Concerns remain following Norfolk and Suffolk NHS trust update on unaccounted mental health deaths report
A local watchdog and campaigners have expressed their concerns following an NHS mental health trust’s update on unaccounted deaths.
Representatives from Norfolk and Suffolk NHS Foundation Trust (NSFT) and both Integrated Care Boards (ICBs) in Norfolk & Waveney and Suffolk & North East Essex, joined councillors from the county council’s health scrutiny committee this morning to provide an update on their actions since the Grant Thornton report.
The report was published in June 2023 and concluded that there were problems in the way NSFT monitored and recorded the deaths of inpatients and those in the community.
It also revealed that out of 11,379 deaths of people in contact with the trust over five years, the number which could have been deemed avoidable was unclear.
At the time, however, the trust pointed out most deaths did not relate to poor care, but included natural causes.
Since then, the representatives said this morning, the trust introduced a new system which addressed many of the recommendations included in the Grant Thornton report.
Andrew Kelso, medical director at the Suffolk & North East Essex ICB, said the new system ensured continuous learning.
He added: “We haven’t just invested in electronic systems, we have also invested in the people that have to run it and use it. Learning from deaths extends long beyond preventing suicide and into other causes of death as well.”
The new system includes a list which holds data on all patient deaths that have occurred during care at NSFT, or within six months of discharge, and a dashboard displaying patient data.
The trust has also established a new Learning from Deaths Action Plan Management Group replacing the board set up following the report.
Gary O’Hare, who represented the NSFT, said: “This won’t be that we’ve completed the Grant Thornton action plan, put it on a shelf and forget about it, it’s about continuous learning and quality improvement.
“When we look back, sorry, this isn’t enough, it will never bring a loved one back, so we have to think about how we go forward. We can’t guarantee we will prevent all deaths going forward but we will prevent as many as we possibly can.”
However, Andy Yacoub, Healthwatch Suffolk CEO, said the watchdog was still extremely concerned about how the review process had been carried out, including the employment of the report’s recommendations.
He added: “The way that this process has been carried out to date has often destroyed trust, created reputational and significant financial cost and hurt all who are involved. There is a vital need for independence and transparency.”
Mr Yacoub also went on to say that the trust’s new system continued to sideline the lived experiences of those affected by its failings.
For these reasons, he said, the watchdog has withdrawn from the action plan’s management group until a guarantee was provided of the trust’s transformation — but still said it would continue to offer its insights.
This came after a group of Norfolk campaigners representing bereaved families also announced they would no longer work with the trust on its new action plan during Norfolk council’s scrutiny meeting.
Although Mr Kelso admitted NSFT had not listened to bereaved families as it should in the past, it maintained that lived experience was important in the trust’s new system.
He said: “The patient voice and the lived experience of users and bereaved relatives are absolutely essential to the work we are doing. There’s no point in me saying ‘yes that’s terrible’ and patting someone on the hand, I have to be curious about what they’re saying.”
Mark Harrison, from the Campaign to Save Mental Health Services in Norfolk and Suffolk, said he fully supported the health watchdog’s decision.
He emphasised his group’s calls for NSFT to be disbanded and put into special administration to give way for a less dysfunctional, and more localised, mental health service. Mr Harrison also stressed the need for an independent statutory public inquiry into the deaths.
In this morning’s report, it is stated that external verification, which was part of the Grant Thornton recommendations, had not yet been conducted due to the recency of the system but added that it would be reviewed as part of the trust’s internal audit schedule for 24/25.
Mr Harrison responded: “We don’t trust them to mark their own homework because they proved time and time again that what’s important to them is corporate reputation. We’re talking about a huge death crisis of which they are at the centre.”
Despite the trust’s failings, Mr Harrison also pointed out that Government policy continued to starve residents across both counties of adequate mental health care. He said: “Conservative MPs that populate Norfolk and Suffolk have continued with austerity as far as mental health is concerned and they failed in their duty of care to the population.”