NHS mental health trust failings in Norfolk and Suffolk linked to more than 30 deaths

More than 30 patients died after risks were not acted on in the decade following a controversial service redesign at a crisis-hit NHS mental health trust, according to an analysis by campaigners.

The report by the Campaign to Save Mental Health Services in Norfolk and Suffolk also logged nearly 20 Norfolk and Suffolk NHS Foundation Trust (NSFT) patients who have died since 2013 after communication failures, while family concerns were ignored in 15 cases.

Long standing concerns about mismanagement and poor care at NSFT were raised after a report from the auditors, Grant Thornton, last year revealed there were 8,440 “unexpected” deaths of the trust’s patients between April 2019 and October 2022.

In a ten-year period, the trust has had nine different chief executives and was placed in special measures four times.

The campaigners’ new report analysed 86 deaths of NSFT patients which were reported by local or national media since the service redesign in 2013, as well as prevention of future deaths (PFD) notices written by coroners.

The report categorised the 86 deaths into different factors that were publicly reported, with “risk not acted on” appearing most frequently (31 cases), followed by “poor communication” (19 cases), and “expressions of suicide ignored” and “family concerns ignored” (15 cases each). Some cases had more than one factor.

In 2013 senior managers at NSFT implemented a “radical redesign” of services that cut beds, reduced the number of consultant psychiatrists, and replaced primary care mental health teams with new ones that proved harder to access. Campaigners warned at the time that the changes would lead to worse patient care.

Campaign chairman, Mark Harrison, told the Observer: “The radical redesign was driven by the coalition government’s austerity programme where they cut 20% of NSFT’s budget.

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“They closed the homelessness team, broke up the crisis team, took NSFT workers out of GP surgeries, made many of their most experienced staff redundant and made the others reapply for their jobs, where they either downgraded them or added extra responsibilities for the same money.

“This is what led to the increased rate of unnecessary deaths. The campaign predicted that all those measures would result in increased deaths. They did and NSFT has never recovered from it.”

Analysing coroners’ PFD notices, the report identified six cases since 2020 where coroners raised concerns about staffing issues.

Two more PFD reports were recently issued following inquests into the deaths of NSFT patients, one warning of failures in risk assessments by the trust and the other detailing a string of concerns.

The campaign is calling for a public inquiry and police investigation into failings at the trust and the high number of deaths.

The campaign’s report concluded: “It is astonishing that despite the high numbers of deaths at NSFT, those with the power to act remain subdued on the matter, hence our keenness to meet the police’s threshold of commencing an investigation into NSFT.”

An NSFT spokesperson said: “We offer our sincere condolences to all families and carers of people who have lost loved ones. We can assure all families and carers that we are working hard to learn from these incidents and do our very best to ensure they are minimised in future.”

The trust said it was improving its collection and use of mortality data, had reduced its nursing vacancy levels through new recruitment, was reviewing PFD reports since 2013 and was working on waiting times, record keeping and carer involvement.