Nikki Fox of the BBC reports:
The trust which runs mental health services in Norfolk and Suffolk has apologised after an inquest found that neglect contributed to a patient’s death.
Neil Jewell, 42, died in 2014 after a series of failures, the inquest said.
He had paranoid schizophrenia and was not properly monitored after being given a tranquiliser.
Why wasn’t Neil properly supported? The review says one of the reasons was because his trusted mental health worker had been made redundant after mental health cuts. Another reason was because the concerns of his family were ignored.
Why was Neil discharged from Care Programme Approach (CPA)? Because Norfolk and Suffolk NHS Foundation Trust (NSFT) didn’t have enough staff to deliver CPA after wasting millions of pounds paying highly-trained and experienced staff to leave. Crisis and community teams were slashed and specialist teams closed. NSFT even closed the base of the adult community mental health teams in Norwich and moved the remaining staff to Hellesdon and a business park outside Wymondham which still lacks any facilities for staff to see patients.
Mr Jewell had lived independently at his home in north Norfolk but, in early 2014, ran out of medication and became agitated.
Neil should never have been discharged from CPA. That decision was driven by mental health funding cuts.
As the nearest specialist mental health bed was in London he was placed in a care home in Norfolk but, as his condition deteriorated, staff could not cope with his behaviour.
There was no mental health bed for Neil in Norfolk. Instead he was sent to a care home rather than a psychiatric hospital. Hamilton House was subsequently rated Inadequate by the Care Quality Commission (CQC). There still aren’t enough mental health beds in Norfolk. In fact, the bed crisis has deepened. NSFT has continued to spend millions of pounds sending NHS patients in crisis to private providers which are in Special Measures and have been rated Inadequate by the CQC.
Neil was transported in acute distress from Norfolk to Bury St Edmunds. As his condition deteriorated, Neil was transported again.
Following a transfer to a mental health unit in Ipswich, the inquest was told trust staff did not adequately monitor his vital signs after he received tranquilisers.
When, on 12 January 2014, Mr Jewell was found head down and foaming at the mouth, the inquest was told an agency worker did not know where to find the oxygen in the unit so valuable time was lost while trying to resuscitate him.
Five days later he was diagnosed with brain damage and his life support machine was switched off.
Highly-qualified and experienced staff were paid millions of pounds to leave NSFT in the middle of a recruitment crisis which left the trust dependent on agency staff.
The inquest jury found Mr Jewell died from complications following a cardiac arrest caused by him not being able to breathe and the effects of sedative drugs used in his “rapid tranquilisation to which neglect contributed”.
At the most recent NSFT Board meeting, the Chief Executive Michael Scott looked bored, drummed his fingers on the table and chatted to the Chair, Gary Page, as we read out the summary of Neil Jewell’s death and tried to ask questions. Gary Page later ended the Board meeting half an hour early rather than allow further questions to be asked.
How can lessons be learned when the Chair and the Chief Executive aren’t listening?
NSFT chief executive Michael Scott previously said: “Since his [Mr Jewell’s] death, our trust has ensured that patients based in the community have a named mental health professional or duty worker co-ordinating their care, to offer greater support
Neil didn’t die because he didn’t have a ‘named worker’. Neil died because the staff needed to deliver safe services were made redundant, the crisis and community mental health teams were slashed, specialist teams and the mental health base in Norwich were closed, link workers were abolished, there weren’t enough beds and his family’s concerns were ignored.
Mr Jewell’s family said in a statement: “The evidence during this inquest clearly points to a catalogue of missed opportunities, poor decision making, inadequate record keeping and routine disregard for policies.”
Even after Neil’s death, NSFT continued to close mental health beds and make staff redundant.
The crisis and community teams are still inadequately resourced.
There are still no assertive outreach teams.
There is still no base in Norwich.
The beds crisis is worse than ever.
Families continue to be ignored.
Mental health deaths have doubled at NSFT.
Meanwhile, the Chief Executive of NSFT, Michael Scott, has trousered more than half a million pounds in salary.
You can read the full review into Neil’s death here.
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