'Unsafe' Cygnet Hospital Coventry put in special measures
A woman on an "unsafe" mental health ward claims she had to untie a ligature from another patient as there were no staff to help, a watchdog said.
The Care Quality Commission (CQC) said two people had died on the "chaotic" Dunsmore ward at Cygnet Hospital Coventry, which it shut following an inspection in July.
The private mental health hospital for women was rated inadequate has been placed in special measures.
Cygnet said it was addressing issues.
The hospital was rated good in June 2018, but the account of the ligature incident emerged in the latest reports, with inspectors also finding high levels of patient self-harm on Dunsmore.
Rating safety at the hospital inadequate, the report said: "Care on Dunsmore and Middlemarch wards was not safe.
"There were not enough staff who knew patients well enough to keep them safe from avoidable harm."
"What we found was unacceptable," said Dr Kevin Cleary of the CQC.
Two patients had died on Dunsmore ward - one in 2018 and one in 2019 - and both "were linked to a failure by staff to carry out patient engagement and observations correctly", the report said.
The report did not go into detail about the deaths, but a Dunsmore patient was the focus of an inquest earlier this year.
A jury found inadequate staffing levels likely contributed to the death of Claire Greaves, 25, from Pontypool, Wales, in February 2018.
And in May this year, a former senior nurse who managed Dunsmore ward said he repeatedly told management he felt staffing levels were not safe.
In the latest report, the CQC said leaders were "out of touch with what was happening on the front line".
But the service was praised for recovery-orientated care plans and managing beds.
Though some patients said some temporary staff referred to them by room number rather than name, "most permanent staff treated patients with compassion," the report said.
Service provider Cygnet Health Care has been ordered to improve staffing levels, training, patient dignity, cleanliness and the recording of incidents.
A spokesman said it had undertaken "significant steps to immediately address the issues raised and have fully implemented a comprehensive action plan agreed with the CQC".