Calls for independent public inquiry as Norfolk and Suffolk Foundation Trust publishes learning from deaths report

A mental health trust has said it would learn from a long-awaited report into deaths of those it cared for, as campaigners renewed calls for an independent statutory public inquiry.

Norfolk and Suffolk NHS Foundation Trust (NSFT) has published a learning from deaths report, covering the period April 2019-October 2023, into deaths of people who had received care from NSFT.

The report also provides evidence about the quality of NSFT services and how they must be improved.

A statement from the trust said: “The trust does not underestimate how much pain and trauma bereaved families and relatives have been through.

“The trust sincerely apologises that we may have added to this pain by not accurately recording the circumstances surrounding the loss of their loved ones and not being able to show our learning and improvement from each and every death.

“This new analysis has produced important learning for the trust and the wider health and care system.”

The report fulfils the commitment made by NSFT chief executive Caroline Donovan when she joined the trust in November 2023, to investigate deaths and publish the findings, involving hundreds of staff reviewing thousands of records.

Key themes from the report include staffing, record keeping, communications between NHS teams and with patients and families and waiting times.

The in-depth analysis screened all 12,503 deaths from 2019 to 2023.

Of these 12,503 deaths:

• 6,118 patients were not in receipt of care from NSFT in the last six months of their life
• 6,385 patients were under the care of NSFT within the last six months of their life and met the scope of the review

Of the 6,385 patients who were under the care of NSFT within the last six months of their life:

• 92 per cent of people died from natural causes, such as heart disease or cancer
• 3,598 deaths were expected due to natural causes – 56 per cent
• 2,293 unexpected deaths were due to natural causes – 36 per cent
• 418 unexpected unnatural deaths – seven per cent
• 76 deaths unknown – one per cent

During this period, there were 14 prevention of future deaths notices issued from coroners instructing the trust to improve care to prevent future deaths.

The analysis shows a number of common themes:

• Communication with patients and carers and between teams needs strengthening
• Waiting times are too long and there are too many barriers to accessing services
• Record keeping and processes are inconsistent
• The trust needs to grow, value and retain its workforce.

NSFT said yesterday there was more work ahead, however progress had been made reducing waiting times; improved staffing and a five per cent reduction of staff leaving the organisation.

Meanwhile, a learning from deaths group had been established to ensure learning and improvement are trust priorities.

However, mmbers of the Campaign to Save Mental Health Services in Norfolk and Suffolk committee said: “The learning in this report has been stated before, on multiple occasions.

“The wrongs that have taken place have been largely preventable. The bereaved and the public are still concerned about the absence of accountability for previous harm. We continue to call for an independent statutory public inquiry.

“The aim of this piece of NSFT work is to learn from deaths. We want to hope this is what the trust is doing.”

Caroline Donovan, chief executive, said: “Every death is a death too many and every person who has died has a family whose lives have been devastated from their loss.

“We will learn from and use this evidence to deal with problems and improve care.

“This report rights a wrong. We can’t learn from these sad outcomes and experiences and we can’t assess our performance and quality if we don’t know what’s happening to the people in our care.

“We now investigate and report on patient deaths, in public, to every board meeting.”

Dr Ed Garratt OBE, chief executive of NHS Suffolk and North East Essex Integrated Care Board, said: “We recognise how difficult this report will be for the bereaved families affected by it​.

“We believe NSFT has made significant progress in understanding mortality data and has better processes now in place for the future.”

Alex Stewart, chief executive of Healthwatch Norfolk, said the detail, intelligence and themes revealed in the review highlighted key areas for NSFT to work on, while it welcomed the trust’s call for a joined-up approach across the health and care system.

“This does not lessen the pain, trauma and upset those who have lost family-members and friends must fee,” he said. “The focus of everyone working in health and social care must be to ensure they do all they can to prevent future deaths.”