Open letter on the use of Oxevision in inpatient settings

By Stop Oxevision and supported by the National Survivor User Network.

This is an open letter to NHS England and to all mental health trusts in England. If you would like to add your support to this letter, you can do so by clicking the button to sign the petition below.

We write to express caution about the continued use of Oxevision in inpatient settings. Currently, increasing numbers of psychiatric hospitals in England use Oxevision — a patient monitoring system consisting of an infrared sensor and camera^[1] — in all patient bedrooms, thus enforcing blanket, 24-hour surveillance without ongoing informed consent and individualised risk assessments. Oxevision, and its surveillance methods, are being promoted as part of the NHS Innovation Accelerator, the same programme that supported the Serenity Integrated Mentoring (SIM) scheme — a coercive health care intervention which involves embedding police officers within mental health teams and promoting coercive practices such as withholding treatments and threatening legal sanctions^[2].

While balancing a patient’s privacy and dignity with their safety is undoubtedly a challenge, surveillance is a restrictive practice and its use demands serious scrutiny. The use of blanket surveillance in this instance risks retraumatising patients who may have experienced trauma related to surveillance, compromises patient privacy and lacks clarity in relation to the use of footage and technology. Oxevision must not be used in place of sufficient staffing to benefit staff rather than to improve patient care, and consent needs to be specific, individual, informed and ongoing.

We call on NHS England and individual mental health trusts to halt rollout of Oxevision whilst an independent review is conducted into the legality and potential risks associated with use of surveillance technology within psychiatric inpatient settings. 

Below, we outline a summary of Oxevision along with our key concerns about the potential risks posed by the use of the technology.

Background

Oxevision technology is specifically designed for psychiatric inpatient settings and records a patient in the room, allowing staff to remotely take the patient’s pulse and respiration rate, as well as using the camera feature to observe where the patient is in the room and check their safety^[3]. The system alerts staff when it detects a patient is out of view; in the bathroom; or when another person enters the room, allowing staff to check the cameras from the office or on a tablet^[4]. Care Protect is a similar video patient monitoring system which records video and audio information from patients and is remotely monitored^[5].

Surveillance as restrictive practice

While under usual treatment patients may be under constant observation from members of staff, which can be highly disruptive. There may be instances where – with appropriate consideration, informed consent and involvement from the patient – surveillance may be considered the least restrictive option. However, Oxevision systems are installed in all patient bedrooms and used as standard care rather than where necessary and assessed on an individual basis^[6]. Such blanket use of 24-hour surveillance in patient bedrooms could be viewed as disproportionately restrictive, not allowing for individualised care planning and consideration of the ‘least restrictive option’^[7]. As highlighted in a report by The Restraint Reduction Network and The British Institution of Human Rights, surveillance is a restrictive intervention with Human Rights implications^[8]. However, the rapid rollout of Oxevision across psychiatric hospitals in England lacks consideration of the significance of blanket use of surveillance, and how this may impact the rights and freedoms of patients.

Additionally, although Oxevision marketing emphasise this equipment is used for taking vital signs, documents highlight that full physical observations will continue to be required in person^[9]. This undermines the legitimacy of use of invasive video surveillance to obtain vital signs and suggests the primary function of the equipment is video monitoring and not taking vital signs. However, the vital signs function of this equipment allows Oxevision devices to be registered as a medical device^[10] and allows Oxehealth to market this product as not being CCTV^[11]. This may have implications in how the device is considered within legal and legislative frameworks.

The use of surveillance technology may pose specific risks and distress for patients who have experienced trauma in relation to surveillance-based abuse or paranoia related to being recorded. If patients are not able to decline use of Oxevision, there is a significant risk of causing harm, distress, and replication of abuse for the individual.

Consent

The processes of obtaining patient consent for use of Oxevision may vary across Trusts. Information about the processes for patients providing consent and/or withdrawing consent is unclear and how detention under The Mental Health Act would impact the right to withdraw consent^[12]. Reports from Patients who have been on wards which use Oxevision indicate these are used as standard procedure without processes for seeking patient consent; where patients have requested that Oxevision is not used, this has been continued without consent^[13]. A policy document from Rotherham Doncaster & South Humber NHS Foundation Trust (RDaSH) is opaque about the consent process and patient’s right to decline the use of Oxevision during their hospital stay, “if a patient or their relative objects and requests that the technology be turned off, this objection is to be noted on the patients record but NOT to be actioned at this stage.”^[14]This increases concerns as to the lack of clarity about patient’s rights where Oxevision is used.

Impact of privacy and dignity

24-hour video surveillance of patients significantly compromises privacy through allowing staff to observe patients without the awareness of the patient, which may include times the person is in a state of underdress. Although this may also occur during standard in-person observations of patients, staff knock on the door prior to entering and the patient would be aware of when a staff member had seen them in such cases. The Oxevision policy for Rotherham, Doncaster and South Humber Trust refers to a patient being undressed or engaging in masturbation stating, “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.”^[15] The policy makes no discussion of whether a patient should be notified if a staff member has attempted observation whilst they are exposed. Furthermore, there are no controls in place to prevent staff abusing these systems and using Oxevision devices to view video images of patients when undressing.

Data protection

Oxevision provides both blurred and clear images which can then be viewed by staff through the Oxevision system or via an iPad. Some clear video footage of patients is ‘clipped’ and may be transported to Oxehealth secure storage facilities and viewed by Oxehealth staff as part of monitoring how the equipment is working^[16]. However, there is little clarity on the use and lifespan of Oxevision footage following a recorded incident in the capacity for remote viewing outside of the inpatient setting, with reference to usage of footage in regards to safeguarding cases, and distribution via an encrypted USB. This includes a lack of clarity about how footage may be used in legal investigations following incidents such as assault or patient death. Concerns have been raised about the use of video recording in psychiatric hospitals and the role this plays in criminalisation of mental health^[17][18].  Additionally, there is a lack of consideration^[19] of how data sharing may disproportionately impact and harm minoritised groups and those who are vulnerable to discrimination such as asylum seekers and transgender people^[20].

Technology as a response to poor levels of staffing and high levels of poor practice

The RDaSH Oxevision policy states: “Oxehealth does not replace therapeutic engagement” however in context of poor levels of staffing across wards, we are concerned Oxevision and other remote monitoring technology may be used in response to inadequate and unsafe staffing levels. For example, an assessment of the economic values of Oxevision highlights this technology can save money through reducing need for additional staff to be employed to cover patient 1:1 observations^[21]. Whilst being on 1:1 is undoubtedly restrictive for patients^[22] and may have limited therapeutic value or increase patient distress, the implications of implementing technology to  compensate for low staff levels raises significant questions and highlights healthcare services as designed to benefit staff rather than the individual needs of patients.

Additionally, there is a wider context of poor practices of treatment in psychiatric inpatient settings which includes staff members failing to respond appropriately to incidents^[23] or complete patient observations as is outlined in their care plans^[24]. The Oxevision website cites preventing staff from falsifying observation records as a value of Oxevision^[25]. This relates to instances where observations of patients are not completed which is known to be a contributory factor in patient deaths in inpatient settings^[26]. As we saw with the StopSIM campaign, the introduction of restrictive and ethically questionable practices are being made in response to service failures, thereby detrimentally impacting the patient rather than demanding that the rights and safety of service users are upheld by their care providers.

Further concerns are raised about how technology may be used as part of dangerous healthcare practices, for example an Oxehealth ‘patient story’ describes staff delaying response to a patient having tied a ligature as they could see on video this was “loose”^[27]. This is an example of unsafe care and may risk loss of life due to failure of staff to respond to incidents in time where video surveillance provides a false sense of confidence about the [lack of] risk to the patient. 

Failure to adequately scrutinise healthcare ‘innovations’

To support the rollout and expansion of Oxevision, the company Oxehealth were awarded financial support from NHS Innovation Accelerator^[28][29]. As was the case with SIM, public funds were awarded by the NHS Innovation Accelerator and AHSNs to promote the spread of an intervention which represents concerning treatments for patients with mental illness^[30]. This demonstrates a repeated failure to undertake due diligence in considering the legal implications and risk of ‘innovations’ posing harm to patients prior to supporting and endorsing these. This raises questions about the processes taken in reviewing innovations; as technology becomes an increasing presence in modern life, the ethical implications this may have in healthcare settings must be reviewed.

We call on NHS England and individual mental health trusts to halt rollout of Oxevision whilst an independent review is conducted into the legality and potential risks associated with use of surveillance technology within psychiatric inpatient settings.

Click the button below to sign the petition on change.org to stop the rollout of Oxevision and invasive video surveillance in psychiatric hospitals. Please note that with change.org petitions you will most likely have to click a confirmation link sent to your email to add your signature – this email might go to your spam folder or “promotions” in gmail.

StopOxevision links and resources:

• Stop Oxevision Twitter
• Stop Oxevision website
• Stop Oxevision email: stopoxevision@gmail.com
• Stop Oxevision Google Drive (Freedom on Information request documentation)
• Oxevision Trust usage mapping document