The region's troubled mental health service has been accused of failing to learn from its mistakes after it emerged that nowhere in the country had more concerns raised about mental health deaths than Norfolk and Suffolk.
Coroners have written to the Norfolk and Suffolk Foundation Trust (NSFT) 13 times after patient deaths since its formation in January 2012, detailing their worries about the state of the service.
Analysis of the coroners' letters, known as Reports to Prevent Future Deaths, show the same mistakes keep being made when patients die.
NHS whistleblower and mental health doctor Dr Minh Alexander has looked at the coroners' letters for every mental health trust in the country going back to 2008 and found Norfolk and Suffolk have received 21 coroner reports.
The reports, formerly known as Rule 43s, are sent by coroners after inquests when they feel lessons could be learned from the case to prevent future deaths.
'If trusts are getting repeated Rule 43s, like the NSFT have, questions clearly need to be asked,' Dr Alexander said. She admitted the data she collected was limited but said her report did show themes in death after death at mental health trusts.
'There are very clear examples of a lack of learning,' she said.
Of the 21 deaths since 2008 in Norfolk and Suffolk covered in Dr Alexander's report, fears have been raised about lack of staff on six occasions. Another six times there are fears over risk assessments.
On two occasions the care plan was not properly implemented and five of the deaths highlighted problems with the mental health trust's relationship with other services, including GPs and the police. The panels on the right show 10 of these cases.
North Norfolk MP and former health minister Norman Lamb said the repeated concerns from coroners were 'really disturbing' because it suggested a failure to learn. 'The approach which I am campaigning to see implemented across the country is for all organisations to commit to a Zero Suicide Ambition,' he said. 'A crucial part of this is that whenever a tragedy occurs there must be a culture of open learning – and critically that lessons are then implemented so that there is no repeat of the failure.'
Norwich South Labour MP Clive Lewis said: 'I know people wanting to minimise this piece of research will say it's difficult to compare different trusts. But we already knew several other alarming things about NSFT before this.
'We don't need any external comparators to know that using just NSFT's own figures, the average of seven people dying each month in 2012 has soared to 21 losing their lives in both April and May this year.' He added government cuts meant there were not enough staff at the NSFT.
A spokesperson for the Campaign to Save Mental Health Services in Norfolk and Suffolk said: 'NSFT has a track record of failing to acknowledge or learn from its own mistakes.
'Again and again, NSFT is criticised for lack of care plans, staff and training, poor risk assessments and relationships with other services. For years, the Board of NSFT has failed to acknowledge the increase in unexpected deaths and prioritise its reduction. This, coupled with a desperate lack of resources from commissioners as demand has grown, has placed front line staff in the position of having to make difficult decisions in complex cases with deeply inadequate mental health services.'
The Samaritans can be contacted by ringing 116 123, emailing jo@samaritans.org or visiting samaritans.org
Matthew Dunham
Matthew Dunham took his own life at the Castle Mall, Norwich, in May 2013, by jumping from height. In his letter to the NSFT, the coroner raised five concerns about his treatment and death, including a lack of coordination between those treating him.
There had been an urgent referral to the trust by the 25 year old's GP and the coroner was concerned about a failure to respond to that emergency referral quickly enough.
There was also a failure by the NSFT to identify serious risk, poor communication, confusion over roles and poor systems for co-ordination between mental health staff.
The coroner said there was a 'fragmented and uncoordinated' approach to Mr Dunham's care and urged the NSFT to address the issues he identified quickly.
Christopher Higgins
Christopher Higgins took his own life in July 2013 by diving over the railings at the NSFT's Fermoy Unit in King's Lynn. The coroner again raised concerns to the trust about staffing, saying that members of staff were not aware of what was required of them when they carried out observations on a patient.
Coroner Jacqueline Lake said in her letter there was 'confusion' about how staff were to engage with a patient.
She also queried how mental health patients were taken to hospital. Before his death, Mr Higgins self-harmed and police transported him to hospital with three police officers and no mental health staff present. When at A&E, he had to wait for two hours in a busy area while showing signs of paranoia.
When he returned to the Fermoy Unit, he was let out for a cigarette and dived over the railings. No risk assessment was done prior to taking Mr Higgins out for a cigarette.
The NSFT said they had made the area where the 36-year-old jumped from safer and reviewed policy around observing patients.
Mark Robert Anstice
Mr Anstice, 38, was found hanged near Mundford on September 2014.
He had a history of mental health problems.
The coroner highlighted the NSFT's failure to allocate a named worker to him as advised by a psychiatrist.
There was also a lack of a carer's assessment and the care plan to attend groups did not address the patient's lack of transport.
There was also concern about insufficient team communication at the trust.
He had been in a relationship with his fiancée for three years and they had planned to get married in 2015.
The NSFT held an investigation after Mr Anstice's death but the coroner said it did not cover all the points in the case and wrote again to the trust with her concerns.
Lorraine Youngs
Lorraine Youngs, from Southery near Downham Market, died by hanging at Hellesdon Hospital in March 2015.
The coroner wrote to the NSFT concerned that a care package had been agreed a month before the 35-year-old's death, but not implemented. 'The lack of a system for tracking the implementation of care packages was a concern and could have a different outcome in future,' the coroner wrote.
At the inquest in January, the NSFT apologised and said they had now improved risk assessments and care plans.
Sebastian Davies
Sebastian Davies died at the Norfolk and Norwich University Hospital in August 2013 after being found unresponsive at the Norvic Clinic at Thorpe St Andrew, where he took an overdose.
The 23-year-old had been detained in a secure unit under the Mental Health Act.
The inquest found the trust's procedures could not have prevented the death, but the coroner wrote a report because he was concerned about the failure to check whether Mr Davies had moved positions during the night.
'There is a risk of future deaths occurring,' he wrote. 'Therefore a review may be needed to be undertaken of the procedure for night time hourly observations to specifically include whether a patient has moved.'
Barbara Mayer
Barbara Mayer was found drowned in a pond in November 2014. The 72-year-old had a long history of depression and had frequently asked her husband to help her end her life.
Two days before her death her husband called the NSFT crisis team who couldn't attend because of work elsewhere.
She took her own life before a member of the crisis team could get to her.
In a letter to the NSFT, the coroner expressed concern that there was an insufficient response to signs of carer's fatigue in her husband and that treatments were offered without sufficient explanation.
The coroner was also concerned the crisis team took two days to respond to an urgent call because they had too much work on.
Ann Wells
Ann Wells died by accident from a brain haemorrhage after a fall.
The 77-year-old fell in winter 2013 while she was a patient on the Sandringham Ward at the Julian Hospital in Norwich and was crossing her room to turn on a light switch.
Coroner Jacqueline Lake wrote to the NSFT after an inquest in September 2014 and expressed concern about the lack of risk assessment in placing the patient in a bedroom that was unsuitable for her limited mobility.
She also said the light switch and emergency call switch could not be easily reached from the patient's bed.
Jamie Barlow
Jamie Barlow was 29 when he took his own life on August 28, 2012.
He died after the NSFT failed to assess him and carry out a home visit following an alert by a GP.
Mental health trust staff were worried there were weapons at his home in Suffolk so didn't want to visit and police were concerned about carrying out a check without mental health staff.
Suffolk coroner Dr Peter Dean wrote to the NSFT and Suffolk Police saying that there needed to be better 'inter-agency working'.
He said a protocol should be developed with the police so that mental health assessments could be carried out on patients who were deemed a risk to staff.
Kathryn Sawyer
The coroner sent a report to the Roundwell Medical Centre in Costessey to prevent future deaths in April 2014.
One of their patients, Kathryn Sawyer, 33, died in August 2013 by accidentally taking an overdose of methadone and other prescribed medication.
She was found collapsed in a communal stairway at her home.
The coroner was concerned that the medication had not been formally reviewed, despite regular contact with the surgery, until a locum GP reviewed it.
The locum GP did not record the consultation in any detail and did not formulate a plan to reduce medication, although this had been the original plan when the patient registered with the practice almost a year previously.
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