EDP: Deaths at mental health service show lack of learning, says doctor

Tom Bristow of the Archant Investigations Unit reports:

The region’s troubled mental health service has been accused of failing to learn from its mistakes after it emerged that nowhere in the country had more concerns raised about mental health deaths than Norfolk and Suffolk.

Coroners have written to the Norfolk and Suffolk Foundation Trust (NSFT) 13 times after patient deaths since its formation in January 2012, detailing their worries about the state of the service.

NHS whistleblower and mental health doctor Dr Minh Alexander has looked at the coroners’ letters for every mental health trust in the country going back to 2008 and found Norfolk and Suffolk have received 21 coroner reports.

The reports, formerly known as Rule 43s, are sent by coroners after inquests when they feel lessons could be learned from the case to prevent future deaths.

“If trusts are getting repeated Rule 43s, like the NSFT have, questions clearly need to be asked,” Dr Alexander said. She admitted the data she collected was limited but said her report did show themes in death after death at mental health trusts.

“There are very clear examples of a lack of learning,” she said.

Of the 21 deaths since 2008 in Norfolk and Suffolk covered in Dr Alexander’s report, fears have been raised about lack of staff on six occasions. Another six times there are fears over risk assessments.

Norwich South Labour MP Clive Lewis said: “I know people wanting to minimise this piece of research will say it’s difficult to compare different trusts. But we already knew several other alarming things about NSFT before this.

“We don’t need any external comparators to know that using just NSFT’s own figures, the average of seven people dying each month in 2012 has soared to 21 losing their lives in both April and May this year.” He added government cuts meant there were not enough staff at the NSFT.

A spokesperson for the Campaign to Save Mental Health Services in Norfolk and Suffolk said: “NSFT has a track record of failing to acknowledge or learn from its own mistakes.

“Again and again, NSFT is criticised for lack of care plans, staff and training, poor risk assessments and relationships with other services. For years, the Board of NSFT has failed to acknowledge the increase in unexpected deaths and prioritise its reduction. This, coupled with a desperate lack of resources from commissioners as demand has grown, has placed front line staff in the position of having to make difficult decisions in complex cases with deeply inadequate mental health services.”

It really is worth reading this important piece of investigative journalism, which tells the tragic stories of ten former patients of NSFT about whom the Coroners raised concerns: Matthew Dunham, Christopher Higgins, Mark Robert Anstice, Lorraine Youngs, Sebastian Davies, Barbara Mayer, Ann Wells, Jamie Barlow, Thomas Thurling and Kathryn Sawyer.

Please don’t forget that you can call the Samaritans, whatever you’re going through, any time, from any phone on 116 123. This number is FREE to call. You don’t have to be suicidal.

Click on the image below to read the article in full on the EDP website:

EDP Deaths at mental health service show lack of learning says doctor

21 thoughts on “EDP: Deaths at mental health service show lack of learning, says doctor”

  1. As @nsftcrisis have raised many times lack of staff and poor/no risk assessments are now officially documented as repeatedly ignored contributary factors. So it is now proven that it’s not just a few making an unsubstantiated fuss and causing trouble. Key areas for criticism are founded.

    Now what are the next steps Board CCGs? Please be mindful of Duty of Candour in your response.

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