Norfolk and Suffolk NHS Foundation Trust (NSFT) has published its papers for the Board of Directors meeting on Thursday 22nd September 2016.
The papers contain the Quality Report for the NSFT Board prepared by Michelle Allott, Deputy Director of Nursing at NSFT. The report states:
Overall, the number of SIs over the past two years has shown fluctuation, but the control chart shows that there has been no trend or special cause variation. Overall, 90% of SIs are unexpected deaths, and we similarly see that there has been no increase or decrease in trends, or significant variation.
But what should be a dispassionate examination of safety data is in fact spin over substance.
In 2012/13, there were 161 Serious Incidents (SIs) of which 53, later revised to 88, were unexpected deaths including natural causes. So, 55% of SIs were unexpected deaths including natural causes and there were on average 7.3 unexpected deaths of people under the care of NSFT per month.
Here’s the relevant section of NSFT’s own 2012-13 Annual Report:
In 2013-14, there were 172 SIs of which 105 were unexpected deaths including natural causes. So, 61% of SIs were unexpected deaths including natural causes and there were on average 8.75 unexpected deaths of people under the care of NSFT per month.
Here’s the relevant section of NSFT’s own 2013-14 Annual Report:
In 2014-15, there were 228 SIs of which 139 were unexpected deaths including natural causes. So, 61% of SIs were unexpected deaths including natural causes and there were on average 11.6 unexpected deaths of people under the care of NSFT per month.
Here’s the relevant section of NSFT’s own 2014-15 Annual Report:
In 2015-16, there were 216 SIs of which 157 were unexpected deaths including natural causes. So, 73% of SIs were unexpected deaths including natural causes and there were on average 13 unexpected deaths of people under the care of NSFT per month.
It will be interesting to see how NSFT tries to spin the 13% increase in unexpected deaths in just one year in its 2015-16 Annual Report to be published next month.
In the first five months of this current 2016-17 year, there have been 86 unexpected deaths including natural causes. There have been on average 17.2 unexpected deaths of people under the care of NSFT per month.
Based upon extrapolation of the first five months of 2016/17, for this year we might expect a shocking 206 unexpected deaths including natural causes. That will be an increase of 31% in just one year.
- So, how can NSFT claim that there is no trend in unexpected deaths?
- Does NSFT’s claim that ‘90% of SIs are unexpected deaths’ have any basis in fact?
- Why does the NSFT Quality Report focus on the number of SIs rather than the number of unexpected deaths?
Since 2012/13, the number of SIs has increased by approximately 59%.
But the number of unexpected deaths has increased by 134%, more than twice the increase in SIs.
Four years ago, less than one hundred patients under the care of NSFT died. This year there may be more than 200.
NSFT initially refused to release information on unexpected deaths to the public.
The number of unexpected deaths has disappeared from the Quality Dashboard published in the papers for NSFT’s Board of Directors meetings.
The Quality Report to the NSFT Board does not contain the latest information about SIs and unexpected deaths.
NSFT’s Chair, Gary Page, promised to publish the number of unexpected deaths each month on its website. It didn’t happen.
When the Chief Executive of NSFT, Michael Scott, and the NSFT Patient Safety Lead, Michael Lozano, appeared before the Norfolk County Council Health Overview and Scrutiny Committee this month, Cllr Emma Corlett asked whether the way NSFT collates data or the criteria for SIs and unexpected deaths has changed since 2012. Michael Scott replied that it has not changed.
Michael Scott’s report to the Board in these papers fails to mention that Norfolk County Council’s Health Overview and Scrutiny Committee (HOSC) was so unhappy with his evidence that it has written to NSFT to demand more information. It doesn’t mention our evidence presented to the HOSC that coroners have expressed more concerns about NSFT than any mental health trust in the country.
The excellent Tom Bristow of the EDP reported:
But the committee’s chairman Michael Carttiss said he found it “extraordinary” that the Verita report found the board had been aware of unexpected deaths of patients, yet minutes from board meetings showed these deaths were not discussed.
Is NSFT dishonest, incompetent or innumerate?
What is not in doubt is that the Board of NSFT is in denial.
Here is our chart of the number of unexpected deaths per month at NSFT. See if you can spot the trend that NSFT can’t.
Isn’t it time for a public inquiry?
