On 30th August 2023, an investigation into the NSFT mortality review by Nikki Fox and BBC Newsnight aired on BBC. You can find the BBC iplayer link here:
Nikki Fox also spoke on radio 4’s Today programme : starting at 00:41:18
Nikki Fox revealed on Newsnight that Norfolk and Suffolk NHS Foundation Trust’s (NSFT) had not only lost track of their numbers of deaths, but also heavily doctored governance criticism within the report. NSFT held the report for 3 months to check ‘factual accuracy’, after Grant Thornton had finished their ‘independent’ and ‘robust’ report. The investigation also explored the concern from the parliamentary ombudsman into the extent to which the mortality report was edited. NSFT CEO Stuart Richardson continues to insist he and the Trust have been ‘open and honest about the failings highlighted in the report’. But which draft is he referring to? Even if it is the one that was heavily doctored by NSFT, the report is deeply concerning and has caused tremendous upset to bereaved families not to mention damaging public trust. Stuart Richardson states he will be attending the Norfolk County Council Health and Overview Scrutiny Committee on 14 September 2023. This is following Committee Chairman Fran Whymark’s concerns after viewing the story by the BBC, stating he needed full confidence that NSFT would be open and would take ‘the right action’. The criticisms that were edited out mentioned weak and inadequate leadership and a culture of fear. Staff also spoke out on the programme expressing fears of becoming a scapegoat and blame cultures. CQC also upgraded NSFT’s overall rating in February 2023, from ‘Inadequate’ to ‘requires improvement’ including ‘well-led’.
The CQC report ‘improvements in the February 2023 findings here and states: ‘The trust leaders recognised the importance of role modelling the appropriate behaviours which was very evident throughout the well led review. They were clear of the need to avoid a blame culture and create one where staff felt supported to learn and improve. They had introduced a leadership and management behaviour framework. Executive leaders were holding weekly online ‘here to listen’ events where any staff could join and ask any question anonymously if they wished. The calls were recorded for colleagues who could not join at the time and were being attended by 200-300 staff. The trust had launched a trust wide piece of work to listen to staff and turn this into action and about 30% of the trust staff had chosen to complete the initial survey. These results were available at the time of the inspection and were enabling the trust to start understanding the scale and nature of the issues. The process will support further work with teams to listen and promote improvements. The trust was working to improve opportunities for staff to speak up and had just started to use an external speak up guardian arrangement to ensure greater independence from the trust. The trust was supporting the staff networks, which each had an executive sponsor, and had been provided with extra resources to develop further.
Yet since the story has broken, there have been no such comments made yet by CQC.
Below is the statement from Caroline Aldridge, Anne Humphrys and Emma Corlett (authors of Forever Gone: Losing Count of Patient Deaths (7th August 2023)) regarding the BBC Newsnight Investigation into the Grant Thornton report on Norfolk and Suffolk NHS Foundation Trust’s (NSFT) Mortality Reporting and Recording.
29th August 2023
When the ‘independent’ review was commissioned in summer 2022, NSFT’s Deputy CEO, Cath Byford, assured Norfolk Health Overview and Scrutiny Committee that the report would give a “single version of the truth”. She said that NSFT knew how many people had died. Grant Thornton’s report, published on 28th June 2023, made it clear that NSFT did not know how many patients had died. We were not given a single version of the truth and we now know there is not even a single version of the report. The arrogance that NSFT did not know that they did not know, or their duplicity in pretending they do, is concerning.
We do not know who provided information to Grant Thornton and who was in the ‘two
different NSFT teams’ cited by the auditors that it is argued led to the material changes to the report. We do not know who placed pressure on whom to have the report changed, or who signed off the changes and the final report. We do not know whether it was internal to NSFT, or whether the wider Norfolk and Suffolk health and care systems were aware of the changes, and/or who is complicit in authorising them.
It is disappointing that NSFT leads looked us in the eye, apologised and told us they were being transparent, in the full knowledge the report had been altered or had no awareness of what was being done in their names. Neither of these scenarios is acceptable and evidences weak, poor and inadequate governance.
NSFT stated it was ‘standard practice’ to check the ‘factual accuracy’ of the draft report. If what has happened is NSFT’s standard practice it then calls into question the integrity of other reports about them or that they produce about concerns. We agree with Rob Behrens, Executive Chair Parliamentary and Health Service Ombudsman, opinion on the report changes: “I am concerned at the difference between the draft report and the published report, and because the differences in texts at key points are so huge, that this is not just a bureaucratic drafting of the issue”.
We have found, during our research for Forever Gone: Losing Count of Patient Deaths (7th August 2023) that there are NHS trusts who seem to investigate the majority of their deaths and have more open and transparent ways of reporting them. We found other mental health trusts (such as Essex) where concerns about patient safety and the inability to accurately count deaths feature. The culture at NSFT has been described as unsafe. There are other trusts that are similarly described to NSFT, such as the Countess of Chester Hospital where whistleblowers’ safety concerns about deaths were not listened to and indeed actively dismissed. Our observations are that NSFT also protects corporate reputation over patient safety, duty of candour and transparency.
We have had no response from Steven Barclay (Secretary of State for Health and Social Care) or Maria Caulfield (Minister for Mental Health) since the publication of our open letter to them as part of the Forever Gone report. We have had no formal response from any of the Norfolk and Suffolk MPs since their briefing and subsequent receipt of the same. This is part of the pit of inaction that believe has led to a point where serious concerns are repeatedly raised about NSFT without any meaningful or tangible action.
We all have difficult decisions to make in life and there are times when you either do the right thing or you are complicit by your silence or inaction. The local and national health and care systems, the regulators, the Secretary of State for Health and Social Care, the Minister for Mental Health and the majority of Norfolk and Suffolk MPs have failed in their duty to hold to account NSFT in terms of governance and regulation. This has happened in plain sight, in THEIR sight. They have valued protecting their reputations over protecting people. Their responsibility now is to do the right thing and initiate a statutory public inquiry into the deaths and cover up at NSFT, to hold the NSFT Board and Council of Governors to account and put in competent, credible and morally sound leadership.
We do not feel it is our place to put the different versions of Grant Thornton’s report into the public domain but we are convinced that the original version should be published so that people can compare the versions. Bereaved families deserve to know the truth. NSFT’s governors, staff clinicians and volunteers deserve to see the original version of the Grant Thornton report, in order to make up their own minds about their leadership, rather than rely on what they are communicated by their bosses. As ever, we are reliant on local journalists for uncovering and reporting on concerns about mental health services.
To avoid dragging out this sorry situation any further we urge all parties to immediately publish all correspondence, notes, meeting minutes and records relating to the Mortality Review that each organisation holds so that the public can see for themselves what has happened and how. We have today submitted Freedom of Information requests to that effect. It will further damage public confidence if, yet again, we have to drag the truth out of people.
There is a single truth that is lived every day by those whose loved ones have died because
they were failed by NSFT and the wider system – their loved one’s are forever gone.
Forever Gone: Losing Count of Patient deaths is available as a free download from the
Since the BBC story was aired on radio, BBC news 24, Newsnight and local BBC Look East, there has been no statements or communication from MPs, the CQC, NHSE or the local ICBs. We urge you all to please keep writing to MPs referring to these stories and programmes.