Oxehealth have FAQs on their website that do not reflect our lived experience of having this technology used on us or our many hours of research speaking to patients, staff and analysing Freedom Of Information (FOI) reports. We decided to answer the same questions based on our own experience and research of Oxevision. This is our perspective as survivors.
What does Oxevision do?
Oxevision is a device that uses an infrared-sensitive camera. It allows staff to remotely view patients in their bedroom at any time, often without the patient’s knowledge or consent. It also measures pulse and breathing rate. It only gives medically reliable results when staff do a manual “spot check” when the person is still and if there is only one person in the room.
Although it is a registered medical device, Oxehealth state that “Oxehealth Vital Signs must not be used as the sole basis for making any decisions or recommendations relating to clinical diagnosis, subject care or treatment”.
From our lived experience, we believe that Oxevision is being used primarily as video surveillance.
Depending on which alerts are enabled, staff can receive notifications if the patient is in the bathroom, out of the room, at the door, on the edge of their bed, out of bed or if another person enters the room. Data collected can be pulled into a graph to measure activity, for example, how long someone is spending in the bathroom. This is concerning because just because you can collect and record data doesn’t mean you should. The aim must be legitimate and proportionate.
We have spoken to people who have shared that Oxevision has caused significant distress, trauma and has exacerbated their paranoia. This has had a long-lasting impact.
What is the purpose of Oxevision?
From our experience and research, we believe that Oxevision has been installed as a blanket restriction on mental health wards including adult, child and adolescent mental health wards and care homes. There is evidence that, on some occasions, it has been installed in all bedrooms regardless of individual needs and risk assessments. There is no way of knowing if it is on or off as the infrared light is always on.
Our research and personal experience indicate that it can and does replace therapeutic engagement with patients. For example, North Staffordshire referred to Coventry and Warwickshire Trust as a case study to justify reducing the equivalent of 2.24 band 3 HCA per ward. Multiple people have told us of reduced contact with staff on wards.
Another purpose of Oxevision is to reduce the costs of pursuing legal action against patients and potentially criminalise distress. Multiple trusts mentioned reduced cost of litigation in their business cases for the technology. Oxevision is constantly recording footage that can be ‘clipped’ and saved at staff’s request, which can then be used in evidence for prosecution or at an inquest. If not clipped, clear footage is automatically deleted after 24 hours. However, blurred footage is kept for 30 days.
How does Oxevision measure pulse, breathing rate and movement?
Oxevision is installed in bedrooms and uses a camera to detect breathing movement and ‘micro-blushes’ in the skin. If there is more than one person in the room it cannot measure pulse or breathing rate and the location-based alerts will also be inaccurate.
Oxevision is registered as a medical device because it can record pulse and breathing rate. Monitoring pulse and breathing rate for 1 minute is most accurate and a 15 second recording is the least accurate. Oxevision monitors for up to 15 seconds to gather a reading and it cannot detect if a pulse is strong or weak. It does not read blood pressure, oxygen saturation or temperature and therefore can not give a full National Early Warning Score (NEWS) which is used to detect and respond to clinical deterioration in patients and is seen by NHS England as “a key element of patient safety and improving patient outcomes”.
For this reason, as the company recognises, it should not be used to replace in-person observations.
Does Oxevision continually collect data on pulse and breathing rate?
Oxevision does not continually collect data on pulse and breathing rate in a way that is reliable measuring or monitoring. The system will attempt to continuously gather pulse and respiration rate if someone is in the room and this data can be turned into a graph to identify trends. However Oxehealth states that this feature “cannot be used to measure or monitor pulse rate or breathing rate” and it “is not intended to be used as a continuous vital signs monitor”. Despite confusion from both staff and patients, it’s important to remember that Oxevision does not alert staff to a change in vital signs.
What evidence is there that Oxevision helps staff improve safety on mental health wards?
The NIHR Mental Health Policy Research Unit was commissioned to do a systematic literature review of all the current evidence on vision based monitoring such as Oxevision. It concluded “there is currently insufficient evidence to suggest that surveillance technologies in inpatient mental health settings are achieving the outcomes they are employed to achieve, such as improving safety and reducing costs. The studies were generally of low methodological quality, lacked lived experience involvement, and a substantial proportion (18.5%) declared conflicts of interest”.
Despite there being inadequate evidence, NHS Trusts have continued to roll out Oxevision since it was first trialed in Broadmoor in 2014.
Oxevision has been mentioned in Prevention of Future Deaths (PFD) reports. This is a legal report where a coroner outlines the actions which need to be taken to prevent future deaths. A coroner stated specifically that she believed Oxevision was being used instead of in-person observations and had concerns that there was no way of knowing which staff had interacted with the system or reset alerts. In another inquest report it was stated that Oxevision was used “as a substitute for observations and engagement, and, in many cases, [staff] failed to use Oxevision correctly”.
Does the use of Oxevision affect patient privacy?
Yes, cameras installed in bedrooms is an invasion of privacy. We know from listening to lived experience that many people describe Oxevision as intrusive, undignified, dehumanising, (re)traumatising and having increased their distress. We have spoken to people who spent entire admissions sleeping on the bathroom floor, in communal areas, even in the garden, to avoid the camera despite begging staff to turn this off. One person told us they still don’t sleep in a bed after 8 months and multiple have said they look for cameras when they go in certain rooms.
Much of Oxehealth’s literature on Oxevision claims it improves privacy and dignity for patients by allowing them not to be ‘disturbed’ by observations. However, just because patients cannot see observations happening, doesn’t mean they aren’t being monitored. Rotherham Doncaster and South Humber NHS Trust recognise the risks in their Oxevision standard operating procedure where they note staff should not continue with an observation if a patient is undressing, masturbating or privately observing religious beliefs. This is not only a huge violation of trust with the patient but also affects patients’ right to privacy.
The purpose of observations is to provide therapeutic engagement and to check the wellbeing and safety of the patient; remote observations remove therapeutic opportunities.
If staff are not considerate or respectful, observations can disturb a patient’s sleep, however installing cameras in bedrooms is not a proportionate response to this. Wards are often noisy places; staff are not quiet, doors slam and the alarms are loud. This is what keeps patients awake at night and putting a camera in patients bedrooms does not solve this.
What controls are in place to protect patient privacy and dignity when Oxevision is used?
Oxehealth argue that national guidance developed by The National Mental Health and Learning Disability Nurse Directors offers some protection. We disagree, believing this guidance to be concerningly inadequate and harmful, including its suggestion that Trusts can choose to use ‘implicit consent’ – where all patients are opted in to the system as standard. This goes against advice issued to Trusts by NHS England that states such practice amounts to blanket restriction. The letter orders Trusts to gain informed consent to ensure that their use of the system is ethical, fair and lawful. Through our FOIs we know many Trusts still do not have a consent policy and are still using Oxevision in this unethical, and potentially unlawful, way.
The National Mental Health and Learning Disability Nurse Directors guidance ultimately prioritises convenience for staff above patients’ rights and was not meaningfully co-produced with people with lived experience, with only one service user representative and one carer representative being involved. A managing director at Oxehealth was also allowed to contribute, and we believe there is a possibility that this may have influenced the guidance.
Another way Oxehealth argue that privacy is protected is that staff view the live feed for just 15 seconds when doing vital signs. However we have found nothing to suggest that staff can’t click that live feed an unlimited number of times, leaving patients vulnerable to abuse, isolation and neglect. Southern Health, who use Oxevision exclusively on CAMHS wards, state in a patient leaflet that senior staff will be alerted in the case of “unnatural usage” when an individual room is viewed too many times. However it does not state what is considered “unnatural usage” nor does it prevent such potential abuse happening in the first place.
Which areas of the ward does Oxevision cover?
Oxehealth state that Oxevision only covers the bedroom area and will alert when the person is out of the room or in the bathroom/ensuite. However, an Essex University Partnership Trust CQC report mentions Oxevision being able to see, and therefore record, a patient coming out of the shower naked.
Many wards use CCTV in communal areas; this means there is nowhere except for bathrooms that are not covered by a form of surveillance. This inability to escape cameras and objectification can be dehumanising and impact the mental wellbeing of a person, especially those already experiencing crisis.
Are patients informed about Oxevision when it is used to support their care?
Patients and their carers are often inadequately informed about the use of Oxevision. Through our FOI requests we have analysed all patient posters available and noted the information is often inaccessible, contains complicated jargon and is not easy to read. None of the posters explained that data is shared with Oxehealth; only two informed patients the technology tracks when and how often they go to the toilet; and seven didn’t even include the word camera, instead using vague and confusing terms like “optical sensor”. ELFT have no poster at all.
What happens if a patient doesn’t want staff to use Oxevision to support their care?
Many trusts use Oxevision as standard care using implicit consent upon admission. This means patients are not asked whether they want Oxevision to be used. Trust policies state that a person’s objection must be documented but they won’t necessarily switch Oxevision off. At least 24 Trusts use Oxevison and at the time of our FOI requests only one had a consent policy in place.
Since our campaign began, Rotherham Doncaster and South Humber NHS Trust have implemented a consent form but we believe that the language of this is biased, coercive, and even passive aggressive, making patients tick a box saying they don’t want their physical and mental wellbeing supported. We believe that the use of coercive language and attitudes can make patients feel afraid of opting out.
Can Oxevision be switched off in an individual patient’s room?
Yes, in theory it is possible for staff to easily switch off Oxevision in individual rooms, however this is not the reality.
Multiple people have shared with us that staff refuse to switch off Oxevision, or say it cannot be switched off either because the technology prohibits it or because there have been no policies in place at their Trust to support this request.
We have also heard from people who have had it successfully switched off, only to later find it had been switched back on without their knowledge. Oxevision has a light that is always on regardless of if the system is switched off in that room, meaning there is no way for patients to know if the system is on or off.
We also note that mental health wards are often coercive environments and patients can be pressured into making decisions that are best for staff due to the significant power imbalance or not being aware of their rights.
Does Oxevision support individualised care?
Most trusts use Oxevision as part of ‘standard care’ regardless of patient objections. NHS England describes person-centred care as “focusing care on the needs of [the] individual”, therefore blanket use of Oxevision is not compatible with person-centred care. Oxevision is installed in all bedrooms regardless of individual needs and risk assessments.
It has been used as a replacement for face-to-face observations and is even sold as a way to step down patients from observations sooner than would have happened otherwise. In their ‘Stories from the Ward’ Oxehealth describe a scenario where a woman with a personality disorder diagnosis is not nursed on 1:1 to stop “reinforcing the negative behaviour” of self-harm and providing a “more measured engagement”. Face-to-face observations may hold therapeutic value and remote observations remove these opportunities for relational care.
Oxevision has the potential to be another tool the NHS can use to gatekeep care, such as enhanced observations.
Does the use of Oxevision mean patients will have less engagement with staff?
As previously addressed, we know from lived experience that Oxevision can mean less engagement with staff.
Oxehealth say their system is cost effective and can lead to savings. In their systematic literature review the NIHR Mental Health Policy Research Unit found that “the key driver of these savings was 36 hours of staff time saved per patient per year, primarily driven by a decrease in one-to-one observation hours”.
The purpose of face-to-face observations is to provide therapeutic engagement and to check the wellbeing and safety of the patient. Oxevision cannot detect when a patient is experiencing distress, only by building a therapeutic relationship can patients communicate their distress to staff: remote observations remove these opportunities.
We know from our own lived experience that in-person checks are an important opportunity for patients to make requests, such as for medication or food and drinks, as well as to seek support from staff. This is especially relevant to those who struggle to communicate and leave their rooms.
Have patients been involved in the development and implementation of Oxevision?
For at least a decade patients’ fears and lived experience have been dismissed and excluded from discussions about Oxevision. NHS Trusts dismissed patients’ concerns and continued to breach patients human rights and cause distress. It took a decade of patient concerns rising and our campaign for NHS England to write a letter addressed to all trusts to check their use of Oxevision is lawful.
We have found no evidence of lived experience involvement in the earliest stages of creation of the technology. Oxevision technology was marketed for police custody suites and in studies on neonatal babies before it was used primarily in mental health wards.
The Experts by Experience that Oxehealth had listed on their website until last year did not mention having direct experience of Oxevision and we believe that there is a lack of transparency about Oxehealth’s recruitment process for their lived experience advisory group.
Oxevision is installed in at least half of mental health trusts and Trusts are tied into contracts with Oxehealth; this indicates that it would now cost money to uninstall the devices. Experts by Experience are being invited to produce best practice guidelines to mitigate potential harms of Oxevision as opposed to having any say about it being there in the first place. Meaningful co-production requires lived experience involvement from the beginning, not after decisions have already been made and it is too late to influence them. It is clear this is not coproduction in the truest sense.