When a coroner issues a Prevention of Future Deaths report (PFD), also known as a Regulation 28, it is a representation of a formal finding that someone has died, that the death was preventable, and unless action is taken, there is a very serious concern that someone else will die in the same way. Over the last 15 years, these reports have been persistently sent to the Norfolk and Suffolk Foundation Trust. However, despite the continuous arrival of these reports and responses being filed by the Trust, deaths keep happening in similar circumstances.
In 2024 we desperately turned to the local police with real concerns that the amount of PFDs and the overlapping failures within these reports, combined with media reported deaths that appeared to show similar failings to the ones documented by the coroner, were representative of corporate manslaughter. Despite the level of analysis and the evidence we provided, the threshold could not be met.
Recently, we have seen more media documentation of deaths that are strikingly similar to those PFDs we analysed, suggesting action hasn’t been taken at all and these pieces of paper continue to represent nothing more than a slap on the wrist.
We have spoken at length about how PFDs issued by coroners have a lack of enforcement and national oversight which can lead to learning getting lost. Although recipients must respond to the report within 56 days, the coroner does not have any legal powers to enforce the changes or compliance if a recipient refuses to take action. There is also no official, standardised system to track, analyse and enforce whether the commitments laid out in organisational responses are actually implemented.
Without these things in place, it is very easy for safety recommendations to be delayed, ignored and forgotten about. There is no organisational memory and there is no monitoring system in existence leading to a number of things, but most evidently a lack of accountability and this ever-present words without action that is pervasive throughout the mental health system especially. The charity INQUEST continues to campaign for a centralised system to follow up on coroner recommendations and push for true accountability and justice for bereaved families (read about their no more deaths campaign here).
Deaths in NSFT inpatient settings
In 2017, JD was found in his room at the Norvic Clinic. He had spent most of his life in secure mental health units and been in this unit for the last 2 years. He had been considered as a ‘low risk’ of suicide and so was on hourly observations at the unit, the minimum required rather than more frequent checks patients considered higher risk. Concerns were raised at the inquest by his family about JD not being given medication and that he had ‘access to the tools to kill himself. This access came despite the fact that he had significantly deteriorated physically and mentally in the months leading up to his death with additional significant weight loss. NSFT responded that he was on hourly observations and had access to certain items due to being at low risk of suicide and self harm at the time.
In 2021, TW was an informal patient at Hellesdon Hospital. Her notes contained a clear warning, written in reed and bolded, that she would not be given a specific risk item due to the danger it posed. She was given it anyway and no record was made of the decision as to why this was the case. When she returned to the ward, the item was not retrieved from her and she ended up using the item to cause serious harm to herself. After this incident, there was no review between professionals. The following day, with the risk item still accessible and insufficient monitoring from ward staff, TW was found unresponsive in her room. She died as a result of the action she took.
Following the inquest, the coroner issued a PFD identifying 16 matters of concern including: risk items remaining accessible (despite documented warning), decisions not being recorded, inadequate MDT review following a serious self harm incident, and a patient safety incident investigation report that was still in draft 9 months post TW’s death that was riddled with errors. One of these errors included the incorrect date of death and an absence of interviews with key professionals involved. It was later reported that NSFT’s own investigation acknowledged that staff “were often left to firefight” however, this sentence was later removed and completely absent from the final version of the report.
In 2024, VB was also an inpatient in Hellesdon hospital. Originally detained under Section 2 of the MHA, her section expired at the beginning of November. At an MDT meeting it was decided that VB should remain as an informal patient rather than having the section reinstated and discharge from the ward was being discussed. Her husband expressed concerns about the risk he felt was present and how this would manifest if she was sent home. Only three days after this discussion, VB was found unresponsive in her room. A jury inquest that has recently concluded (May 2026) found that items previously identified as presenting a risk had remained accessible at the time of the incident. VB died in the same hospital, having been found the same way, on the same ward as TW in 2021.
| TW, 2021 | VB, 2024 | JD, 2017 |
| Hellesdon Hospital | Hellesdon Hospital | Norvic Clinic, now known as Northside house |
| Informal patient | Informal patient | Sectioned under MHA |
| Risk items remained accessible despite documented warnings | Previously identified risk items remained accessible | Risk items accessible |
| No in-depth review post serious self-harm incident that preceded death | Section not reinstated despite family raising concerns about risk | Determined to be low risk and on basic observations |
| Found unresponsive in room | Found unresponsive in room by another patient | Found unresponsive in room |
Three years after TW’s PFD identified nearly exact failures, VB’s family are now sitting where those who cared about TW sat.
And it doesn’t stop there… This pattern is not just confined to inpatient care, it is persistent throughout the cases of those who die in the community too, often because there has been limited response to the crises the patients are presenting with.
In July 2023, CS sustained fatal injuries after exiting a moving taxi. He had been diagnosed with paranoid schizophrenia and been suffering a period of psychosis for over three months. During the inquest, there was found to have been “missed opportunities to provide appropriate and timely care”. It was concluded that mental health assessments had been inadequate and the coroner issued a PFD raising concerns including: a lack of understanding within CRHTT around assessing mental capacity and recording the rationale for decisions, important emails not being circulated to relevant people, and a person assessed as needing “an immediate response within four hours” having their assessment arranged for the following day instead.
Additionally, NSFT’s crisis team was repeatedly warned of CS’s deteriorating mental health by his sister. She pleaded with staff to allow her brother to be admitted to hospital. But her concerns were ignored.
NSFT responded that there would be further staff training, a redesigned triage tool and that they would be making updates to patient history recording systems.
In January 2025, MF died, just 18 months after CS. MF had lived with paranoid schizophrenia for decades but had been stable until he had a stroke in 2022 which destabilised his mental health. His family raised concerns with his GP in June 2024 and warned about the amount of unmonitored medication he had access to whilst he was expressing suicidal thoughts. In November of 2024, his brother drove him to Hellesdon Hospital whilst he was in crisis, hearing voices and expressing suicidal ideation. They were turned away and advised to call NHS 111.
The family described “an arsenal of unmonitored medication” which they believed gave him “the means to kill himself.” They state their repeated calls for help were “not actioned.” Following multiple acts of self harm and an attempt to end his life, a mental health nurse concluded it was unsafe for him to remain home alone and requested a bed at Hellesdon hospital. This was in January 2025, 7 months after the family had begun raising their concerns. On the day a bed was finally found for MF at Hellesdon, he had already taken action to end his life and became unwell in his brother’s car, needing to be transferred to the NNUH by ambulance. Unfortunately, MF died that evening. The inquest stated communication between agencies could have been better, and acknowledged the families belief that “the system did not recognise the depth of his need until it was too late”.
His family states: “We believe seven months of sustained attempts to get him mental health help was what caused his death”
In both CS and MF cases, the attempts from family to get them help were unsuccessful. This is something we repeatedly hear. Families’ concerns about their unwell relatives being ignored or not taken seriously, resulting in horrendous outcomes. This has been repeated across the deaths of those under the care of NSFT and is also something we hear from bereaved relatives now navigating the unimaginable, and also carers still trying to get their family members support.
NSFT states that learning from deaths is their top priority. They formed a learning from events group and now have a system to keep track. They stated they had gone through every PFD and taken the learning from it, so why are people still dying in similar circumstances? The similarities within just a few individuals’ sad deaths suggest that action hasn’t been taken, and if it has, it clearly hasn’t been properly embedded in the spaces where it matters. It’s still inconsistent and people are still dying. The question is not whether NSFT knew about the failures in the situations mentioned here, we know they knew, the PFDs proved they knew and the inquest process proved they knew. The question is why, after these warnings, have more individuals died in very similar circumstances and why is nothing being done about it? The Trust has said that they have made changes in response to sad incidents like these.
We have to ask: if that is the case, then why are people still dying?