Our Campaign has analysed the Prevention of Future Death (PFD) reports, issued by coroners, that relate to NSFT since the disastrous ‘radical redesign’ in 2012. A Freedom of Information request means that we have NSFT’s responses to the PFDs. We have been looking for the patterns and themes that characterise the issues at NSFT. The errors they repeat, the promises they make (and break), the lessons they could learn.
Since 2012, there have been hundreds of deaths but only 30 PFDs have been issued. We are going to publish these one at a time. We think it is important to reflect on the lives lost.
*Trigger warning *
Who was Matthew and what happened to him?
Matthew was 25 when he died. He fell from Castle Mall in Norwich. Matthew was a IT web designer. He had a loving family. In an EDP report, Matthew’s mother said:
‘I think you get a stereotype of someone who does what Matthew did, but depression can affect anybody, whatever their age or background. It has opened my eyes to that … I just want people to know that Matthew was a good, hard-working lad, who was sadly battling a vicious war with depression.’
You can view the article here: https://www.edp24.co.uk/news/mother-pays-tribute-to-25-year-old-son-who-fell-660262
At his inquest, The coroner, William Armstrong, criticised the trust for ‘fundamental deficiencies’ . He went on to issue a PFD. You can view Matthew’s PFD on the Ministry of Justice website here:
Key points from the PFD:
a) An emergency GP referral was not followed up within 4 hours. It was 2 days before phone triage and 4 days before an assessment with a mental health nurse. The Coroner stated that emergency referrals should be dealt with within timescales there should be policies and procedures to ensure this.
In their response the trust said that they had ”…made a number of resource changes to be in a position to respond” in timescales “according to assessed urgency.” And, implemented monitoring systems, 4 hour referrals that were reported daily to commissioners and monitored by senior managers/clinicians.
They go on to say that CHRT clinical team leaders have daily face-to-face or phone conversations to coordinate, assess risk, and ensure service-users have contact details.
b) There was no “clear shared understanding between professionals” about which team to refer Matthew to. Therefore a need for clear understanding of the roles and interface between assessment and CHRT.
In their response, the trust said that CHRT clinicians are based within Access and Assessment (AAT).
c) Matthew had expressed explicit suicidal ideation and had prepared means but he was not referred to CHRT for “robust intervention”.
The coroner was clear that the risk of suicide or serious self-harm needs to be recognised and acted upon when “person concerned has gone beyond vague suicidal ideation” and moved to contemplating specific means.
The trust’s response: That there is an audit in progress to look at “robustness of assessment structure” from framework and individual clinicians’ judgements.
d) A letter sent, following the assessment to GP, was not drafted appropriately. The Coroner said there was a need for specific guidance and template letter.
Trust response: Clinicians and GPs were working on a template letter.
e) “Most disturbingly” there was a lack of coordination between mental health professionals. The nurse who saw Matthew the day before his death had no knowledge he was being seen by the wellbeing service. Thus, the coroner stated there was a need for effective information sharing between professionals and for them all to have access to records (including interventions and actions of other practitioners).
The trust response: They were working on implementing a single electronic record.
The Coroner highlighted that there was a “fragmented and uncoordinated “approach to Matthew’s care and a need for “these issues to be addressed speedily and comprehensively”.
NB: This issue is ignored in trust response. In fact, not properly answering the question is habitual in the responses.
Matthew’s PFD is an interesting starting point because the key points relate to themes we have seen over and again.
- Explicit suicidal intent, or attempts, not acted upon.
- Fragmented services, where no one takes overall responsibility for someone’s care.
- Lack of coordination between mental health professionals.
- Unclear policies and procedures.
- Recording issues.
- Issues with letters.
Overarching themes of managing risk, communication, collaborative working, and accountability feature in pretty much every PFD we looked at.
We are left with the distinct impression that no one actually checks the validity of the trust’s responses or whether they have done as promised. We know the CQC do not. They have told us in letters it is not within their remit.
Another theme, that we observed repeatedly, is the empty rhetoric of ‘learning the lessons’. It was trotted out in the trust’s response to the coroner by the CEO at the time (Andrew Hopkins): He said that NSFT had already “undertaken an internal review and is committed to taking a number of measures as a result of lessons learned from this tragedy”. A report into Matthew’s inquest cites a trust spokesman as saying: “…changes were going to be made to rectify the concerns raised to ensure it would not happen again”. You can read the EDP report here: https://www.edp24.co.uk/news/man-who-jumped-to-his-death-from-norwich-s-castle-595812.
Sadly, we know they didn’t learn any lessons from Matthew’s death. Less than a year later, Luther Hughes, aged 39, also fell to his death from Castle Mall. His death did not merit a PFD. We guess the coroner felt he had already said all he had to say. Maybe he believed that the trust had implemented their promised changes. However, we know, because we have supported countless bereaved relatives since we started our campaign seven years ago, that the issues that contributed to Matthew’s death remain unresolved and there have been too many similar deaths since.
One shocking finding from our analysis of the PFDs and the trust responses is that with a very few exceptions there are no expressions of regret or condolences made. The exception is: when Jonathan Warren took over, and he was responding to deaths that occurred before he was CEO, he did express how each loss was tragic. Unfortunately, he cut, copy, and pasted these from one letter to the next. Then he stopped bothering with even the token gesture.
NSFT might have forgotten Matthew but his family and friends will not. He was a son, brother and friend. Our thoughts are with those who grieve for him. We will not forget Matthew.