Psychiatric unit failed to report ‘serious sexual assault’ allegations 

The assault is said to have happened on the 16 bedded mixed sex acute Mulberry 2 ward of Fulbourn Hospital in February

The assault is said to have happened on the 16 bedded mixed sex acute Mulberry 2 ward of Fulbourn Hospital in February - Credit: Archant

A Cambridgeshire psychiatric unit failed to report an alleged “serious sexual assault” says a report by the Care Quality Commission (CQC).  

The assault is said to have happened on the 16 bedded mixed sex acute Mulberry 2 ward of Fulbourn Hospital in February.  

Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) should have notified the CQC but failed to do so. 

The CQC also noted the absence of a “missing observation form of a patient” on March 14 when a male patient twice went into the female corridor and was seen “touching a female staff inappropriately.  

“This follows a loss of observation documentation following a serious incident in February 2022.  

“We raised this matter as a concern with the trust. The above incident on March 14 was documented as a significant incident and noted as a risk. 

“However, there was no evidence of a management plan to ensure safety of female patients and staff or for the male patient.” 

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The CQC says it was “not assured” assured robust plans were in place to manage paper observation records and to ensure they were uploaded onto the electronic record in a timely way.  

“We requested observation records relating to two significant incidents,” says their report. 

“Staff were unable to provide either the paper record or the uploaded electronic copies and told us they had gone missing.” 

The CQC inspection of the acute ward for adults of working age and psychiatric intensive care unit at Fulbourn Hospital was conducted in May. 

“We carried out this unannounced focused inspection because we received information giving us concerns about the safety and quality of the services,” says the CQC report. 

Their findings cover a range of issues and their recommendations have been accepted by the CPFT.  

The report found that: 

* Staff could not observe patients in all parts of the wards.  

* There were no clear lines of sight into each of the bedroom corridors.  

* Staff had not ensured a patients’ bedroom was fit for purpose. The room was in a very poor condition, the floor was very heavily soiled with food and drink spillages.  

* Dirty crockery and debris were visible, and the en suite toilet had dried faeces around the bowl and seat and urine stains on the floor.  

The report adds: “Staff we spoke with were aware, however they told us they had made a decision not to clean the room due to fear of the patient making allegations of theft and being angry about staff being in their room.  

“The severity of the lack of cleanliness could be considered an act of neglect by the ward to ensure appropriate hygiene measures were in place.” 

The CQC says that there was limited evidence in the patient care records of attempts to explore with the patient their concerns and address the issue.  

“We raised this concern with the ward and trust immediately,” says their report. 

“We saw in the daily bedroom checks that on four occasions there was evidence that the same patient had been smoking in their bedroom.  

“The care records reported that staff had removed a lighter from the patient on one occasion.  

“Staff had not followed trust policies and procedures to search the patients’ bedroom to remove any lighters to keep them and others safe from harm.”  

On staffing the CQC said the ward planned to have three registered staff and two healthcare assistants during the day and two registered staff and one healthcare assistant at night. 

“But we were told this was not always achieved,” says the CQC. 

“We saw staff had reported staff shortages on 10 occasions between 1 February and 15 May 2022 via the electronic incident system.  

“We reviewed the electronic rota from 27 March to 15 May 2022 which showed 91 gaps where shifts had not been filled, of these 51 were for registered nurses, with no documented mitigation of managing the shortfall.” 

On the use of ‘restrictive interventions’ the CQC says staff told them about the work they were doing to reduce the number of these. 

In mitigation, the CQC said staff told them they had experienced a prolonged time of intense pressure and did not feel supported by senior managers.  

In particular they felt there was a lack of communication regarding the decision to temporarily re-provide Mulberry 3 to an external provider. This was because of staff shortages on the ward, and the impact this would have on their patients and service.  

“They reported the ward manager was very supportive,” says the CQC. 

“However, they did not feel listened to or acknowledged by anyone above these roles. 

“Staff also told us that black colleagues reported receiving racial abuse from a patient for a sustained period of over two months.  

“Staff raised this with managers during and did receive support from ward team leaders.  
 

“However, staff raised concerns that this was not listened to or acted upon by more senior colleagues and did not feel supported.  

“We raised this concern with the trust. Governance managers did not ensure regular governance meetings were taking place and the records of the meetings had little detail.” 

The CQC also reported that managers did not ensure a bed was available if patients needed to return to the ward from leave.  

“We were told the ward had 19 patients admitted into 16 beds,” says the CQC. 

“Three patients were on home leave which meant those patients may not have access to a bed on the ward if they needed to return to hospital.” 


Craig Howarth, CQC head of inspection for mental health and community health services, said: 

“We had significant concerns about the safety and dignity of patients on the acute ward for adults of working age and psychiatric intensive care unit at Fulbourn Hospital. 

“Patient observations were poor in this service, which in at least one case led to a patient coming to harm.  

“We also found some areas of the premises were unacceptably dirty, which undermined people’s safety and dignity. 

“Behind this was a lack of good leadership to ensure issues were identified and addressed.  

“This includes a failure to consistently develop approaches to support patients who presented challenging behaviour. 

“These issues led to us serving the trust a warning notice, so the trust now has a legal obligation make improvements.” 

The CQC also carried out an inspection of the psychiatry service at Peterborough City Hospital which was “was meeting standards people have a right to expect, and people could access it when needed. 

“However, work was needed to ensure training targets were met, and better access to a psychology specialist was needed to support patients to have the best possible outcomes. 

“We have communicated our inspection findings to the trust, so its leaders know where improvements are needed. 

“We continue to monitor these services closely, including through future inspections and to ensure compliance with the warning notice.”