Kept in the Dark: Should we expect the ‘independent inquiry’ into unexpected deaths at NSFT to be a whitewash?

The ‘independent inquiry’ into unexpected deaths at Norfolk and Suffolk NHS Foundation Trust (NSFT) is being published on Thursday, 26th May 2016 at the NSFT board meeting at Hellesdon Hospital, Norwich. The board meeting starts at 0930. Why not join us?

So, should we expect a whitewash? Well, sadly, given our previous experience of being kept in the dark by NSFT, we should.

The inquiry isn’t fully independent:

• the prescriptive and restrictive terms of reference were set by NSFT without input from stakeholders;
• the consultancy firm was chosen by NSFT;
• the invoice for the consultancy is being paid by NSFT;
• the case review undertaken was based upon a sample of NSFT’s own flawed Root Cause Analysis (RCA) reports (see comments from the Higgins family below);
• the final report has not been distributed to participants for comment prior to publication;
• NSFT has retained the right to decide when and which parts of the report are published.

So, expect lots of the usual claims and spin from NSFT:

• NSFT is a ‘high reporter’ – despite the fact that NHS Improvement rated NSFT as one of the ten worst NHS trusts in England for openness, with a ‘poor reporting culture’
• NSFT implements recommendations – despite the BBC reporting that NSFT failed to implement 258 recommendations
• NSFT is open – despite refusing to publish its own data on unexpected deaths and removing the information from the regular reports released for public board meetings.  The Chair of NSFT, Gary Page, promised NSFT would publish its unexpected deaths data on its website on a monthly basis. It hasn’t done so.
• NSFT cares about suicide – despite its repeated failure to get in touch with and offer proper support to families of the bereaved or those who have suffered life-changing injuries. NSFT is still failing to do this, even in the last few weeks.

NSFT did very little to investigate the near-tripling of the number of unexpected deaths over three years until we pushed it to do so.

When we first raised unexpected deaths at Board meeting in 2014, a current non-executive director demanded that our comments were struck from the minutes. The Chair of NSFT called us ‘irresponsible’ when we asked for the publication of NSFT’s data on unexpected deaths in 2015.

We’ll leave the last word to the parents of Christopher Higgins, whose son died whilst in the care of NSFT:

“After Chris’ tragic death, the Trust carried out an internal investigation. It was a complete whitewash and we challenged them on it. They granted a limited further review by an ex Non-Executive Director of the Trust, although highly critical of the failings prior to Chris’s admission to the unit, the multiple disastrous failings leading to Chris’ suicide in the unit only 36 hours after admission were unbelievably deemed not to have contributed to his death: The second whitewash. These findings were accepted by the Coroner despite the wealth of contrary evidence. The Coroner’s inquest ended up being an incredibly frustrating and disappointing experience, in which the Coroner refused to allow the jury to comment on the serious failings: The third whitewash. Since the inquest finished just before Christmas, we have been working tirelessly with INQUEST and local campaign groups to make sure that the Trust know that we are not going to give up: We want justice for Chris and to know that their failings have been addressed. We are pleased to hear that an independent investigation into deaths at the Trust has been announced. The Trust appear to be listening to us now, but we are desperate to avoid a fourth whitewash. We want them to get it right this time.”