A call for urgent action: Open letter to CQC and NHSE & I about NSFT

The CQC have been inspecting NSFT and some of our members were able to meet with the Inspection Manager to express their concerns. It was decided by the wider membership to follow up this meeting with a written request, in the form of an open letter, for urgent action. The concerns expressed in this letter are the opinions of the Campaign members which are based on members’ lived experiences or the information people share with us. We will not be posting the letters and emails referred to in the letter because they contain sensitive information.

To: Craig Howarth, Inspection Manager, Care Quality Commission (CQC). cc. NHS England and Improvement (NHSE & I).

11th December 2021

Dear Mr Howarth,

Thank you for meeting with some representatives of our campaign on 6th December. We think you will agree that people shared with you some harrowing accounts of life and death situations. Due to time constraints, not all attendees were able to tell their stories. As you know, the campaign represents a wide cross-spectrum of patients, service-users, carers, bereaved relatives, NSFT staff and ex-staff. Many patients, service-users, carers and staff members feel unable to speak openly due to fear of repercussions. Therefore, the representatives who met with you, or attend our meetings, are a minority of our members. Following our meeting with you, campaigners met and it was agreed we should:

–  Send you additional information from campaign members via separate emails.

–  Write this open letter to the CQC, copied into NHSE & I, that includes additional information and clarifies our concerns. This is a call for urgent action by the CQC.

Since NSFT first entered ‘special measures’ in 2015, we have raised serious issues with successive CQC inspectorate teams. Therefore, we hold the institutional memory of the CQC’s involvement with NSFT. What may have felt new, or shocking, to you will be reiterations of long-standing concerns from our perspective. The unsafe situation at NSFT has been allowed to continue for way too long. CEOs and Board Chairs have come and gone: disproportionate numbers of people are in mental distress; people continue to die; and, in our opinion, services are the worst they have ever been. Across two counties, people cannot access a service, those in crisis are not safely responded to, carers live in fear of harm coming to their loved ones, and staff are demoralised and exhausted. NSFT, in our opinion, is still not clinically or well led and the Board is completely ineffective. All previous interventions as a result of failed inspections have not succeeded in transforming this dysfunctional trust. This cannot be allowed to continue. It is imperative that the CQC exercises its duties and powers to take incisive and urgent actions. We are calling for the following:

  1. NSFT should be placed in special administration. Should this happen then points 3 and 4 would likely become irrelevant. At the very least, a recovery support team needs to be appointed with the necessary resources to implement change very quickly.
  2. Consideration should be given to splitting the two counties.
  3. The present Council of Governors have been ineffective and incompetent. Governors, who have failed to challenge the current leadership team and failed to represent public concern, need to resign. The current Chair of the Trust, Marie Gabriel should resign immediately. The Lead governor should not be a member of staff.
  4. The Non-Executive Directors (NEDs) need radical reform. Those NEDs who have not been proactive in addressing problems at NSFT need to resign and be replaced with NEDs who have clinical experience.
  5. The CQC needs to enforce actions by NSFT to ensure people on waiting lists are identified and assessed and treated promptly.
  6. The CQC needs to enforce actions to ensure all possible beds are safely open at NSFT and reduce the use of Out of Area (OOA) beds.
  7. The CQC needs to scrutinise and count the unexpected deaths at NSFT and look closely at how any actions from Prevention of Future Deaths (PFD) reports are followed up and monitored.
  8. The CQC needs to scrutinise the recruitment process how appointments are made and take strong action to ensure these are transparent, equitable, and safe processes. Recent replacement of service-users and carers by salaried Patient Participation Leads (PPLs) in the interview process should be reversed.
  9. The CQC and NHSE & I should make formal public announcements of their action decisions.

Our rationale for these actions is based on the following:

Our views are supported by evidence that has already been presented to the CQC and/or NHSE & I in person (to yourself and other inspectors) and/or via correspondence over several years. We shall not reiterate evidence but will attach the most relevant for ease.

We raised detailed concerns with a previous CQC Inspection Manager, Jane Crolley, in a letter dated 12th October 2020. Ms Crolley did not meet with campaign members or service-users and carers. This is something we view as a significant failing on the CQC’s part. Following a meeting with Stuart Dunn, then CQC Lead Inspector, we wrote to him on 24th April 2021. These letters are attached for your reference. The concerns detailed in these, and other, letters and in various meetings with CQC inspectors have not been adequately addressed.

To date, the following concerns raised are ongoing or unresolved:

Safeguarding – unresolved

We raised concerns that NSFT have employed and continued to employ persons who have been convicted of very serious offences. This, potentially, puts patients, service-users, and their families at risk. We are grateful to the brave people who have told us of incidences, but how many more are there? When we exposed this NSFT responded by sending two accusatory letters to the late Terry O’Shea (a founder member of the campaign) in the mistaken belief that he was solely responsible for the campaign and in possession of confidential documents/information. By mid-January 2020 Terry’s terminal illness was known throughout NSFT, therefore we feel the letters’ authors were aware that Terry was terminally ill when the second letter was sent (copy attached).

Waiting list ‘management’ – deteriorated

Children Families and Young People waiting lists have exponentially risen. It is difficult to establish exact figures because there are discrepancies between statistics shared with the board, governors and the media. We are aware that across NSFT service lines some waiting lists are so out of control that people are regularly getting lost from them. We remain very concerned about how unsafe things could become as we enter another wave of Covid 19.

Medical & clinical staffing crisis deteriorated

Everything we detailed in our letters to Ms Crolley and Mr Dunn remains an issue. Staff morale is very low and they report to us feeling exhausted and overwhelmed, experiencing bullying, and being asked to perform tasks in ways that feel unsafe. Many areas of services are operating on unsafe staffing levels but staff do not feel able to raise this freely. Staff would not contact us if their concerns were being addressed fully within the NSFT whistle blowing protocols.

Leadership – unresolved

The governance of NSFT needs urgent action. We still have no confidence in the Board of Governors or NEDs’ abilities to initiate safe, timely and effective mental health services across the two counties. Based on accounts provided by internal sources, we are concerned to hear that information provided to the governors is sometimes incomplete, or inaccurate, and that some governors feel excluded. In our view, as Chair, Marie Gabriel has been rarely physically present and her focus has remained on her other responsibilities elsewhere in the country. She has not delivered on promises.

Inpatient Crisis – deteriorated
This situation has markedly deteriorated since we wrote our letter with wards closed and/or closed to admissions due to safety concerns.

Service-user and carer participation – unresolved

NSFT continues to refuse to recognise the campaign and and only engages with service users and carers who offer no resistance to the official perspectives. We remain concerned at the use of People Participation Leads and the lack of engagement with, or representation of, service users and carers who offer dissenting views.

Board meetings – unresolved
The board meetings continue to be preoccupied with trivia while skipping over or omitting important or difficult issues.

We are hopeful that the incoming Chair could effect change but this will not be possible if she does not have a strong and effective Council of Governors and Board of Directors to support her.

Recruitment processes -unresolved

The recruitment processes are consistently worrying. The appointment of the CEO was reported to be a fiasco and some stakeholders on interview panels felt overruled. We cited in our letter to Mr Dunn examples of inappropriate appointments and promotions and how these could ultimately negatively impact on patients and service-users.

Learning from deaths – unresolved

It has become impossible to keep track of the numbers of unexpected deaths at NSFT. We know that the deaths remain too high. Often PFDs are not issued because NSFT give the coroner assurances that they have already implemented changes. However, we can see no evidence of learning from deaths and PFDs. Our campaign has analysed PFDs since 2012 and we can see repeating patterns.

Our concerns about the CQC – partially resolved

We continue to be concerned about a lack of professional distance and impartiality and unwillingness to investigate and prosecute. We need to see evidence that the CQC will call

NSFT to account and use their powers to put an end to years of non-improvement and unsafe practice.

An example, raised in our letters to Ms Crolley and Mr Dunn, was the case of Peggy Copeman. The CQC did not respond like other agencies we contacted. Peggy’s family remain distraught that two years after her death the CQC have failed to enforce actions on any of the organisations involved.


We are pleased that you have met with us and hope you will take our concerns seriously. Our members are committed to campaigning until we see the improvements in services so desperately needed.

We accept that the demand on mental health services is a national issue. However, we feel that the inadequate and unsafe situation at NSFT is disproportionately worse than other Trusts. The problems are long-standing and entrenched. In our view, the culture at NSFT needs to change fundamentally. We consistently hear stories from staff, service-users and carers who are fearful of whistle-blowing or speaking to yourselves. This has to change.

Voluntary agencies are too often left trying to support people with serious mental illness or in psychiatric crisis without any support from NSFT. We do not accept NSFT’s self- evaluation as the ‘fastest improving trust in the county’. Indeed, we find this deluded view to be an insult to those in our community who cannot get a mental health service that meets their needs, or any service at all, or who are bereaved. We implore the CQC to take urgent action.

We would welcome a response from you about how you intend to act.

Yours sincerely,
Committee of the Campaign to Save Mental Health Services in Norfolk and Suffolk

About the campaign:

We are the largest grassroots local mental health campaign in the country with over 2,500 supporters. Started more than seven years ago by front line staff and people who rely on NHS mental health services in Norfolk and Suffolk, we are fighting the enduring disastrous effects of the cuts and incompetent management at Norfolk & Suffolk NHS Foundation Trust.

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