Surveillance is not safety - an analysis of Essex Partnership's use of Oxevision and the inconsistency of CQC's position on the technology

To our knowledge Oxevision is currently used, or about to be implemented, in 24 mental health trusts [1]. A further two trusts have previously used Oxevision but have discontinued use following internal reviews [2]. This blog considers Essex Partnership University Trust (EPUT) as a case study to contextualise our concerns around Oxevision. Early adopters of the technology, Essex appear to have spent a staggering £2,484,913 on Oxevision since 2020 [3] and are now using this on their CAMHS, adult and older adult wards with plans to expand to secure services and dementia wards. In May 2022, Essex Partnership had installed Oxevision on 438 rooms [4], representing rapid expansion since installation began in 2020.

It is reasonable to outline EPUT as having had long standing issues with patient safety failings. After years of campaigning, EPUT is currently subject to a statutory inquiry investigating 1,500 deaths of patients in inpatient mental health units in the trust between 2000 and 2020 whilst they were in hospital or within 3 months of being discharged [5,6].

Processes around conducting and recording patient observations was outlined as an area EPUT needed to urgently improve as part of a 2020 CQC inspection [7]. In response, Essex Partnership announced they were implementing Oxevision [8], positioning the technology as a way of addressing their patient safety failings and part of their 3 year ‘Safety-First, Safety Always’ strategy [9].

Undoubtedly, significant public and media attention on the trust and its patient safety failings has posed risks to the trust’s corporate image. It is therefore clear EPUT need to be seen to be making significant, tangible changes to address issues with their historic poor practice; a 2.5 million pound investment in innovative technology, purporting to improve patient safety, may seem a positive move reputationally. However, being seen to be making changes isn’t equivalent to actually addressing the systemic issues which drive poor practice and adding technology without robust changes risks furthering patient harms.

Indeed, the 2022 CQC inspection report, rating EPUT as inadequate, identifies concerns about the consent processes for use of Oxevision as well as continued issues with patient observations including many incidents of staff falling asleep or not engaging when on patients 1:1 observations [10]. One month before this rating, the trust were finalists for an AHSN award for their use of Oxevision [11]. The subsequent 2023 report rating EPUT as ‘requires improvement’ reiterates the same concerns about patients, across multiple wards, not being aware the technology was in use; not having information provided; a lack of robust consent processes and documentation; and patients being recorded unclothed on the cameras.

This is not poor implementation of trust policies in isolated cases, rather this is the intended use of Oxevision within EPUT. EPUT documents identify they do not have any consent processes in place, instead relying on “implicit consent” [12]. EPUT state “Oxevision is continually switched on and monitored in every bedroom as part of the safety care plan. Therefore all patients are opted in upon admission as part of the standard ward practice [13]. The trust’s standard operating procedure for Oxevision outlines patients may object to the use of the technology but orders staff to not action this for 72 hours for an MDT decision to be made. The document does not consider the risk or harms 3 days of non-consensual video recording would inflict on patients.

Additionally, as CQC noted, EPUT have a lack of processes in place to ensure patients know Oxevision is in operation and know what the functions of the technology are [14].

Oxevision poster. Oxehealth
NHS
Essex Partnership University
NHS Foundation Trust
APPENDIX 4: PATIENT POSTER
oxevision
A tool to help staff care for you more safely
Oxevision technology is installed in all bedrooms
What Oxevision does • Oxevision is a medical device that uses an infrared-sensitive camera to measure your pulse and breathing rate without
disturbing you. • It let's staff know when a second person
enters your room. • It sends notifications to staff and uses this information to help with your care (ask a member of staff for further
information). • Alerts staff when you have entered the bathroom and are out of range of the
sensor. Camera
sensor Infrared
lights
Use of video: When can staff see you in your room?
• A clear image can be seen for up to 15
• A blurred image can be seen for up to
seconds only when checking your pulse
15 seconds only when a notification has
and breathing rate.
been received
Have concerns or want to know more?
Please speak to the Ward Manager or Nurse in Charge Privacy Notice in the use of person identifiable salient video data (SD) - further information on
your data rights and how the Trust uses your data can be found at: www.eput.nhs.uk.
Alternatively, you can contact the Trust's Data Protection Officer at: epunft.DPO@hs.net.
Page 21 of 21

The EPUT ward poster explains Oxevision includes a camera and can take a patient’s pulse and breathing rate, however it does not clearly state the video images are recorded; can be viewed by Oxehealth staff; alerts after 3 minutes of being in the bathroom; or mentions any processes around withdrawing consent for use of the technology. It also doesn’t include any reference to the activity tracker report which can create a log of the number of times someone visits the bathroom and time spent there, as well as the amount of time they spent in bed.

Sharing our concerns about the lack of informed patient consent for use of Oxevision, CQC issued the following instructions to the trust [15]:

“The trust must ensure patients understand the use of the contact-free patient monitoring and management system, including why it is used and how information will be stored and accessed. (Regulation 12 (1).

The trust must ensure care and treatment is provided with the consent of the patient around the contact-free patient monitoring and management system. (Regulation 12 (2)).”

Despite the clarity of these directives, CQC have previously been supportive of Oxevision, including the technology as a case study of ‘driving improvement through technology’ [16]. This report was even used by Tees, Esk and Wear Valleys NHS trust (TEWV) as justification for not viewing oxevision as a blanket restriction, despite them also not requiring consent from patients for its use: “Oxevision is part of routine clinical care, therefore consent is not required… This is not seen as a blanket restriction as the CQC have cited it as good practice in their ‘Driving improvement through technology Case Study’” [17]. Furthermore, in spring 2022 during an inspection of EPUT’s child and adolescent wards, CQC discuss the trusts new Oxevision equipment but focus on Wi-Fi connectivity issues, overlooking the arguably more pressing issue of why novel surveillance technology was being used on children, presumably at that time also without informed consent processes in place [18].

Furthermore, Oxevision is mentioned in recent CQC reports for at least 9 other mental health trusts using the technology but is largely mentioned briefly in passing or considered positively [19-28]; in the West London report even mentioning patients had no rights to opt-out but accepting this on the basis of the ‘complexity of patients’ [29]. With the exception of South London and Maudsley, who no longer use Oxevision and didn’t supply documentation, none of these trusts seek patient consent for their use of Oxevision, all considering this as ‘treatment as usual’. It is not clear whether CQC were aware of the lack of consent processes during the other inspections; didn’t investigate thoroughly enough; lack consistency between individual inspection teams; or have changed their approach to surveillance on wards. In any eventuality, we consider this a failure of CQC to identify widespread issues with the use of Oxevision.

The example of EPUT – a mental health trust which has chronically failed to protect the safety of those in its care – demonstrates the risks of rapidly rolling out multi-million pound ‘innovative’ technology without due consideration of how to ensure patient’s rights are upheld within this. However, the responsibility extends beyond individual trusts. We believe there have been missed opportunities by CQC to consider the issue of this blanket use of restrictive interventions and provide consistent responses between trust inspections. Additionally, as was seen with SIM [30], the Academic Health Science Network and NHS Innovation Accelerator have rapidly funnelled public funding into private for-profit companies [31]. This has enabled the spread of Oxevision to nearly half of NHS trusts in England without any robust action taken to ensure plans are in place uphold the Human Rights of patients. Whilst struggling mental health trusts may be keen to use digital investment as a smokescreen for their failure to address critical patient safety concerns, we fear technological innovation without cultural change, will only serve to magnify abuses.

At the time of writing, CQC are yet to respond to our request for a meeting or issue any public statement in relation to Oxevision.

[1] see here for list of names, we are awaiting confirmation from Cambridge and Peterborough so they are excluded from this figure https://docs.google.com/spreadsheets/d/1UILG8r06LAaaUBHTKoLxlZzni2s6BDWrVss9dVw2ANE/edit#gid=0 (we are awaiting confirmation from Cambridge and Peterborough)

[2] Camden and Islington and Nottinghamshire https://docs.google.com/spreadsheets/d/1UILG8r06LAaaUBHTKoLxlZzni2s6BDWrVss9dVw2ANE/edit#gid=0

[3] https://docs.google.com/spreadsheets/d/1UILG8r06LAaaUBHTKoLxlZzni2s6BDWrVss9dVw2ANE/edit#gid=0 (note: figures obtained from viewing the trusts Transparency of Transactions reports which outline spending about 25K https://eput.nhs.uk/about-us/reports-and-accounts/transparency-of-transactions-expenditure-over-25k/. There is potential for mathematical errors both in the original reports and our own calculations.

[4] https://docs.google.com/document/d/1r5ZVkFOk-_abmuu4-M8M5moDpfefREjFAVbhxsj_0tQ/edit

[5] https://www.gov.uk/government/news/government-acts-to-improve-patient-safety-in-mental-health-care

[6] https://www.theguardian.com/society/2022/mar/28/inquiry-investigates-deaths-of-1500-nhs-mental-health-patients-in-essex

[7] https://api.cqc.org.uk/public/v1/reports/7136b52b-fac3-47c9-8e88-b95282505715?20221129062700

[8] https://eput.nhs.uk/news-events/posts/eput-makes-immediate-improvements-following-cqc-visit-as-part-of-wider-safety-measures/

[9] https://eput.nhs.uk/about-us/safety-first-safety-always/

[10] https://api.cqc.org.uk/public/v1/reports/ac080cf3-2ad9-4f63-b634-f4f86c3f55bf?20230403070039

[11] https://www.oxehealth.com/news/oxehealth-eput-finalists-innovate-awards-2022

[12] https://drive.google.com/drive/folders/1ysiF3JZKpOGDpYNQ5Kr5KS6YGbwDfwH_

[13] https://drive.google.com/drive/folders/1ysiF3JZKpOGDpYNQ5Kr5KS6YGbwDfwH_