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Something Must Change: Our press release about terrible CQC report.

Press Release

The Campaign to Save Mental Health Services in Norfolk and Suffolk welcome’s the decision by the CQC to give NSFT an overall quality rating of inadequate.

Patients, service users, NSFT staff, family members and carers welcomes the decision by the CQC to give an overall trust quality rating of inadequate.  We are pleased that the CQC has recognised what those with lived experience have been saying consistently since 2013 – that the mental health trust for Norfolk and Suffolk is a failure, however, it is not enough and there are now serious questions for NHS England and Improvement and the local Clinical Commissioning Groups (CCGs) who have allowed this dire situation to continue.  The decision is too late for many who have lost their lives and the bereaved families who have lost loved ones.

Our campaign has consistently raised concerns over the last 9 years but the improvements needed have been lacking. NSFT have broken their promises time and again and they have failed to deliver a safe, effective and well-led service which has resulted in serious harm, unsafe services and deaths which were wholly avoidable. The people of Norfolk and Suffolk deserve better. The previous Chair, Marie Gabriel, repeatedly described NSFT as the ‘fastest improving trust in the country’, which was reiterated by NSFT senior staff and initially came from NHS England. It is clear from the CQC report that this was a completely misleading and untrue narrative. 

The Campaign welcomes the new Chair of the Trust who appears to have the right values, however this report demonstrates that the Trust has continued to be poorly governed and led at governors, board and senior management level.  The current Chief Executive was the Chief Operating Officer from 1st August 2018 and so this has happened on his watch and he has to fully accept his part in this.  NHS England and Improvement (NHSE&I) forced various chief executives and the previous chair onto NSFT citing they were the people needed to turn the trust around.  The trust has had every level of support including Improvement Directors, buddy trusts, new board members and the Improvement Intensive Support for Challenges Systems team from NHSE&I and yet it has continued to deteriorate. None of this support has had a sustained impact and when service users, carers, staff and campaigners have raised concerns they been vilified and made out to be troublemakers and accused of living in the past.  

The time for talking about plans has long since expired.  All previous interventions from CQC and NHSE&I have failed. There is no accountability for NHSE&I, the local Clinical Commissioning Groups, the Integrated Care Systems in both counties, the Conservative MPs or the Chief Executives and Chairs that the trust has seen in the last 9 years.  NSFT has continued to be commissioned at the direction of NHS England despite people continuing to die, being left without the support that they need and commissioners knowing that services are not fit for purpose.  Conservative MPs have heard from their own constituents about their devastating lived experiences and this includes the previous Secretary of State for Health and Social Care. It is not enough for the report to be published or for the status quo to continue.  The accountability for the failure of the trust lies with NHSE&I, NSFT and the Department for Health and Social Care.  We need to know what actions the Department for Health and Social Care is going to take, what accountability there will be for those who have maintained the irresponsible and inaccurate narrative that the trust is improving but, more importantly, when and how the people of Norfolk and Suffolk will get a mental health service that is fit for purpose.   It is imperative that the commissioners, MPs, CQC, NHSE&I and NSFT all apologise publicly to service users and carers for the failures that have been allowed to continue and the deaths that are on their hands as a result.

The report shows that the Trust have continue to mislead the press, the public and their own board through a lack of transparency.  This is not a culture which shows a trust who is willing to learn and changing.  This is not a trust who is well-led as demonstrated by the CQC report who rated this as inadequate overall and 7 of the individual services inspected were either inadequate or requires improvement.

As a Campaign we believe the following needs to happen:

  • There needs to be an independent enquiry into NSFT looking at the unexpected deaths and also how a trust has been allowed to remain in special measures for such a long time whilst continuing to fail.  This needs to look at the actions of the NHS England and Improvement, CQC, the Clinical Commissioning Groups and NSFT.
  • That NHE England and Improvement work with the Campaign to set out the options for structural change
  • A humble and open apology from NHSE & I, CQC, the Conservative MPs who have blindly continued to support the Trust, Clinical Commissioning Groups and NSFT acknowledging their role and accountability in the failure of mental health services.
  • The Chair of NSFT needs to be given a stronger role to enable her to fully hold to account and oversee culture change.
  • NSFT needs to start being open and transparent in their communication and acknowledging where things are not working  and what they are doing to address this
  • Staff need to be supported as we still hear too many stories where they have been victimised for raising concerns or their ideas of how to improve services are ignored.  Trade unions have a role in supporting staff to do this.  NSFT need to start listening to their staff

Too many people have died while NSFT have been in ‘special measures’. Too many people are desperate for help for themselves or a loved one. People in mental distress and exhausted carers have been robbed of hope. This cannot be allowed to continue and NHS England and Improvement cannot be allowed to just continue doing what they have before because it has not worked and it is not good enough.  We need a complete change of culture and the proposed changes need to be coproduced with patients, service users, staff and carers.

The Campaign to Save Mental Health Services in Norfolk and Suffolk is holding a protest outside Hellesdon Hospital at 10am on Thursday 28th April to coincide with the publication of the CQC report and to commemorate all those who have died unnecessary deaths over the last 9 years.  Bereaved parents and campaign members will be available for interview.

Background information about the campaign:

In 2013, the Campaign was set up by service-users, carers, bereaved families, and staff involved with the Norfolk and Suffolk Foundation Trust (NSFT), who were concerned about the impact of the drastic cuts to services (the ‘radical redesign’).

We are the largest grassroots local mental health campaign in the country with over 2,500 supporters. Started more than nine years ago by front line staff and people who rely on NHS mental health services in Norfolk and Suffolk, we are fighting the enduring disastrous effects of the cuts and incompetent management at Norfolk & Suffolk NHS Foundation Trust.

Every year since the things seem to have got worse and the death count steadily rises.

Here is our open letter we sent to the CQC in December 2021:

To: Craig Howarth, Inspection Manager, Care Quality Commission (CQC).

cc. NHS England and Improvement (NHSE & I).

11th December 2021

Dear Mr Howarth,

Thank you for meeting with some representatives of our campaign on 6th December. We think you will agree that people shared with you some harrowing accounts of life and death situations. Due to time constraints, not all attendees were able to tell their stories.  As you know, the campaign represents a wide cross-spectrum of patients, service-users, carers, bereaved relatives, NSFT staff and ex-staff. Many patients, service-users, carers

and staff members feel unable to speak openly due to fear of repercussions. Therefore, the representatives who met with you, or attend our meetings, are a minority of our members. Following our meeting with you, campaigners met and it was agreed we should:

– Send you additional information from campaign members via separate emails.

– Write this open letter to the CQC, copied into NHSE & I, that includes additional

information and clarifies our concerns. This is a call for urgent action by the CQC.

Since NSFT first entered ‘special measures’ in 2015, we have raised serious issues with successive CQC inspectorate teams. Therefore, we hold the institutional memory of the CQC’s involvement with NSFT. What may have felt new, or shocking, to you will be reiterations of long-standing concerns from our perspective. The unsafe situation at NSFT has been allowed to continue for way too long. CEOs and Board Chairs have come and gone: disproportionate numbers of people are in mental distress; people continue to die; and, in our opinion, services are the worst they have ever been. Across two counties,

people cannot access a service, those in crisis are not safely responded to, carers live in fear of harm coming to their loved ones, and staff are demoralised and exhausted. NSFT, in our opinion, is still not clinically or well led and the Board is completely ineffective. All previous interventions as a result of failed inspections have not succeeded in transforming this dysfunctional trust. This cannot be allowed to continue. It is imperative that the CQC exercises its duties and powers to take incisive and urgent actions. We are calling for the following:

1. NSFT should be placed in special administration. Should this happen then points 3

and 4 would likely become irrelevant. At the very least, a recovery support team needs to be appointed with the necessary resources to implement change very quickly.

2. Consideration should be given to splitting the two counties.

3. The present Council of Governors have been ineffective and incompetent.

Governors who have failed to challenge the current leadership team and failed to represent public concern need to resign. The current Chair of the Trust, Marie Gabriel should resign immediately. The Lead governor should not be a member of staff.

4. The Non-Executive Directors (NEDs) need radical reform. Those NEDs who have not been proactive in addressing problems at NSFT need to resign and be replaced with NEDs who have clinical experience.

5. The CQC needs to enforce actions by NSFT to ensure people on waiting lists are identified and assessed and treated promptly.

6. The CQC needs to enforce actions to ensure all possible beds are safely open at NSFT and reduce the use of Out of Area (OOA) beds.

7. The CQC needs to scrutinise and count the unexpected deaths at NSFT and look closely at how any actions from Prevention of Future Deaths (PFD) reports are followed up and monitored.

8. The CQC needs to scrutinise the recruitment process how appointments are made and take strong action to ensure these are transparent, equitable, and safe processes. Recent replacement of service-users and carers by salaried Patient Participation Leads (PPLs) in the interview process should be reversed.

9. The CQC and NHSE & I should make formal public announcements of their action decisions.

Our rationale for these actions is based on the following:

Our views are supported by evidence that has already been presented to the CQC and/or NHSE & I in person (to yourself and other inspectors) and/or via correspondence over several years. We shall not reiterate evidence but will attach the most relevant for ease.  We raised detailed concerns with a previous CQC Inspection Manager, Jane Crolley, in a letter dated 12th October 2020. Ms Crolley did not meet with campaign members or service-users and carers. This is something we view as a significant failing on the CQC’s part. Following a meeting with Stuart Dunn, then CQC Lead Inspector, we wrote to him on 24th April 2021. These letters are attached for your reference. The concerns detailed in these, and other, letters and in various meetings with CQC inspectors have not been adequately addressed.

To date, the following concerns raised are ongoing or unresolved:

Safeguarding – unresolved

We raised concerns that NSFT have employed and continued to employ persons who have been convicted of very serious offences. This, potentially, puts patients, service-users, and their families at risk. We are grateful to the brave people who have told us of incidences, but how many more are there? When we exposed this NSFT responded by sending two accusatory letters to the late Terry O’Shea (a founder member of the campaign) in the mistaken belief that he was solely responsible for the campaign and in possession of confidential documents/information. By mid-January 2020 Terry’s terminal illness was known throughout NSFT, therefore we feel the letters’ authors were aware that Terry was terminally ill when the second letter was sent.

Waiting list ‘management’ – deteriorated

Children Families and Young People waiting lists have exponentially risen. It is difficult to establish exact figures because there are discrepancies between statistics shared with the board, governors and the media. We are aware that across NSFT service lines some waiting lists are so out of control that people are regularly getting lost from them. We remain very concerned about how unsafe things could become as we enter another wave of Covid 19.

Medical & clinical staffing crisis deteriorated

Everything we detailed in our letters to Ms Crolley and Mr Dunn remains an issue. Staff morale is very low and they report to us feeling exhausted and overwhelmed, experiencing bullying, and being asked to perform tasks in ways that feel unsafe. Many areas of services are operating on unsafe staffing levels but staff do not feel able to raise this freely. Staff would not contact us if their concerns were being addressed fully within the NSFT whistle blowing protocols.

Leadership – unresolved

The governance of NSFT needs urgent action. We still have no confidence in the Board of Governors or NEDs’ abilities to initiate safe, timely and effective mental health services across the two counties. Based on accounts provided by internal sources, we are concerned to hear that information provided to the governors is sometimes incomplete, or inaccurate, and that some governors feel excluded. As Chair, Marie Gabriel has been rarely physically present and her focus has remained on her other responsibilities elsewhere in the country. She has not delivered on promises.

Inpatient Crisis – deteriorated

This situation has markedly deteriorated since we wrote our letter with wards closed and/or closed to admissions due to safety concerns.

Service-user and carer participation – unresolved

NSFT continues to refuse to recognise the campaign and and only engages with service users and carers who offer no resistance to the official perspectives. We remain concerned at the use of People Participation Leads and the lack of engagement with, or representation of, service users and carers who offer dissenting views.

Board meetings – unresolved

The board meetings continue to be preoccupied with trivia while skipping over or omitting important or difficult issues.

We are hopeful that the incoming Chair could effect change but this will not be possible if she does not have a strong and effective Council of Governors and Board of Directors to support her.

Recruitment processes -unresolved

The recruitment processes are consistently worrying. The appointment of the CEO was reported to be a fiasco and some stakeholders on interview panels felt overruled. We cited in our letter to Mr Dunn examples of inappropriate appointments and promotions and how these could ultimately negatively impact on patients and service-users.

Learning from deaths – unresolved

It has become impossible to keep track of the numbers of unexpected deaths at NSFT. We know that the deaths remain too high. Often PFDs are not issued because NSFT give the coroner assurances that they have already implemented changes. However, we can see no evidence of learning from deaths and PFDs. Our campaign has analysed PFDs since 2012 and we can see repeating patterns.

Our concerns about the CQC – partially resolved

We continue to be concerned about a lack of professional distance and impartiality and unwillingness to investigate and prosecute. We need to see evidence that the CQC will call NSFT to account and use their powers to put an end to years of non-improvement and unsafe practice.  An example, raised in our letters to Ms Crolley and Mr Dunn, was the case of Peggy Copeman. The CQC did not respond like other agencies we contacted. Peggy’s family remain distraught that two years after her death the CQC have failed to enforce actions on any of the organisations involved.


We are pleased that you have met with us and hope you will take our concerns seriously.  Our members are committed to campaigning until we see the improvements in services so desperately needed.

We accept that the demand on mental health services is a national issue. However, we feel that the inadequate and unsafe situation at NSFT is disproportionately worse than other Trusts. The problems are long-standing and entrenched. In our view, the culture at NSFT needs to change fundamentally. We consistently hear stories from staff, service-users

and carers who are fearful of whistle-blowing or speaking to yourselves. This has to change.

Voluntary agencies are too often left trying to support people with serious mental illness or in psychiatric crisis without any support from NSFT. We do not accept NSFT’s self-evaluation as the ‘fastest improving trust in the county’. Indeed, we find this deluded view to be an insult to those in our community who cannot get a mental health service that meets their needs, or any service at all, or who are bereaved. We implore the CQC to take urgent action.

We would welcome a response from you about how you intend to act.

Yours sincerely,

Committee of the Campaign to Save Mental Health Services in Norfolk and Suffolk


The NSFT has endured turbulent times in the past decade, with care regulators placing it in special measures on three separate occasions.

February 2013

“Radical redesign” of mental health services is announced – it leads to the loss of 400 jobs and a 20pc reduction in bed numbers

November 2013

Campaign to Save Mental Health Services in Norfolk and Suffolk launches.

January 2014

Out-of-area placements increase by 750pc and the Trust sets a four-month deadline to end the practice

February 2015

Trust becomes the first in the country to be placed into special measures

October 2017

It is taken out of special measures, but still requires improvement

March 2017

Trust spends £571,000 on out-of-area placements in a single month

August 2017

Damning report from Healthwatch Norfolk lays bare the grievances of 680 patients

October 2017

Trust enters special measures for the second time and Mundesley Hospital is closed down

December 2017

Ashcroft Centre in Wicklewood, a specialist unit for women’s mental health, closes down

March 2018

A further 36 beds are lost, with bosses blaming staffing levels and unsafe environments

April 2018

Trust sets itself a target of 2021 to end all out of area placements

November 2018

Placed into special measures for a third time

January 2021

“Significant improvements” acknowledged by the CQC, but Trust’s rating does not change


Trust misses its target of 2021 to end all out of area placements.

Maladministration leads to the closure of the 10 bed Rollesby ward in March 2021, after several months of reduced patient numbers.  It is the only PICU in Norfolk, and its closure means the loss of 10 beds every day. This ward remains closed to date.

February 2022

New figures show 15 people still out-of-area as the Trust awaits results of its latest CQC inspection

3 thoughts on “Something Must Change: Our press release about terrible CQC report.

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