A major review enacted after a 57-year-old woman's broken back went unnoticed has called for raft of improvements to be made to a Northampton hospital ward branded as 'medieval' by a grieving family.
Claire Masters had a history of paranoid schizophrenia and after an incident where she tried to harm herself on September 5, 2014, she was admitted to the Harbour Ward of Berrywood Hospital, Upton.
The 57-year-old made numerous attempts to harm herself while at Berrywood including what she described to doctors as 'throwing herself from her chair onto the floor' and 'banging her head', an inquest heard las year.
But despite her openly telling nurses she had broken her back, two fractures were not diagnosed until September 26, some 17 days after they were likely caused.
Miss Masters died on October 16 as a result of a subsequent infection.
The authors of a review into her death by the Northamptonshire Safeguarding Adults Board, published today, have now called for a series of improvements to be made across health and social care in the county - at the Harbour ward in particular.
Chairman of the board Tim Bishop, said: “It is very tragic and sad that Claire died in this way and our condolences are with her family. The Northamptonshire Safeguarding Adults Board has worked with all of the agencies involved to establish what lessons can be learned."
Miss Masters was a talented flute player in her youth, danced ballet, spoke two languages and went to university to study speech therapy.
She enjoyed listening to classical music but she was not allowed a radio in her room because the plug and cord could have been used to tie a ligature.
On one occasion a staff nurse called her to complain of Miss Masters’ 'unacceptable behaviour'. On another, a key worker called the police when she was 'kicked' by Miss Masters.
But the report highly criticises the 'culture' of Harbour ward at the time of Miss Masters' death.
"There was a rigid and discriminatory view regarding Claire’s behaviours that led to oppressive and at times abusive responses to her," the report reads.
"There was a disregard for Northamptonshire Healthcare Foundation Trust’s procedures and apparent indifference to responding to physical health needs."
In an interview with the Chron following last February's inquest, Miss Masters' sister Michelle Power said: “I think Victorian mental health care would have been far more superior.
"There were so many incidents where she was so cruelly treated."
Among the recommendations made, the safeguarding board called for Northampton Healthcare Foundation Trust to appoint an independent team review to examine Harbor ward's 'leadership, behaviours and culture'.
All Harbour ward registered nurses should be required to undertake medication competency assessments and the review has also called for the trust, which runs Berrywood Hospital, to carry out a separate study of the behavioural 'rules' on Harbour ward.
All-in-all the 81-page report makes it clear that communication between various parts of the trust and to consultants at Northampton General Hospital was also not up to scratch at the time of Miss Masters' death.
In particular, the nature of Miss Masters' back pain was not fully communicated to Northampton General Hospital consultants. The inquest found Miss Masters could have suffered for 17 days after sustaining the fatal fracture.
the report concludes: "There was limited evidence of joint working between Northamptonshire Healthcare Foundation Trust and Northampton General Hospital and a need to further develop a culture of shared care and collaboration between these services.
"The combination of these factors contravened basic standards of dignity and decency as well as failing to provide Claire with adequate mental or physical health care. Care provided breached professional standards and Codes of Practice."
A spokesman for Northamptonshire Healthcare NHS Foundation Trust, said: "We immediately completed a thorough investigation into Claire’s treatment and worked closely with her family and involved other agencies to understand what happened.
"The coroner had a number of improvement actions at inquest for all involved agencies; we are confident that we have identified and addressed these as part of our own investigations.
"As a result of our investigations in 2014/5, we have identified and taken action to improve our services, processes, staff training, and handover procedures. Our priority and investigations have been focussed on understanding Claire’s experience from her point of view and her journey through all agencies. We have been thorough and robust in the actions we have taken as a result of our investigation."
"The actions include a transformation of our mental community teams, with a much closer relationship between crisis and other services.
"A detailed and robust change and improvement in-ward structures led by service users and carers needs
"Building on our successful acute hospital liaison service in place in both KGH and NGH. Improvements to the handover processes between all hospitals to address the specific concerns raised by the coroner regarding communication between trusts.
"Training for all mental health ward based staff in physical health care skills.
"We have appointed physical health nurses across all the adult wards in Berrywood service users and carers co-producing a range of service improvements in both wards and community teams based on a recovery focus."