Nic Rigby of the BBC reports:
A mental health trust failed to act on 258 recommendations from 98 reviews into serious incidents, such as patient deaths, a report has revealed.
Former Norfolk coroner William Armstrong said the trust’s failure to act was a “serious concern”.
Serious incident reviews take place after there are unexpected or avoidable deaths or severe harm to a patient, or allegations of abuse.
Mr Armstrong, who is also chairman of watchdog Healthwatch Norfolk, said as Norfolk coroner he had seen a number of cases of deaths of mental health patients where serious incident inquiries had been conducted by the trust.
“It would be a serious concern if recommendations in a report make a commitment to learn lessons to reduce risks… and they are not implemented,” he said.
Vicki Nash, head of policy and campaigns at Mind, said: “Serious incident reviews are an essential part of the process of understanding how incidents including deaths, severe harm and abuse have occurred and what, if anything, could have been done to prevent them.
“Any recommendations that come out of them have to be taken seriously and implemented swiftly to ensure that healthcare providers learn from past mistakes.”
Emma Corlett, who represents Unison members at the trust, said: “It is a surprise to see that level of recommendations still to be implemented. Our staff will be really concerned about that.”
A spokesman for the Campaign to Save Mental Health Services in Norfolk and Suffolk said: “It is deeply shocking and insulting to patients and their families that the trust has failed to implement 258 recommendations, despite repeatedly promising ‘lessons will be learnt’.”
Here’s what NSFT’s then Acting Chief Executive, now Finance Director, told the EDP eighteen months ago after the inquest into the death of Matthew Dunham (the emboldening is ours):
Was there (or will there be) any internal investigation into what happened?
The trust conducts a detailed internal investigation (known as root cause analysis) into all serious incidents. Action plans from the outcomes of such reports are then developed for all services and are shared with the commissioners of our services. Action plans are monitored to ensure learning is embedded across the trust.
What has been done to prevent this from happening again?
Since Mr Dunham’s tragic death we have introduced new patient safety indicators to better highlight risks related to patient care. We have also reviewed policies and practice related to information sharing to ensure this has been improved.
We are also changing the way clinical risk management training is given to staff to recognise the different skill levels of staff.
Do you want to say something to reassure people in Norfolk and Suffolk that the issues surrounding Mr Dunham’s treatment will not happen again?
The trust puts patient safety at the heart of everything it does and when things do go wrong we have a good track record in responding to concerns and making improvements. We are determined that lessons are learnt and we have already made changes to the areas highlighted by the coroner.
As part of the Access and Assessment Team we also report daily to the Clinical Commissioning Groups on how quickly referrals are being processed so there is instant feedback on any potential gaps or issues.
The trust plans to reduce 500 jobs and cut 20pc of inpatient beds as part of a strategy to save money over the next four years. Is that not likely to lead to more “deficiencies” in the future?
Some funding has been secured from the Norfolk CCGs to help us ensure that staffing levels, skill mix and the ability to deliver safe services are not negatively affected by the changes we are making.
Click on the image below to read Nic Rigby’s article in full on the BBC News website:
The nhs is being hung out to dry by the tories. And being sold off slowly to private companies. The nhs wont get any better until they start taxing all those huge corporations that dodge their tax and use that to get the nhs back up on its feet again. Its so easy to see whats happening around us yet the rich will always vote conservative to get tax cuts.
I agree; I was inerviewed by Radio Norfolk about the Trust going into Special Measures; I told them we were sick of fine words and challenges from Norman Lamb and that the service could only be turned around by an injection of funds. The interviewer then asked if the country could afford it; I replied yes if the rich and multinational companies pay their taxes. Needless to say the interview with me wasnt on the radio.