the ward, the young person’s behaviour escalated, which included attempts to self-harm and to harm hospital staff.
The young person was treated for the paracetamol overdose in intensive care but made further attempts to abscond when they returned to the paediatric ward. After a stay of ten days, the young person was transferred to an alternative facility for children with mental health needs whilst waiting for a children and young people’s mental health inpatient bed.
If you would like to speak to us about this report prior to publication, please email enquiries@hssib.org.uk.
HSIB makes the following safety observation:
It may be beneficial if NHS organisations ensure that systemic risks associated with caring for children and young people with high-risk behaviours on the paediatric ward, including the safety and wellbeing risks to patients and staff, are escalated to integrated care boards for consideration.
HSIB makes the following safety observation:
It may be beneficial if NHS organisations ensure that systemic risks associated with caring for children and young people with high-risk behaviours on the paediatric ward, including the safety and wellbeing risks to patients and staff, are escalated to integrated care boards for consideration.