EDP: Tranquilisation changes came too little too late for Norwich man, says sister

Geraldine Scott of the Eastern Daily Press reports:

“The sister of a mentally ill man who died after being tranquillised in hospital has slammed the region’s mental health trust for not addressing problems with the practice sooner.

And a inquest into his death found failings in the care he received from Norfolk and Suffolk Foundation Trust (NSFT) – including how he was observed after being tranquillised.

On January 25 this year NSFT committed to improving the checks on patients as it was revealed they could only be sure checks had been carried out 18pc of the time – but for Mr Jewell’s sister Christine Welfare, the changes came too late.

Mr Jewell died on January 17, 2014 – 11 days after he initially arrived at Norwich’s Hellesdon Hospital, having run out of Clozapine, his schizophrenia treatment drug.”

We have already written about the shameful ‘treatment’ of Neil Jewell. If Neil Jewell had received support in the community or there had been a local NHS mental health bed, he would probably be alive today. The police investigated whether his death could be grounds for a manslaughter prosecution and the Coroner found that neglect contributed to Neil Jewell’s death.

Mrs Welfare, who lives in Aylsham with husband Edward, said: “At the time we were reassured that these things had already been looked at, Jane Sayer (the trust’s former director of nursing, quality and patient safety) said staff at Ipswich Hospital knew it was a poor standard of nursing.

“Obviously Dawn Collins (the interim director) has been tasked with addressing these ongoing issues which Jane Sayer stated had already been reviewed a year ago following Neil’s inquest. This was a very serious area brought under scrutiny by the jury and coroner. It is not acceptable to turn this in to a paper exercise of form filling.

When we raised our concerns about the circumstances of Neil Jewell’s death at a Board of Directors meeting of Norfolk and Suffolk NHS Foundation Trust (NSFT) in April 2017, the then Chief Executive of NSFT, Michael ‘Pay out’ Scott, initially refused to respond to us until he was prompted to by the Chair of NSFT, Gary Page. Michael ‘Pay out’ Scott refused to engage with any of the issues, petulantly stating that he was ‘satisfied with the improvements made’.

His statement looks complacent and inaccurate given the subsequent disclosure that checks are only carried out 18pc of the time and the NSFT’s subsequent inadequate rating following its most recent inspection by the Care Quality Commission (CQC)Michael ‘Pay out’ Scott is still being paid his £175,000 per annum salary from NHS funds meant for mental health treatment despite resigning after learning of the trust’s second inadequate rating.

The Chair of NSFT, Gary Page, refused to take any further questions and ended the meeting Board of Directors meeting half an hour before the time scheduled for questions and despite being told that people were travelling from north Norfolk to ask questions. During this disgraceful behaviour, the rest of the Board, including the other executives and non-executives, sat meekly by and said nothing.

At the most recent meeting of NSFT’s Board of Directors in January 2018, we raised the most recent inpatient death at NSFT on 29th November 2017, which happened after the latest CQC inspection and after NSFT was placed into Special Measures. Again, the NSFT Board of Directors failed to engage. We said that the honourable and appropriate action for the trust Chair, Gary Page, in the light of NSFT’s second CQC failure, second Special Measures and yet another inpatient death, was to resign and that if he would not resign, the Board should remove him and if the non-executives refused to do so, the Board of Governors should ensure his removal (though there is no chance of that with the current Lead Governor, Catherine Wells, and ridiculously-titled and overpaid ‘Company Secretary’, Robert Nesbitt).

Marion Saunders, the most senior non-executive director, offered a weak defence of the NSFT Chair, Gary Page, and said that ‘her committee’ had decided he should stay. These are the same directors who thought they would pass the most recent CQC inspection; the same directors who awarded inflation-busting £10,000 pay rises to NSFT executives for getting NSFT out of special measures only to go back in; who decided that Michael Scott’s performance was satisfactory and that he was worth paying more than the Prime Minister; that the Company Secretary, Robert Nesbitt should be moved from the Agenda for Change pay scales so he could be paid an even more ridiculous salary while front line staff received pay rises of one per cent. These directors sat by as Gary Page refused further questions and closed the Board of Directors meeting an hour early rather than take questions from the public.

This isn’t what genuine engagement looks like. Corporate governance at NSFT is completely dysfunctional.

Sadly, the latest Improvement Director, Philippa Slinger, doesn’t observe NSFT Board of Directors meetings: we noticed behaviour ‘improved’ markedly when the last Improvement Director observed them.

“If these basic physiological checks are not made at very crucial times following rapid tranquilisation, then people will continue to die unnecessarily.”

Mrs Welfare also met with former chief executive Michael Scott, who told her policies had been put in place. And statements from the trust at the time said improvements had been made.

But in the trust’s latest inspection report, released in October last year, the Care Quality Commission found rapid tranquilisation was being used too often and physical checks required after tranquilisation had not been done.

And at the trust’s board of director’s meeting on January 25 it was revealed proof patients had been checked often enough were filled out just 18pc of the time.

With people like this in charge, there will be more deaths at NSFT.

Enough is enough.

Read Geraldine Scott’s article in full on the EDP website by clicking the image below:

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