The number of safety incidents involving teenagers admitted to an inpatient mental health service increased significantly this summer after the unit had to relocate due to a legionella outbreak. 

A report to the Leicestershire Partnership Trust (LPT), which provides NHS mental health support for people in Leicestershire and Rutland, has revealed the issues since the Beacon unit at Glenfield Hospital in Leicester had to move due to an outbreak of the waterborne bacteria in April. The trust says the bacteria was detected early and there were no connected illnesses.  

Breathing in water droplets containing legionella can lead to the potentially fatal Legionnaires' disease. 

The young patients had been moved to an adult inpatient ward at the Bradgate mental health unit at the same Leicester hospital site and returned to the Beacon unit on 17th July, but during the period they were out of the dedicated unit, self-harm, violence and the use of restraint all increased significantly. 

In patients were moved to Bradgate Mental Health Unit following a legionella outbreak (Photo: Google Maps)

It says: "Staff have reported that as a result of the different environment on Thornton Ward, echoey, not as spacious and lack of seclusion facilities, has led to protracted incidents which might have otherwise ended sooner; the increases in incident relates to three patients." 

Currently the unit is staffed by 50 per cent agency staff and during the move had reduced the number of patients it was looking after. At full capacity, Beacon, which opened four years ago, can look after 15 young people who are suffering with severe mental health problems. 

Some of the young patients treated by LPT are force fed due to eating disorders and the patient safety report recorded that there had been 378 restraints used by LPT staff on patients throughout its settings in May and June, with just over 60 per cent of those occurring in the temporary Beacon unit. 

The report says: "The increase reflects the interventions when patients are self-harming and the needs of patients who continue to require nasogastric tube feeds twice a day under restraint. Patients care and treatment is continually reviewed to minimise the need to restrain during nasogastric feeding." 

Police had to be called out to assist staff. 

The report continues: "Additionally, in CAMHs Beacon unit there has been an increase in physical aggression amongst the patients at the end of May 2025. This has been related to changing risks, self-harm interventions and behaviour aimed at property damage, requiring police support and uncertainty regarding discharge arrangements."  

At the meeting LPT's deputy director of nursing Emma Wallis said: "From staff feedback and looking at some of the incidents there were those environmental factors. I think there were also patient factors as well. There is an expectation that with the environment going back to the unit's normal environment that some of the things that were highlighted as contributory will resolve, but until we see the data it is difficult to say." 

Across the trust, which is led by chief executive Angela Hillery, there were 3,641 patient safety incidents that were attributable to the trust. Of those, 1,930 of the incidents resulted in non-harm to the patient, however 46 incidents were recorded as moderate harm, eight incidents were severe, and 25 patient safety incidents were recorded as deaths. 

A fifth of safety incidents were classified as 'tissue viability' which relates to pressure ulcers and wounds and 517 incidents were related to self harm. 

The report says: "These incidents were reported in May and June 2025 and will be being reviewed through local and corporate governance structures and the degree of harm may therefore change. Since moving to the national NHSE Learning from Patient Safety Events (LFPSE) system there is a requirement to report incidents by 'harm' to the patient as a result of an incident, even if this does not involve care delivered in your organisation. 

"This accounts for the increase in number of deaths reported compared to the same reporting period in 2024. To note some deaths will be reported by staff that may not have been as a result of an incident, this is to ensure that we do review the care delivered by LPT to identify any opportunity for learning and the degree of harm may be amended after this review." 

Beside the Beacon unit incident, the trust also had detected Legionella at Melton Hospital last September. 

Legionella can lead to the potentially fatal Legionaires' disease (Photo: Public Health Image Library)

In a statement today it said: "As a trust, we routinely test for legionella across our estate.  This allows for early detection of legionella bacteria which if unresolved can – in extreme circumstances – cause Legionnaires' disease. Our testing shows mostly negative results although on very rare occasions we have detected trace levels of the legionella bacteria. 

"By detecting trace levels of legionella bacteria early means we can treat the affected areas before there is a risk to patients, staff or visitors.  Treatment takes the form of dosing the system and many of our older buildings now have built in dosing systems.  Alongside the treatment to the water system, we have fitted filters to taps to ensure everyone's safety and we make sure that bottled water is always available if needed. 

We have had no reported cases of any connected illness. 

"The LPT legionella testing programme has been adopted by other NHS trusts across the region."