Mental health: Investigation finds number of unexpected deaths at Norfolk and Suffolk Trust is not above national average

PUBLISHED: 08:20 26 May 2016 | UPDATED: 09:22 26 May 2016

Michael Scott CEO of the Norfolk and Suffolk FoundationTrust  answering questions on the findings in Care Quality Commission report. Photo : Steve Adams

Michael Scott CEO of the Norfolk and Suffolk FoundationTrust answering questions on the findings in Care Quality Commission report. Photo : Steve Adams


Investigators today said the number of unexpected deaths at the region's mental health trust is not above the national average, amid fears over a rise in patient deaths while in care.

Background to report

Concerns were raised by campaigners in November last year when this newspaper reported that NSFT had experienced a rapid rise of unexpected deaths.

In 2012/13 the trust reported 53 such deaths, but this figure rose to 105 in 2013/14. Last year there were 139 unexpected deaths and half-way into the 2015/16 financial year the number stands at 77.

The term ‘unexpected deaths’ describes patients treated by the trust whose cause of death is not yet known.

One such patient was Christopher Higgins, who died while in the care of the trust at the Fermoy Unit, King’s Lynn.

His parents, Ann and Jon Higgins, were among campaigners calling for an inquiry into the rise.

At the time NSFT insisted their figures were in line with the national average, and pointed to the fact that it took on the Norfolk Recovery Partnership in 2013/14, which provides services to people with substance and alcohol misuse, putting them at additional risk of death because of their addictions.

A rise in demand was also cited as possible reasons for the increase.

But chief executive Michael Scott announced in January that the trust would hire an external company to carry out an investigation into the number of unexpected deaths.

The decision was welcomed by campaigners, MPs, and other health authorities.

The findings are a boost to the trust ahead of a vital inspection in July, when health watchdog the Care Quality Commission inspects services.

If inspectors have seen enough improvements since February 2014, then the trust could be taken out of special measures.

This newspaper launched its Mental Health Watch campaign last October.

However, researchers concluded that a lack of national data on unexpected deaths meant they were limited in making comparisons.

While it was praised for its openness in commissioning the study, Norfolk and Suffolk NHS Foundation Trust (NSFT) was criticised for the quality of its investigations into the cause of unexpected deaths and how it deals with the bereaved’s family.

The report, by Verita and published today, contains 13 recommendations for how the trust can improve its investigations into patient deaths and its communication with affected families, and calls for more national data to be collected by health authorities.

The findings of the report were welcomed by NHS England.

Michael Scott, chief executive of the trust, said: “All of the recommendations made are already, or will be, acted upon.

“We are far from complacent, and there would be no point in our commissioning this investigation if we turn a blind eye to where it indicates we need to do better. That is something we simply will not do.”

The report, which cost the trust up to £50,000, saw investigators review 126 cases of unexpected patient deaths – while interviews were carried out with Mr Scott and three directors, and representatives from clinical commissioning groups, Norfolk coroner Jacqueline Lake, and MPs Clive Lewis, Norman Lamb, and Therese Coffey.

It was carried out after the trust experienced a rapid rise in unexpected deaths and serious incidents between 2012-16.

This was backed up by an FOI sent by Mr Lamb to all mental health trusts.

But the report concluded: “It is likely that the number of unexpected deaths recorded by the trust is influenced by the fact that the trust reports incidents at a rate that is substantially higher than the national average for mental health trusts.”

It also found the quality of investigations into unexpected deaths was “inconsistent” and that they lacked “national benchmarks” to evaluate the trust’s practice.

Verita also said one-in-three reports contained no written evidence that the trust had told a bereaved family about an investigation into an unexpected death, nor shared a copy of its findings.

The researchers recommended that NSFT meets with affected families to offer condolences and explain any investigative work that will be taken.

The trust has subsequently appointed two people to improve engagement with families.

Mr Scott added: “The safety of our service-users and our services is paramount and one single avoidable death is one too many – that is why we commissioned this investigation.

“We are reassured by Verita’s findings, which reflect that we are a trust which is a high reporter of unexpected deaths and serious incidents, and one which reports early.

“It is recognised that organisations with high levels of reporting are generally safer organisations. It is where there is a culture of hiding, blame or deflection that things go very wrong.” The trust’s board meets today at Hellesdon Hospital at 9.30am.

• If you need someone to talk to call the Samaritans on 116 123.

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