Questions are answered by mental health trust of Norfolk and Suffolk following inquest of man who jumped to his death at Castle Mall in Norwich
The mental health trust of Norfolk and Suffolk responds to 12 questions from the EDP and Norwich Evening News about the circumstances which led to the death of Matthew Dunham in Norwich.
The NHS mental health trust of Norfolk and Suffolk has responded to 12 important questions about the lessons which will be learned following the death of Matthew Dunham.
An inquest into the 25-year-old’s death was held on Wednesday, with Norfolk’s coroner William Armstrong concluding Mr Dunham had intended to kill himself, while suffering from a mental disorder.
The web designer, who lived in St Augustine’s Street in Norwich, jumped to his death in the city’s Castle Mall on Thursday, May 9.
During the inquest hearing Mr Armstrong criticised the “fundamental deficiencies” of the Norfolk and Suffolk NHS Foundation Trust (NSFT).
With NSFT in the midst of a cost-cutting exercises to shed 500 jobs and cut 20pc of inpatient beds in the next four years, we set out a series of questions asking the trust to provide public assurance of its work.
As reported yesterday, initially the trust had only responded with a statement and was criticised by North Norfolk MP Norman Lamb, whose portfolio as health minister includes mental health services.
Andrew Hopkins, interim chief executive of the NSFT, has now responded to all 12 questions saying: “This has been a very tragic case and our heartfelt sympathies and condolences are with the family. The standard of care provided to Mr Dunham was unacceptable and we apologise for that.”
What went wrong in this case?
As has been reported by the coroner, information sharing was a key factor in Mr Dunham’s death. We addressed this by making improvements to the way we monitor risks related to patient safety. We have also made significant changes to our risk management and suicide prevention training.
How can it be that at least two members of staff in the same trust were unaware that they had both seen the same patient?
It is clearly unacceptable that not all staff members involved in Mr Dunham’s care were aware of the risks that had been highlighted. We have already reviewed the policies and practices related to this to prevent this from happening again.
The trust has started using a new IT system that alerts teams to other staff involved in a patient’s assessment and treatment.
What mechanisms were in place at that time for the sharing of information and why did that system fail in this case?
The system used to share information at the time of Mr Dunham’s death was not robust enough for the trust’s needs. It has already been replaced by a system that addresses these issues.
In addition, referral review meetings that used to take place every two weeks now take place twice weekly with a view to become daily. This will allow high priority cases to be flagged at the earliest opportunity.
Was there (or will there be) any internal investigation into what happened?
The trust conducts a detailed internal investigation (known as root cause analysis) into all serious incidents. Action plans from the outcomes of such reports are then developed for all services and are shared with the commissioners of our services. Action plans are monitored to ensure learning is embedded across the trust.
Has or will anyone face disciplinary proceedings? If they have, what was the sanction?
Part of the trust’s standard investigation process looks at the practice of staff who are involved in a person’s care and whether this has had an impact on that person’s death. Where this is found to be the case the trust responds accordingly, which would mean an internal disciplinary hearing and/or referral to the professional governing body, such as the Nursing and Midwifery Council for nurses.
However, in relation to Mr Dunham’s death we share the coroner’s view that there were no failings on the part of individuals.
Has the trust met the coroner to discuss his concerns? If not, are you intending to?
In addition to the inquest itself, the coroner will write to the trust setting out what improvements are expected and the trust is required to respond with a plan for making those improvements. The trust already has regular meetings with the coroner.
What has been done to prevent this from happening again?
Since Mr Dunham’s tragic death we have introduced new patient safety indicators to better highlight risks related to patient care. We have also reviewed policies and practice related to information sharing to ensure this has been improved.
We are also changing the way clinical risk management training is given to staff to recognise the different skill levels of staff.
How are you going to open the trust up to more scrutiny on issues such as this?
The trust welcomes scrutiny from all of its stakeholders and will respond to complaints, queries and recommendations openly and honestly. The trust board of directors examines such issues in public on a bi-monthly basis. This includes:
- A report on unexpected deaths and other serious incidents at each meeting
- An annual review of the Trust’s suicide audit, which is compared with national data and trends. In October the Board will receive the National Confidential Enquiry into Suicides and Homicides (a bi-annual report) and will use this information to benchmark our own prevalence and practice. Nationally this report has identified an increasing trend in the numbers of suicides.
- Reports from unannounced visits by external bodies, including commissioners, Care Quality Commission and governors, as well as board members’ own commitment to visiting clinical areas, both planned and unannounced.
Does the trust have any other inquests or complaints pending for patients in the care of the trust? If so, please provide further details.
The coroner holds inquests into any unexpected or unexplained deaths of patients within our care. The schedule for coroner’s cases is subject to the circumstances of each case.
We publish data on complaints within our annual report. During April 2012 to March 2013 the trust received 430 complaints.
Of these complaints 19.8pc were upheld, 30.8pc were partially upheld, 40.4pc were not upheld by the trust and 9pc of complaints were stood down.
Twenty complainants requested review of their complaint by the Parliamentary and Health Service Ombudsman.
Has the trust met Mr Dunham’s family to speak to them? Has the trust apologised about what happened or do you want to do so through the papers?
Staff have met with Mr Dunham’s family and have said how sorry we are their loss and have apologised. We have already planned to meet with the family in six months’ time to show that we have done what we said we would do.
Do you want to say something to reassure people in Norfolk and Suffolk that the issues surrounding Mr Dunham’s treatment will not happen again?
The trust puts patient safety at the heart of everything it does and when things do go wrong we have a good track record in responding to concerns and making improvements. We are determined that lessons are learnt and we have already made changes to the areas highlighted by the coroner.
As part of the Access and Assessment Team we also report daily to the Clinical Commissioning Groups on how quickly referrals are being processed so there is instant feedback on any potential gaps or issues.
The trust plans to reduce 500 jobs and cut 20pc of inpatient beds as part of a strategy to save money over the next four years. Is that not likely to lead to more “deficiencies” in the future?
Some funding has been secured from the Norfolk CCGs to help us ensure that staffing levels, skill mix and the ability to deliver safe services are not negatively affected by the changes we are making.
Following our staff consultation, we have made a number of changes to the service strategy. As a result the trust has recently publicly updated the proposed reduction in staffing levels. As we progress through the implementation of the trust service strategy final staff numbers will become clearer. We believe a reduction of 400 posts is more accurate.
This week the trust has updated the Norfolk Health Overview and Scrutiny Committee of its plans, where patient safety was a key area for discussion. We will continue to work with them throughout the service strategy implementation.