Health minister says mental health trust needs to answer questions following tragic death of Norwich man
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A health minister has demanded answers over how a young Norwich man, who went on to take his own life, was seen by three mental health workers, yet information about his suicide risk rating was not shared.
While bosses at Norfolk and Suffolk NHS Foundation Trust have said they will learn lessons following the tragic death of Matthew Dunham, the trust has yet to explain exactly what went wrong to cause what a coroner described as 'fundamental deficiencies' in his treatment.
The trust said it has taken steps to improve care since the tragedy, and acknowledges two main issues were a delay in Mr Dunham receiving an appointment and information not being shared appropriately between clinical teams, but bosses have been reluctant to elaborate on the reasons for the failures.
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And North Norfolk MP Norman Lamb, whose portfolio as health minister includes mental health services, said the situation sounded 'chaotic' and the trust' should explain itself.
Mr Dunham, 25, a web designer who lived in St Augustine's Street in Norwich, jumped to his death in the city's Castle Mall on May 9.
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He had been rated a seven out of 10 suicide risk by one practitioner at the mental health trust, but two other workers in contact with him were not able to access that information.
At an inquest, Norfolk coroner William Armstrong said there were 'fundamental deficiencies' in the trust's care for Mr Dunham.
Mr Armstrong said: 'There was no lack of help being given to Mr Dunham, but the care and support was clearly fragmented and uncoordinated. The evidence reveals problems accessing information and about sharing information. These are serious inadequacies that must be addressed. It's alarming that information about a patient's care was not being shared.'
He also expressed concern an emergency GP referral which should have been followed up within four hours took two days, Trust staff told the inquest that was because a computer system was in its infancy.
Mr Armstrong concluded Mr Dunham intended to kill himself, while suffering from a mental disorder.
The inquest was told he was being treated by Lauren Lawrie, a psychological well-being practitioner with the trust, and he told her he had suicidal thoughts, including jumping off Castle Mall. She assessed him as a seven out of 10 suicide risk.
Mental health nurse Robert Carey said he subsequently met Mr Dunham, but had not known Miss Lawrie had been treating him.
Beverley Hare, a charge nurse with the trust's crisis team, spoke to Mr Dunham on April 24. Following their conversation, he was passed back to the trust's assessment team and an appointment made for May 23.
The inquest heard Ms Hare had no knowledge Mr Dunham had previously expressed suicidal thoughts, before talking to him.
Staff told the inquest they now had a new computer system where you could see which other mental health workers were seeing a patient.
Mr Armstrong stressed no individuals were to blame, but the problems were systemic. He said it was encouraging the trust had continued talking to Mr Dunham's family.
We asked the trust a string of questions about the circumstances which led to the tragedy.
But we were told the trust was not prepared to answer them on a point by point basis, because the issues had been discussed at the inquest.
However, the trust did say a full investigation had been carried out, and the report shared with Mr Dunham's family.
They did issue a statement from Roz Brooks, director of nursing and patient safety at Norfolk and Suffolk NHS Foundation Trust, who said: 'The trust is deeply saddened by the tragic death of Matthew Dunham and I would like to reiterate how sorry we are for his family's loss.
'We are determined that all lessons can and will be learned and, since Matthew's death, the trust has conducted a full investigation into what happened and has reviewed the areas of policy and practice raised at the inquest.
'Patient safety is - and remains - a key priority for the trust. Information sharing has been improved and new patient safety indicators have been developed.
'These are reviewed regularly by myself and the medical director and shared with the Clinical Commissioning Groups.
'Transitional funding provided by the Norfolk CCGs is being used to ensure staffing levels and skill mixes are in place to deliver safe, high quality services during this period of change for the trust.'
However, Norfolk MP and health minister Mr Lamb said the trust owed it to the public to answer questions about what had gone wrong with Mr Dunham's care.
He said; 'If two people were supporting him and did not know of the other's involvement that is extraordinary. It sounds chaotic and poor care.
'Quite often, we get frustration because of a failure to share information between organisations, but for this to happen within the same organisation is an extraordinary situation.
'The coroner's conclusions are pretty damning and the trust has to explain how this could have happened.
'The first practitioner who saw him had rated his suicide risk as high, so what did that trigger within the trust?
'This is an extremely serious matter and the trust needs to explain itself. They have said they will learn from this, which is vital, but how did it happen and why were there processes such that this could happen? Where is the accountability for what has happened?'
Vicki Nash, head of policy and campaigns at mental health charity Mind, said she could not comment directly on the tragic case of Mr Dunham.
But she said: 'In a mental health crisis there may be an immediate risk of self harm or suicide. Your mind is at melting point and you need the right help and support, urgently.
'Excellent crisis care can be the difference between life and death, but joined-up services are needed to deliver this. In an emergency, effective and coordinated care is paramount.'