Unsaid truths of a CAMHS hospital
By Nirbhay Kaul
12 February 2022. 15 minutes. A failing system. That was all it took for little Pearl (assigned name) to end her own life.
Dear reader, you are about to embark on a journey with me through my experiences shadowing in a Child and Adolescent Mental Health Services (CAMHS) hospital Paediatric Intensive Care Unit. Rarely, outside of bold journalism, do we get to see the intersectionality between social care, medical care, the Care Quality Commission (CQC), and senior management, alongside their ignorance of each other’s reality. All it takes is one national scandal to expose the inherent flaws of an institution like the NHS.
Institution not individual
Before this tragedy, I witnessed many problems plaguing the hospital which were not covered by mainstream media. The BBC coverage of this case chose the angle of poor hiring practices.They focused on the fault of the Ghanaian support worker, Ebo, who was revealed to be a refugee working illegally who subsequently fled to avoid prosecution. The article itself was a short piece with no thorough investigation, no BBC Panorama special - just a picture of the grieving parents in their worst moment, reading out their prepared statement alongside an image of their late daughter. The Active Care Group, who owned the hospital, vehemently denied wrongdoing, blatantly blaming the agency that provided the worker.However, the problems at this hospital ran much deeper than recruiting.
Gaps in care
A lack of continuity of care, weakened social care services and their disjointed communication with the healthcare teams are significant underlying factors for poor care under CAMHS.
The staff shortages, poor pay and inadequate training for highly specialised roles in social services need no introduction However, the cumulative impact of these shortcomings lead to unsafe care, putting patients in danger without social workers to advocate for their management and best interest.
In sensitive cases faced by mental health services, social care and healthcare services need to work closely to provide continuity of care. However, even if social workers are available and well-trained, the deliberate separation of social services and healthcare services creates a chasm in patients’ care. This is particularly evident when patients enter adulthood. 18 year old patients often struggle more in the transition from CAMHS to adult mental health services due to the expectation of receiving less structured and integrated social care. Structures for this transition exist, including Care Programme Approach (CPA) meetings where transition plans are made. However, decreased prioritisation of access to and losing access to safeguarding, advocacy and practical support in adult care services increases the risk of relapse or crisis at a critical stage of care.
An organisation entrusted with this responsibility is the Active Care Group (ACG), a large care service provider delivering specialist care in its units and hospitals around the UK. Due to the lack of bed availability, the NHS pays ACG for its beds. Scattered bed availability means patients are sometimes transferred to units far from home, oftentimes with no explanation. One concerned father was unaware that their child was being transferred because communication from the unit had been sent to the mother, even though the child lived with the father. This administrative mistake reflects the pervasive lack of communication between teams involved in CAMHS. Repeated harmful lapses in communication necessitated decisive action from the ACG leadership. Unfortunately, the only tangible change from the 2019 CQC report was the appointment of senior governance to uphold CQC standards, rather than addressing the core issues surrounding communication gaps. The senior governance denied Pearl’s parents multiple requests to increase their visiting time with their daughter and her psychiatrist's recommendation of moving her to a different ward that they thought had a better environment. These factors, as the jury rightly concluded, significantly contributed to her death. Repeated failings of the ACG were found to have contributed to Pearl’s death and the blame lies in the misjudgements of the CQC, ACG and support workers, and the gaps in the processes between them.
Cutting corners
In December 2021, Active Care Group was taken over by a different private equity firm named Montreux, declaring its objective to “harness innovation to raise standards and deliver better outcomes for children, young people and adults”.
However, financial troubles soon began, with a rise in interest rates that directly correlated with the danger of defaulting on their £188 million debt. In order to not default, they introduced drastic cost cutting measures that were widely unpopular among the healthcare professionals leading to poor staff retention. Every CAMHS ward is meant to have at least one consultant and one junior doctor. However, three out of the four wards had no junior doctor due to high staff turnover. In a shocking display of unity, I remember how the staff pitched in to buy ear defenders for the patients – 60% of whom had Autism Spectrum Condition – who suffered from sensory overload when the antiquated bell system was used to alert healthcare professionals of emergencies (which ACG also did not change). How ludicrous is it that underpaid healthcare workers were compelled to pay out of pocket for ear defenders while the ACG directors received a £1 million bonus between them, despite the company facing liquidation?
Currently, the NHS gives out contracts to private companies to run specialist hospitals and care homes. However, in many such hospitals and care services across the country, NHS standards are not upheld due to the profit-oriented nature of the care. The lack of investment in bells and ear defenders are just small microcosms of the larger structural deficits of the system.
Clashes in care provision
The CQC argued in its 2021 inspection of one hospital that “staff relied on restrictive interventions such as sedating medications, increased nursing observations, and restricted access to items within the ward environment, without evidence of considering person-centred or less restrictive alternatives.” And yet, even in 2022, the staff on the wards were still using IM lorazepam pro re nata (PRN) and restraints to manage their patients. The CQC, hampered by bureaucracy and short-sightedness, is inadequate in detecting problems and enforcing its authority. Despite being placed under special measures by the CQC, the ACG did not make any changes. Astonishingly, the CQC did nothing more than routine annual checks in 2021 and 2022, the years leading up to the closure of the hospital. Why did the CQC not enforce any changes after their 2019, 2020 or 2021 annual inspection reports, despite noting that none of their recommendations had been acted upon?
While sitting in an MDT meeting, I looked out into the garden and saw one patient absconding from the ward. This was a very serious situation, due to the risk of injury whilst escaping, and the subsequent risk of suicide, self harm, or becoming lost in an unprotected environment. In the 2019 CQC report, which praised the care at this hospital, they noted a similar incident that occurred during the inspection and which was followed by an “external root cause analysis” commissioned by the hospital. Unfortunately, there was no tangible change in the hospital’s approach, despite the CQC considering it a serious incident. Circumstances like this were common, yet there was no formal process to deal with such situations. Chaotic responses to chaotic situations only cause further chaos.
CQC reports, with their bureaucratic manner, can never truly capture the extent of such systematic failures.
I recall one instance while I was in the nursing station at Severn Ward. The walkie-talkies in the back of the room started blaring, “ALL UNITS TO THAMES WARD! ALL UNITS TO THAMES WARD!” No one, not even the healthcare assistants or nurses from Tamar or Thames Ward responded; only the ones in Severn did. After some time, three support workers returned from Thames Ward battered with injuries and tears streaming down their faces, complaining to me about the thorough lack of support they faced. Following the health and safety guidance, all three workers went to A&E for an evaluation due to bite marks, leaving an already understaffed ward dangerously empty. One of the support workers, enraged and desperate, wanted to complain to the CEO of the hospital to prevent such precarious situations in the future. The patient they supported had become manic because no one attended their Care Programme Approach (CPA) meeting - no social worker, no consultant, no nurse, psychologist, or healthcare assistant - because everyone was too busy with new admissions. A vulnerable young person should never feel unwanted and unsupported, and yet a culmination of staffing shortages, lack of funding, poor work culture and insufficient action both from the CQC and the ACG left a CAMHS hospital bereft of the care it promised.
No individual staff member was directly responsible for the culture at the hospital. In fact, I was inspired by their resilience and dedication to their work and patients, despite the turbulent nature of care provision. Cultural issues are always systemic, which need solutions from the top. But with changing leadership and volatile power dynamics between senior governance and clinical staff, it was patient care that took the brunt of the damage.
Eulogy
With growing calls for changes to the NHS,increasing frustration with long waiting times and the narrative pervasive in the media and public of ‘less effective care’, many are turning to private healthcare for quicker diagnoses, faster prescriptions and better outcomes. Upon closer inspection, NHS funding of private hospitals, once deemed a viable solution to temporarily manage the waiting list backlog, fails to deliver due to a lack of enforcement of standards.
Pearl was well-known and loved in the hospital; a brilliant girl let down by the chaos of the system designed to protect her. Just as mental health awareness campaigns have made tremendous strides perhaps we need to bring more awareness to the disjointed nature of care systems and how this lack of integration is preventing the delivery of safe and effective care. I desperately urge you to ask more questions and hold this system accountable. We cannot fail more little pearls.
Read the rest of the edition here
References:
Keep, M. (2025) Economic update: Interest rates cut to their lowest level for over two years. House of Commons Library. Available at: https://commonslibrary.parliament.uk/economic-update-interest-rates-cut-to-their-lowest-level-for-over-two-years/
Care Quality Commission (2019) Huntercombe Hospital – Maidenhead quality report: 11–13 June 2019 [PDF]. Available at: https://api.cqc.org.uk/public/v1/reports/d5afb85c-28aa-4c30-b9b6-09622d3d57ec?20210115234836
Care Quality Commission (2021) Huntercombe Hospital – Maidenhead comprehensive inspection report [PDF]. Available at: https://api.cqc.org.uk/public/v1/reports/5798981c-1c51-4f90-9993-37e92390c67c?20210301171833
Montreux Healthcare Fund PLC (2024) MHCF shareholder update: 12 June 2024 [PDF]. Available at: https://xn--enyk60lt73bbjclvh.com/wp-content/uploads/2024/06/1.-2024-06-12-MHCF-Shareholder-Update.pdf
bank of england interest rate graph -ttps://commonslibrary.parliament.uk/economic-update-interest-rates-cut-to-their-lowest-level-for-over-two-years/
BBC News. (2021, February 17). Maidenhead mental health hospital placed in special measures. https://www.bbc.co.uk/news/uk-england-berkshire-56087045
BBC News. (2025, August 6). Huntercombe Hospital ward short-staffed when girl left alone. https://www.bbc.co.uk/news/articles/cx23847x73ro
Briant, N. (2025a, August 14). Girl who died after Maidenhead hospital failure unlawfully killed. BBC News. https://www.bbc.co.uk/news/articles/c17np9vly51o
Briant, N. (2025c, August 15). Girl’s unlawful killing after Huntercombe Hospital errors “shocking.” BBC News. https://www.bbc.co.uk/news/articles/ce35x9wd2r1o
Federation, N. S. (2024, July 3). Leading private mental health provider to the NHS narrowly avoids liquidation - The Lowdown. LowDownNHS. https://lowdownnhs.info/contract-failure/leading-private-mental-health-provider-to-the-nhs-narrowly-avoids-liquidation/
Huntercombe Hospital - Maidenhead - Care Quality Commission. (n.d.). https://www.cqc.org.uk/location/1-130101073/inspection-summary
Mental Health Law Online. (2023, June 25). Rebecca Thomas, “Hospital of horrors: 1,643 ‘sexual safety incidents’ in a single 59-bed children’s unit” (Independent, 11/4/23) - Mental Health Law Online. https://www.mentalhealthlaw.co.uk/Rebecca_Thomas,_%27Hospital_of_horrors:_1,643_%E2%80%98sexual_safety_incidents%E2%80%99_in_a_single_59-bed_children%E2%80%99s_unit%27_(Independent,_11/4/23)
Morris, S. (2025, August 5). Girl, 14, died at psychiatric hospital after agency worker with false ID left her unwatched, inquest hears. The Guardian. https://www.theguardian.com/uk-news/2025/aug/04/ruth-szymankiewicz-died-huntercombe-hospital-agency-worker-false-id-inquest
Nhsfund. (2025a, November 19). Active Care Group - NHS for sale. https://www.nhsforsale.info/private-providers/active-care-group/
Nhsfund. (2025b, November 19). Active Care Group - NHS for sale. https://www.nhsforsale.info/private-providers/active-care-group/
One Hatfield Hospital - Care Quality Commission. (n.d.). https://www.cqc.org.uk/location/1-15475038495
Ruth Szymankiewicz: Inquest finds 14 year old Ruth Szymankiewicz was unlawfully killed. (n.d.). Inquest. https://www.inquest.org.uk/ruth-szymankiewicz-inquest-finds-14-year-old-ruth-szymankiewicz-was-unlawfully-killed
Taplow Manor - Care Quality Commission. (n.d.). https://www.cqc.org.uk/location/1-10206536544/inspection-summary
Thomas, R. (2024, June 18). Hospital group agreed six-figure bonuses for bosses – while warning it would stop paying for patients’ drugs. The Independent. https://www.independent.co.uk/news/health/hospital-nhs-drugs-active-care-group-b2564453.html
Thomas, R. (2025, August 30). ‘Chaotic, scary and intense’: Inside the scandal-hit hospital where teen spent final days. The Independent. https://www.independent.co.uk/news/health/huntercombe-taplow-manor-ruth-szymankiewicz-inquest-unlawful-killing-b2815189.html
