The BBC has reported this week that a campaign group say a Norfolk and Suffolk NHS Foundation Trust failed to act on Coroners’ safety warnings, and the group has now given the BBC access to new evidence they have gathered from reports of Coroners to substantiate their claims.
The campaign group is now calling for a criminal investigation into why so many patients died at Norfolk and Suffolk NHS Foundation Trust. They have passed the evidence they have gathered onto the police.
Major Issues at Norfolk and Suffolk NHS Foundation Trust
Last year, a report found that more than 8,000 mental health patients had died unexpectedly in Norfolk and Suffolk between 2019 and 2022. This is defined as a patient who dies but has not been identified as critically ill, or whose death was not expected by the clinical team.
Campaigners and bereaved families claim that the Trust is failing to make vital safety improvements, despite promising to do so.
The evidence provided by the campaign group is based on 38 Coroners’ prevention of future death reports since 2013, and suggest that repeated warnings were given to the Trust that more patients could die unless safety issues were addressed.
Campaigners say that the failure to improve safety has led to yet more deaths.
Some of the main issues identified in those reports were:
- Unsafe staffing levels at the Trust
- Family concerns being ignored
- Dangerously poor record-keeping and communication
Campaigners say that the Trust continues to be in a crisis which was triggered by cuts to funding in 2013.
Coroners were so concerned by issues at the Trust that, between 2017 and 2022, they issued 25 PFD reports. The Trust promised to address the problems highlighted, which persuaded Coroners to stop issuing PFDs, but the latest issues and figures do nothing to convince bereaved families and campaigners that the necessary improvements are being made.
Last year, the Guardian reported that a former senior manager at the Trust had described it as “dysfunctional” and “one of the worst examples of the management paradigm that has been applied to mental health services in the NHS.”
Change is Needed
The campaign group recently met with the Minister for Mental Health, demanding an independent public inquiry over the ongoing crisis at Norfolk and Suffolk NHS Foundation Trust.
The Trust said:
“We can assure all families and carers that we are working really hard to learn from these incidents and do our very best to ensure they are minimised in the future. A review of prevention of deaths is already under way to ensure improvements in practice have been made and learning is embedded across our clinical services.”
NHS England said:
“We are working with Norfolk and Suffolk Foundation Trust and have already helped them to achieve an improved CQC [Care Quality Commission] rating. The Trust will remain in NHS England’s national recovery support programme to receive the highest level of scrutiny and support.”
Comment
This is an incredibly sad story of a Trust which is clearly failing some of its most vulnerable patients.
It is not acceptable that there has been a failure to act on the clear issues and concerns highlighted by Coroners, nor any real action taken to learn from the death of innocent patients over the last several years.
It is little wonder that the families of those who have died, and campaigners alike are now desperately calling for more to be done, and it seems that a thorough investigation is absolutely necessary to understand how this is being allowed to happen, and more importantly, what needs to be done to stop further unnecessary deaths occurring.
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Danielle Young is a Legal Director in our Medical Negligence team, which is ranked in Tier One by the independently researched publication, The Legal 500, and Commended in The Times Best Law Firms 2024.
If you have any questions about the subjects discussed in this article, please contact Danielle or another team member in Derby, Leicester, or Nottingham on 0800 024 1976 or via our online enquiry form.
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