‘She had ligated to get the attention of staff’: how is Oxevision enabling poor practice on psychiatric wards?

Content note: suicide, self-harm, psychiatric hospitals, neglect

Oxevision is a patient monitoring system that uses an infrared camera to allow staff on psychiatric wards to take vital signs and observe a patient remotely. It was created by the private company Oxehealth and is being rapidly rolled out across the country, with multiple NHS Trusts using the technology, often in all patient bedrooms on a ward.

This raises questions about the potential harm of using this kind of surveillance technology in inpatient mental health settings. A frequent response to this concern by Oxevision supporters is that it matters how the technology is being implemented rather than what it does.

This sounds potentially difficult to distinguish, but we can learn a lot by looking at Oxehealth and individual NHS Trusts own material. Oxehealth have gathered anecdotes from ward staff into reports they call ‘Stories from the Ward’, which are meant to show their technology being used at its best.

In one, a ward manager talks about a patient who he believes ties ligatures to get attention from staff. He states that attending to this patient after an attempted ligature was ‘reinforcing a negative behaviour’ and due to Oxevision they ‘now provide more measured engagement which has reduced her dependency on our attention’. We know that this approach is often used for patients with a personality disorder diagnosis as a way for the patient to ‘take responsibility’ for their perceived bad behaviour. These failings have been recognised by the charity INQUEST, whose director Deborah Coles identifies that it is mostly women given the Emotionally Unstable Personality Disorder (EUPD) diagnosis. In a statement she says these women are ‘frequently and repeatedly let down by mental health services’, and calls for national oversight on deaths in mental health settings.

It seems Oxevision is enabling this practice with potentially fatal consequences. Another ward manager describes a situation where the technology is used to reduce observations for a patient with EUPD, leading to her ligating in a bathroom and nearly dying, requiring oxygen treatment. It is not acceptable to use this technology to take such risks and it is even more egregious that this is presented as an example of best practice. The ward manager says Oxevision ‘prevented a potential fatality’. However, this situation should never have been allowed to happen in the first place and might have been avoided if the patient had been put on an appropriate level of observation for her risk, instead of relying on the Oxevision activity-tracker alerts.

In Robert’s* ‘Story from the Ward’, a ward manager explains how they saw Robert had attempted to ligate while in seclusion. They used Oxevision to ‘keep an eye on him’ instead of going in to help immediately because they believed the ligature had only been tied ‘loosely’ around his neck. Given the limitations of this technology, delaying a response to a potentially life-threatening situation is a big risk to take.

In another worrying example, a charge nurse shares an experience of using Oxevision to take vital signs remotely instead of getting a doctor immediately, because she believed the patient had faked a seizure. This ‘Story from the Ward’ comes from Essex Partnership University NHS Foundation Trust who were early adopters of Oxevision and are currently the subject of a statutory inquiry into deaths of mental health inpatients across the Trust.

There are also multiple anecdotes of staff using the technology to interact with patients less. One healthcare assistant talks about using Oxevision to view an agitated patient, asking himself, ‘is it worth sending someone in to talk to them, or is anyone going to be at risk of getting hurt?’. While staff safety must be protected, making this kind of decision risks staff relying on technology rather than de-escalation and building trust with a patient.

Similarly, Oxevision brings up issues about staff safety vs patient interaction in relation to COVID-19. The manager of an older adults ward talks about using Oxevision to monitor a patient in her 80s with the virus, allowing staff to avoid ‘unnecessary contact’ and only provide in-person care when its ‘needed’. How is this distinction made and by who? Does Oxevision mean patients with COVID-19, or who are otherwise considered ‘a risk’, become more isolated?

In another example, a charge nurse talks about using Oxevision to monitor ‘distressed patients’ to understand how they’re doing without ‘disturbing them’. The power imbalance between staff and patients on psychiatric wards is huge and building a patient-staff relationship that is satisfactory, let alone therapeutic, is challenging. By choosing to observe patients through a live feed rather than interact with them personally, staff are cutting off an opportunity for connection.

However, the staff in Oxehealth’s promotional material often claim that Oxevision has actually increased patient interaction. It seems this increased contact staff are self-reporting is from interactions with patients in the communal area. We know that many patients have a tendency to isolate when unwell, or may have sensory needs that make being in communal areas distressing. Oxevision means these patients are even more overlooked.

These stories also highlight the huge issue of privacy and dignity related to Oxevision. One nurse explains that a patient who kept taking her clothes off was monitored remotely ‘to uphold her her privacy and dignity’. How is Oxevision upholding dignity in this situation when staff are now just viewing her naked via a camera? The nurse states that part of the rationale was there being male staff on observations, however there has been no guidance produced on the use of Oxevision and gender, and male staff are able to check the technology to monitor female patients.

We know that at least some NHS Trusts are aware that privacy and dignity can be compromised through the use of Oxevision because it is mentioned in this Trusts guidance on its use. It states:

‘There may be instances when it is not appropriate to continue with an observation, for example:
– If a patient is in a state of undress
– A patient is engaging in sexual activity (masturbation) and needs individual private time
An observation should be cancelled immediately in these circumstances. Upon observation if it is not appropriate to continue with the observation to maintain the patient’s privacy and dignity, then record their position and activity and re-attempt when privacy and dignity is no longer compromised’

It is not addressed what staff should do if they are monitoring a patient who is regularly taking their clothes of as a presentation of their illness, agitation or distress.

Oxevision uses a tablet that staff can take with them around the ward, meaning there is also the potential for video to be seen by other patients in the vicinity. Oxehealth themselves recognise this possibility, stating ‘be careful to maintain the privacy and dignity of your subject by ensuring that your screen is not visible to any members of the public’.

Perhaps the most shocking feature of all these ‘stories’ is that they are being displayed as good practice. If this is how NHS staff and Oxehealth are happy to say Oxevision is being used, what has been left unsaid? We know poor practice is usually hidden and that is part of the reason why it’s difficult to eradicate. All these examples were readily available to find on Oxehealth’s website or in individual NHS Trust’s own materials, and yet this will be the tip of the iceberg in terms of potential harm.

The Stop Oxevision campaign is calling for an immediate halt to the rollout of Oxevision while a review is conducted into its legality and the potential risks associated with it. If you would like to read more about our concerns please see our open letter and sign the petition here.

* all names in the ‘Stories from the Ward’ reports are changed for anonymity