Call for Public Inquiry at NSFT

The radical restructure is the end of hope for a better NSFT

Campaigners meet with MPs to call for an independent statutory public inquiry into the deaths at NSFT

On Tuesday 5th July 2022 some of our campaign members went to London to meet with our region’s MPs. Below are some of the key points we were making, Caroline Aldridge’s speech, and links to some of the media reports.

We are indebted to the journalists who consistently cover stories about failing mental health services and those who sadly lose their lives as a result. We are grateful to Clive Lewis MP who hosted the meeting with minister Gillian Keegan and to the MPs who turned up or met with their constituents (Duncan Baker, Peter Aldous, Tom Hunt, Dan Poulter and Jerome Mayhew). We are disappointed in all those who did not attend or, worse still, those did not even respond to their constituent’s letters or emails.

It was an emotional and exhausting day and we want to honour the bravery of the bereaved relatives who shared their stories.

We will not rest until we see actual improvements at NSFT and our loved ones are safe.

These are our key points:

  1. We want our Norfolk and Suffolk MPs to support us in a call for an independent statutory public inquiry so that we can establish how many people have lost their lives and why the wider system has failed the citizens of Norfolk and Suffolk by allowing this unsafe situation to go on for so many years.
  2. We want our MPs to understand the scale of the problem, actively scrutinise NSFT, and for them to lobby the Health Secretary (whoever that might be) to intervene, so the same mistakes are not repeated and more lives needlessly lost. 
  3. We want NSFT be placed in special administration and replaced with a well-funded and functioning mental health organisation.
  4. It took 2 months, since NSFT were issued with an enforcement notice by the CQC and 28 days to come up with a plan, for one to be publicised. We want to know – what will be different? What is going to change?

The link to Rob Setchell’s ITV report:

The link to BBC Look East Report:

The links to EDP articles:

The link to EADT article:

Caroline Aldridge’s speech:

I am Caroline Aldridge, my eldest son Tim had bipolar disorder and he died in 2014, aged 30. I am representing many other bereaved people, who I am in contact with, who cannot be here today. I am here with bereaved relatives, carers, service-users, and campaigners (some of whom, including myself, have worked for NSFT). We want to pay tribute to NSFT’s frontline staff who mostly deliver compassionate and competent care in very difficult conditions. We all share one goal: for mental health services in Norfolk and Suffolk to be safe and effective.

In 2013, NSFT underwent cuts to staff and services in a ‘radical redesign’. There followed a surge in deaths. My son was one of them. He died waiting for an appointment. Ever since, I have been trying to work with the trust to learn from Tim’s death and prevent others going through the agony I did. Sadly, if anything, things have got worse rather than better. Too many other parents have endured the heartbreak of losing their children because of failings in mental health services.

My son’s death occurred near the beginning of a tragic timeline of young men and women, whose requests for help were not met with a timely response that recognised, and responded to, obvious risk. We have with us: Sheila Preston, whose son Leo died, aged 36, in 2016; Esther Brennan, whose son, Theo, died, aged 21, in 2019; and Trevor Stevens, whose daughter, Tobi, died, aged 19, in 2020. The unsafe situation in Norfolk and Suffolk effects people from around the country – Theo and Tobi came to Norwich to study at our universities but, like too many other students, they never went home. Every time I hear of another lost life, I find it acutely painful. My heart goes out to all those who grieve.

All mental health related deaths are of people who have died prematurely. Often these deaths happen in traumatic circumstances. This has a devastating impact on their families however old they are. Nick’s mother-in-law, Peggy, was a frail 81-year-old who died on the hard shoulder of the M11 having been transported out of Norfolk because there were no local beds. She had never left Norfolk before.

Those left behind can struggle with their mental health when they lose someone to an avoidable death. Bereaved families, who might already be traumatised by the circumstances of their bereavement, find themselves further traumatised by insensitive, and often brutal, organisational responses and processes, such as inquests and investigations.

Over the years, countless bereaved relatives, concerned NSFT staff, or people who are desperate to keep their loved ones alive and well, have connected with the campaign. The levels of unmet need and distress seem to be increasing at an alarming rate. It feels almost daily that we hear of another death. Many of those who die will not count in NSFT’s statistics because if someone is not receiving, or has not recently received, a service they do not meet the criteria. If we were to compare like-with-like, the death rate would be higher because drug and alcohol services were out-sourced a few years ago and people with a dual-diagnosis have a high mortality rate.

There have been 8 CEO’s and 2 Chairs at NSFT since the campaign began. Some of the campaign members here have been trying to provoke positive change in different ways since 2013. Among us there are people who are, or have been, governors, clinicians, carer representatives, or involved in working with the trust’s learning and development team. We want to support improvements. Founder members, like Emma and Mark who will speak after me, hold the history of NSFT.

When the trust failed its 4th CQC inspection in April, campaigners and bereaved relatives held a hearts memorial event because, from information freely available, it seemed that over 1,000 people had died since 2013. NSFT’s response to this deeply upset bereaved relatives. No one from the trust offered condolences or regret about the lost lives. Instead their communications team refuted the figures. This was an insult to every single one of our loved ones who have died. It also highlighted that NSFT might have lost count of how many have died from unexpected or avoidable deaths.

The trust said that they ‘do not recognise’ the figure of 1,000 deaths but they have been unable, or unwilling, to produce any alternative figures. It has been very difficult to establish numbers from the information NSFT disclose because it is often contradictory. This reflects a national issue in the NHS about the way statistics are gathered. Closer examination of the data available in the public domain, which is based on documents NSFT has produced for various bodies such as NHS England, suggests that the figure could be in excess of 2,500. Frankly, the statistics do not add up. Some of the official documentation is no longer available to us. The campaign’s Freedom of Information requests to NSFT, to try and confirm the deaths, have been refused on the basis it will take them too long to find the information.

At their latest Board meeting, NSFT announced they would hold an independent investigation to establish how many have died. This suggests that they have not got any reliable system for monitoring how many of their patients die. For us, the issue is not about numbers, it is about learning. If the trust do not even know who has died, how can they be keeping track of the reasons why, and any practice or organisational changes they need to make to prevent other deaths? We do not believe that investigating this should be left in the control of NSFT because they have already had an investigation into deaths that did not lead to change and the deaths reflect a wider systemic issue.

In 2016, NSFT commissioned an independent report into the deaths that had occurred since the radical redesign. I was one of only two bereaved relatives to give evidence to that review. The report is a shocking read. I remember feeling very upset when I discovered that what had happened to Tim was not unusual. The trust’s attitude towards losing patients seemed to be casual, sloppy, and disrespectful. To the best of my knowledge, not all of Verita’s recommendations were implemented and some of the same defensive and dismissive attitudes remain. This is evidenced by Theo Brennan-Hulme’s recent Prevention of Future Deaths report, where the coroner said that a ‘bullying’ culture not a learning culture prevails at NSFT. 

Since 2013, there have been 36 Prevention of Future Deaths (PFD) reports. The trust initially disputed these figures but the information is on the Ministry of Justice website. If a coroner, and there are several covering NSFT, has recently issued a PFD about a particular issue, or they believe that ‘changes have already been made’, they do not issue a PFD. Many press reports on inquests will state something like, ‘I am reassured by the trust’. This was the case for Peggy, NSFT was not issued with a PFD because the trust said that older people would no longer be transported to out of area beds.

The campaign has analysed the PFDs issued to NSFT and there are repeating themes. However, it is only by reading media reports of inquests, where no PFD is issued, that the themes become clear. It is heart-breakingly stark. There are clusters of deaths: such as suicides in North Norfolk; deaths due to unsafe discharges from inpatient units; drug-related deaths in Norwich; inpatient deaths; chaotic systems; fragmented services; families and GPs who are raising concerns being ignored; or people repeatedly attempting suicide, and saying they wish to end their lives, who are assessed as ‘low risk’. This is all happening in plain sight in every part of Norfolk and Suffolk.

There have been 6 PFDs issued against NSFT in the last 12 months, including one for 15-year-old Mary Bush, who like my son, died on a waiting list. All of these PFDs repeat previous mistakes and evidence that the trust are not learning from their errors. This reinforces our concern that NSFT does not have effective systems and processes in place for recording deaths and the recommendations from PFDs and serious incident reviews.

It is disgraceful that it is left to bereaved parents, acting in a voluntary capacity, to research how many have died because there are statutory agencies who should be monitoring this. If it wasn’t for the diligence of our local journalists, no one would know about these deaths.

This concerning situation at NSFT is part of a wider problem with coronial, commissioning, and monitoring bodies. We think that the lack of outrage, or even interest, in the deaths of people with mental illness is because they are seen as having low value to society. There is no ‘them and us’ any of us could need support with our mental health and what happened to our families could happen to anyone.

We are asking you, as our elected representatives to work together and support our call for an independent statutory public inquiry into how many people have died, and why, with a view to establishing how to stop our loved ones from dying.

Those who have died are almost invisible but they mattered to their friends and families. I am going to end with a quote from He Died Waiting, which tells Tim’s story:

“Some people are deemed to be of so little worth that their lives (and their deaths) are mere whispers but his whispered life echoes loudly in the hearts of those who loved him.”

Emma is going to explain more about the current unsafe situation at NSFT and the legislative gaps that need addressing.

Thank you for listening.


Aldridge, A. (2020). He Died Waiting: Learning the Lessons – A Bereaved Mother’s View of Mental Health Services. Norwich. Learning Social Worker Publications.

Verita. (2016). Independent review of unexpected deaths, April 2012- December 2015: A report for Norfolk and Suffolk NHS Foundation Trust. Available online.

267 thoughts on “Call for Public Inquiry at NSFT”

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