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EDP: Woman saw 25 mental health professionals in 14 months before her death, coroner’s report reveals

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Geraldine Scott of the Eastern Daily Press reports:

A coroner has issued a warning over the death of a young woman who saw more than 25 members of the region’s mental health crisis team in the 14 months before she took her own life.

We’ve been talking about the lack of any focus from Norfolk and Suffolk NHS Foundation Trust (NSFT) on continuity of care since our campaign was founded more than five years ago. Discontinuity is expensive, in terms of lives as well as finance.

Tamsin Grundy, 23, and from Denver, near Downham Market, was found dead at her home.

At an inquest into her death in March, Norfolk coroner Jacqueline Lake gave the conclusion of suicide, but said she was concerned at the number of people involved in her care and would be writing a report to Norfolk and Suffolk Foundation Trust (NSFT).

In the report, which was released on Tuesday and is designed to prevent future deaths, Ms Lake said: “Miss Grundy had a history of depression and had previously made attempts to end her own life.”

She said: “Miss Grundy repeatedly spoke about her concern about the number of people involved in her care, particularly from the Crisis Resolution Home Treatment Team.

During the radical redesign, therapeutic relationships between clinicians and patients were assigned zero value by the TSSers’ spreadsheets, as front line staff were moved or sacrificed like pawns on a chess board. Now, those same TSSers, many bullies and incompetents with poor values and track records, have been given pay rises and promotions in the disastrous ‘radical restructure’. The only people who could believe the shambolic ‘radical restructure’ is a good idea are the bank managers of the existing incompetent management.

“It is understood Miss Grundy saw 25 plus members of the team in some 14 months.

“The evidence was that she found it difficult to relate to so many people, having to repeat the difficulties she was experiencing which she felt was adversely impacting on her mental health. “It was not clear from the evidence that this issue was addressed during Miss Grundy’s contact with the service.”

Ms Lake also said this had been raised by Miss Grundy’s family in the serious incident report produced by the trust after her death, but there was “no definitive, timed action arising from it, and no named person responsible for any such action”.

NSFT has 56 days to respond to Ms Lake with a plan of action.

NSFT will respond that lessons will be learned, with mealy-mouthed platitudes, but nothing will change. The Coroner should look at how many permanent staff have left the crisis teams at NSFT since August 2018.

According to our figures, NSFT has been the subject of more coroner’s reports than any other trust in the country. Most of which are repetitive.

Following the inquest in March, Miss Grundy’s mother, Rev Judith Grundy, said: “The system is really broken, there are too many people involved. I will miss her all my life.”

How many more preventable deaths? There have been hundreds since our campaign began. This must stop.

Stuart Richardson, chief operating officer at NSFT, said at the time: “I am so sorry to hear about the tragic death of Miss Grundy and would like to offer my sincere condolences to her family and friends.

How often can NSFT’s management be sincere when its values, actions and personnel don’t change?

“We accept the findings made by the coroner today and will work with our commissioning partners to make every effort to reduce the number of different care professionals a service user sees when under the care of the crisis resolution and home treatment team.

Since Stuart Richardson became Chief Operating Officer of NSFT in August 2018, the number of out of area placement bed days has tripled, as NSFT’s Board focussed on internal NSFT power politics and pushing through the disastrous radical restructure rather than patient welfare. As of yesterday, there were 43 NSFT patients in out of area beds across England.

Experienced front line staff have been leaving in droves, particularly from the crisis resolution and home treatment teams, as a direct result of their treatment by Stuart Richardson and his subordinates and despair at his radical restructure.

Now, the demotivated crisis teams are forced to attempt to rely on inexperienced temporary staff, which guarantees less continuity of care, in a climate of fear for the experienced front line clinicians who remain.

“We are getting in touch with the family again and I hope to be able to meet with them soon to discuss this further.”

“Lessons will be learned.” Ad nauseam.

We don’t need meetings. We need mental health services that work for people who need them rather than bureaucrats.

When the bereaved get together and compare notes, most soon realise that they hear the same platitudes from NSFT, sometimes years apart in time, but that they are only mealy-mouthed words and that nothing changes or has changed.

The values of the management of NSFT are self-interest, pay rises, promotions, endless meetings, getting themselves ‘deputies’ and ‘P.A.s’ and blaming front line staff for their own utter incompetence.

Click on the image below to read the article in full on the EDP website:

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