OPINION: Why an independent inquiry into mental health services is crucial

Councillor Emma Corlett

Emma Corlett, deputy leader of the Labour group at Norfolk County Council - Credit: Archant

An attempt to get Norfolk County Council to call for a public inquiry into the repeated failures of Norfolk and Suffolk NHS Foundation Trust (NSFT) was blocked this week.

The motion by Emma Corlett - in response to the Care Quality Commission rating the mental health service trust as inadequate - was amended by Conservatives at County Hall to remove the call for the independent inquiry.

The Conservatives said the soon-to-be created Norfolk and Waveney Integrated Care System - and the council's involvement in it - was the best way to bring about change.

This is the speech Ms Corlett gave at the annual general meeting of the county council:

"The state of local mental health services has caused real harm over the past 10 years.

"This harm has happened in plain sight of every part of the system that is meant to protect and care for people and despite repeated warnings being made loud and clear throughout this time. 

"Many of the safety concerns raised in a UNISON letter to all Norfolk county councillors, MPs and commissioners in January 2013 are safety breaches detailed in this most recent CQC inspection report. Seven whole years before Covid, so let’s not hide behind that excuse.

"But this is not simply a failure of leadership of one NHS Trust. It is a failure of the whole system; of commissioning, of scrutiny, of the coroners' process, of safeguarding and ministerial failure, including local MPs who have held those ministerial positions. It is also a failure of regulation and of intervention. 

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"This is the fourth time that NSFT has been placed in special measures. Since the 'improvement partner' trust imposed on NSFT by NHS Improvement  – including the appointment of senior executives to the NSFT board – things have got even worse, with the trust now rated as inadequate for safety.

"Unsafe services continue to be commissioned, scrutiny and intervention has proven impotent.

"Meanwhile people living with a mental illness and staff trying to provide care remain trapped in a broken system and real harm has been caused.

"The mental health of Norfolk residents is all of our business. We cannot sit back and allow ‘more of the same’. People’s lives quite literally depend on it.

"Bereaved family after bereaved family have been made empty promises that ‘lessons will be learned’ but still deaths occur with the same themes emerging – communication break down and missed opportunities to keep people safe. 

"The most recent prevention of future deaths notice issued by the Norfolk coroner called out the shameful situation where concerns raised by staff themselves about staffing levels, a chaotic ward environment and lack of management supervision and leadership were deleted from the final incident report before it was presented to her.

"The level of unexpected deaths is staggering. The grief of bereaved families is compounded by failure to even properly document the harm with the repeated moving of goal posts of definitions used and the way deaths are reported. As one bereaved relative put it “some people are deemed to be of so little worth that their lives and their deaths are mere whispers”.

"Until a genuinely independent public inquiry into the disaster of the last 10 years is undertaken lessons cannot be learned and we cannot safely make decisions about what needs to happen next with our mental health services.

"Enough is enough. We need to stand up for Norfolk residents who need mental health services now, who may need them in the future and those who have lost their lives and support calls for a public inquiry."