Mental health trust linked to 30 deaths
Campaigners call for inquiry into fatalities in Norfolk and Suffolk
More than 30 patients died after risks were not acted on in the decade following a controversial service redesign at a crisis-hit NHS mental health trust, say campaigners.
A report by the Campaign to Save Mental Health Services in Norfolk and Suffolk also logs nearly 20 patients of Norfolk and Suffolk NHS Foundation Trust (NSFT) who have died since 2013 after communication failures, while family concerns were ignored in 15 cases.
Longstanding concerns over mismanagement and poor care at NSFT were raised after a report from the auditors Grant Thornton last year revealed there were 8,440 “unexpected” deaths of patients of the trust between April 2019 and October 2022. The trust has had nine chief executives in 10 years and has been placed in special measures four times.
The new report analysed 86 deaths of NSFT patients that were reported by local or national media since the service redesign in 2013, as well as prevention of future deaths (PFD) notices written by coroners.
The report categorised the 86 deaths into different factors that were publicly reported, with “risk not acted on” appearing most frequently (31 cases), followed by “poor communication” (19), and “expressions of suicide ignored” and “family concerns ignored” (15 each). Some cases had more than one factor.
In 2013, senior managers at NSFT implemented a “radical redesign” of services that cut beds, reduced the number of consultant psychiatrists and replaced primary care mental health teams with new teams that proved harder to access.
“The radical redesign was driven by the coalition government’s austerity programme where they cut 20% of NSFT’s budget,” Mark Harrison, chairman of the campaign, told the Observer. “They closed the homelessness team, broke up the crisis team, took NSFT workers out of GP surgeries. They made many of their most experienced staff redundant. And they made the others reapply for their jobs, where they added extra responsibilities for the same money. This is what led to the increased rate of unnecessary deaths.”
The campaign is calling for a public inquiry and police investigation.
Sheila Preston’s son, Leo Jacobs, was diagnosed with paranoid schizophrenia in 1998 but his service provision went downhill after the 2013 service redesign. The workload of community nurses shot up and family carers such as Preston were sidelined.
About 18 months before he died, Leo said he did not want to see his family. His behaviour became increasingly erratic and paranoid. But a restructure of nursing teams in late 2016 brought disaster. “Everybody was given a different patch. His nurse, who used to visit him every two weeks, had to say goodbye and he got a new nurse,” she said.
But the change was implemented during school half-term. Leo’s new nurse went on holiday and was ill when he came back. Leo should have been seen every two weeks, but instead he was not seen at all.
During that time he had been “cuckooed” – county lines drug dealers had moved into his flat.
Leo died of a drug overdose – it is not known whether it was intentional – aged 38. Preston believes if the nurse had been visiting, they would have seen what was happening.
She spoke to the Observer in a personal capacity but she previously spent nine years as a governor at NSFT and has recently returned to the role. NSFT’s new strategy involves another restructure, which she fears will have the same poor outcome.
An NSFT spokesperson said: “We are working hard to learn from these incidents and ensure they are minimised in future.” The trust said it was improving its collection and use of mortality data, had reduced its nursing vacancy levels, was reviewing PFD reports and was working on waiting times, record keeping and carer involvement.