‘Catalogue of missed opportunities’ before death of Norwich mental health patient Neil Jewell

Neil Jewell, 42, died while under the care of Norfolk and Suffolk Foundation Trust. Photo: CONTRIBU

Neil Jewell, 42, died while under the care of Norfolk and Suffolk Foundation Trust. Photo: CONTRIBUTED - Credit: Archant

The family of a Norwich man has hit out at a lack of resources for mental health and said there was a 'catalogue of missed opportunities' before his death.

The inquest of Neil Jewell, 42, of Philadelphia Lane, finished yesterday, identifying failings in his care by the Norfolk and Suffolk Foundation Trust (NSFT).

Speaking after the inquest, his family said in a statement: 'Neil was a gentle person, quiet and unassuming, but extremely naive and vulnerable and who became increasingly isolated because of the deterioration in his mental health.

'The evidence during this inquest clearly points to a catalogue of missed opportunities, poor decision making, inadequate record keeping and routine disregard for policies.'

A 'pale' Mr Jewell arrived at Norwich's Hellesdon Hospital clinic on January 6, 2014.

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He had run out of Clozapine, his schizophrenia treatment drug which had kept him stable for three years.

He had previously been sent away without enough supply, the inquest heard.

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The NSFT placed him in a bed in Hamilton House care home in Catfield as they did not have enough beds for him.

But when his condition deteriorated, he was handcuffed, sedated and taken to West Suffolk Hospital and then on to Ipswich Hospital with police aid.

He was laid face down on an ambulance stretcher with his arms and legs restrained.

He was placed in a seclusion room under constant observation at Ipswich Hospital's Woodlands Unit.

The next day, January 12, he was found unresponsive after suffering a cardiac arrest. He never regained consciousness.

The inquest jury in Ipswich concluded he died from complications following a cardiac arrest caused by postural asphyxia, with the asphyxia caused by the position in which he was lying, and the adverse effects of sedative drugs used in his rapid tranquilisation to which neglect contributed.

The family said if it had not been for the inadequate treatment Mr Jewell received while still in Norfolk he would never have reached the point of being handcuffed, sedated and strapped to a stretcher.

'It is no exaggeration to say that the investigations into Neil's death have together probably run into hundreds of thousands of pounds,' the family said.

'If only a fraction of that money had been spent on proper resourcing and care, Neil would still be with us.'

The NSFT apologised after the jury inquest.

Dr Peter Dean, coroner for Greater Suffolk, said he will write to the NSFT asking for a review of protocols.

•What the NSFT says

Dr Jane Sayer, director of quality and nursing at the NSFT, said: 'Our thoughts are with this patient's family and friends. This was an extremely sad situation, and they have our deepest sympathy.

'We fully take on board the findings of the Coroner and the jury and unreservedly apologise for what has been deemed as our Trust's part in the contribution to this patient's death in 2014. The care provided was not acceptable and is not the standard of care we would offer to patients in our services today.

'Since the patient's death, and following our own extensive internal reviews into what went wrong we introduced immediate measures to put things right to avoid this happening again. This has included ensuring that our patients based in the community always have a named mental health professional or duty worker coordinating their care, to offer greater support.

'We have invested in increasing the capacity of our community mental health teams, and have held a complete review of our Crisis Resolution Home Treatment teams (CRHT) to ensure they can provide patients with adequate support and assessment.

'At NSFT we have also already reviewed our rapid tranquilisation policy and improved training for our staff, and introduced advanced training for our staff to identify and avoid risk of postural asphyxia.

'Our Trust is a different organisation with different leadership today and over the past three years since this tragic death took place, we have continued to ensure we always keep the patient at the centre of our services and will do so into the future.'


Neil Jewell's death at the age of 42 came during a troubled time for the region's mental health services.

The Norfolk and Suffolk Foundation Trust (NSFT) was in the middle of a 'radical redesign' of services which saw cuts to beds, staff and services.

Its chief executive, Aidan Thomas, stepped down during the redesign and a month after Mr Jewell's death inspectors found failings at the NSFT's Hellesdon Hospital in Norwich.

Improvements have now been made - the NSFT is no longer rated as 'inadequate' by inspectors. But Mr Jewell's death exposed a lack of mental health beds in the region which is still a problem now.

Patients are still sent away, sometimes to facilities rated 'inadequate' by the Care Quality Commission.

Mr Jewell was sent to Hamilton House care home at Catfield, which has now closed, because the NSFT did not have any beds itself. It was there that his condition deteriorated.

Inspectors warned in 2011 that improvements were needed at Hamilton House and in 2015 it was rated as 'inadequate'. After his death, the Norfolk and Suffolk Safeguarding Adults Board carried out an investigation.

The review named Mr Jewell as AA. It described him as a 'quiet and gentle man who lived with paranoid schizophrenia' which he managed thanks to community support workers.

But in 2011 this all changed when the NSFT made Mr Jewell's care coordinator redundant. 'The level of care support that he received reduced dramatically', the review found.

The report found a series of events then led to his death – he ran out of medication, there was no suitable mental health hospital bed for him so he was admitted to the care home which seemed unsure about how to deal with his challenging behaviour.

The police were asked to intervene in a situation which required mental health professionals.

Rather than getting help, he was handcuffed, sedated, strapped to a stretcher and put in confinement in Suffolk because there were no beds in Norfolk.

Mr Jewell's death has rightly served as a warning about how we treat people with mental health conditions.

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