EDP: Mental health service failure “significantly contributed” to suicide of Norwich mother

Dominic Gilbert of the Eastern Daily Press reports:

Failures of mental health services “significantly contributed” to the suicide of a mother struggling with depression and post-traumatic stress disorder, a jury has found.

Katherine Rought-Rought died at her home in North Park Avenue in Norwich on June 1, 2016 from asphyxiation due to strangulation.

Only hours earlier she had been discharged by the Crisis Resolution and Home Care Team (CRHT) from Norfolk and Suffolk NHS Foundation Trust.

The CRHT has been massively cut.

Following a four day inquest, area coroner Yvonne Blake said she had “not been able to find a rationale” for the decision of CRHT not to take on her care in April, and would be writing informally to NSFT to express her concerns.

“I think there were gaps in the care given to Ms Rought-Rought,” she said.

And to many, many others.

Mrs Rought-Rought described her daughter as a “great artist and musician” with a “great sense of humour”.

In a written statement, she said: “I strongly believe Katherine should have been sectioned.”

To be sectioned, there needs to be a bed available.

Commissioners, including the newly-appointed Chief Executive of Norfolk and Suffolk NHS Foundation Trust (NSFT), Antek Lejk, have ignored the findings of two inspections by the Care Quality Commission that NSFT does not have enough beds.

In fact, Antek Lejk has serious questions to answer about his attitude to safety and his role in the out-of-hours deaths scandal.

But after five hours of deliberation, a jury found “no alternatives were actively pursued” and the ECT led to a “deterioration in her mental health…culminating in her decision to commit suicide.”

They added she “did not receive appropriate care” which was “inadequate both in scope and implementation”, which was “likely to have had a bearing on her decision to commit suicide.”

In 2012, people like Michael Knight were dying because of a lack of mental health beds. Since then, many more beds have closed and many more people have died.

Back in 2013, the then director of nursing at NSFT, Roz Brooks, assured the press that NSFT had enough beds:

Officials from Norfolk and Suffolk NHS Foundation Trust (NSFT) reiterated that the number of deaths of patients in their care was in line with regional and national averages after recording four unexpected deaths so far in October.

They added that they remained committed to reducing bed numbers by 20pc, despite four patients currently being placed at inpatient beds outside Norfolk and Suffolk.

Roz Brooks, director of nursing at the NHS trust, said the reduction in bed numbers came as the organisation introduced more community care-based teams as they look to reduce their budget by 20pc up until 2016 – which could result in about 400 job losses.

In March 2018, NSFT needed more than thirty beds more than it had.

In the last few months, NSFT has closed another 36 beds, claiming it cannot safely staff them  – after NSFT wasted millions of pounds paying staff to leave.

Although commissioners promised to stop all out of area placements by the end of April 2014, they have in fact overseen the loss of more beds and a deepening beds crisis.

In fact, NSFT and commissioners wasted £58,000 on a fixed, flawed report from management consultants to contradict the CQC and claim there were enough beds.

Unexpected deaths have risen dramatically.

Roz Brooks meanwhile retired on a large pension.

The self-proclaimed architect of the radical redesign which the King’s Fund called was promoted and is now, astonishingly the national ‘Programme Manager, Mental Health Intelligence and Leadership Programme’. Unsurprisingly, Kathy Chapman’s biography at NHS Providers makes no mention of her role at NSFT.

The inquest had heard from Dr Robert Higgo, an expert clinical psychiatrist, who said the set up of mental health services across the country were “terrible” because the separation of mental health care into different teams meant no one person had an overview of a patient.

There is strong evidence to support Dr Higgo’s opinion published recently in a study in the British Journal of Psychiatry published by the Royal College of Psychiatry.

He said: “Mental health services have changed substantially since I have been in psychiatry. Back in the day all new referrals were seen by a medical doctor, a psychiatrist. Now people are more seen by a non-medic and more never see a medic.”

He added he felt Ms Rought-Rought should have been admitted to hospital – and would have been had she seen a psychiatrist.

Medical input into the CRHTs has been cut to save money. NSFT tried to claim the crisis teams had been ‘enhanced’.

“After the incidents in April consultant psychiatrists strongly recommended either admission or involvement of the CHRT – these recommendations were not followed. Katherine received apt visits, but upon her refusal of continued visits, no review or further assessment was undertaken.

“There is no record of a formal care plan review in light of the April events and the consultant psychiatrists assessment.

“There was a failure to undertake an assessment under the Mental Health Act following the incident on May 29. On the balance of probability this significantly contributed to Katherine’s death.

“A review of the evidence supports the view that Katherine did not have an effective advocate for her needs.”

Area coroner Yvonne Blake said she will write to NSFT with concerns including “people being passed from team to team, falling through the cracks with not enough supervision.”

This should be a formal Prevention of Future Deaths report.

NSFT’s anonymous spokesman disgracefully tried to play down the jury’s concerns:

“Having heard and digested the evidence provided at the inquest, the jury recorded a narrative conclusion which the Trust notes expresses some concerns over the care provided to Ms Rought-Rought,” said a spokesman.

‘Some’. Nice. Taking that seriously, then.

What has the so-called Improvement Director at NSFT, Philippa Slinger, been doing? The crisis is getting worse.

Join us at our protest on 1st May.

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