A neurologist whose brother died following a series of failures by an NHS mental health trust has warned there will be more avoidable deaths without fundamental reforms to psychiatric care.
Dr Katie Sidle’s concerns about the Norfolk and Suffolk Foundation Trust’s (NSFT) refusal to give her brother Christopher, who was psychotic, a crisis admission were repeatedly ignored in the days and weeks before his death last July, a report has found. coroner this month.
“It is dangerous – there is no doubt that unless they make major changes there will be more deaths,” Sidle, who specializes in neurological disorders that often manifest as psychosis, told the Guardian. “I could not have been better informed about his condition and history, and yet I was unable to get help for my brother.”
The evidence at the inquest suggested Christopher’s case was due to gaps between the trust’s community and the crisis team. The coroner highlighted a number of missed opportunities to save him, including ‘inadequate’ assessments, uncirculated emails, failure to recognize his well-documented ability to mask symptoms and the inadequate telephone monitoring to ensure he was was taking his medications.
Christopher was repeatedly refused help because he was assessed as being able to take his own medication, despite not having done so in the past.
The hearings convinced Sidle to back calls for a public inquiry into the trust, which has increasingly been put into special measures since deep cuts in 2013. An audit report last year found that between April 2019 and October 2022 there were 8,440 unexpected deaths of patients who were under the trust’s care or had been in the previous six months.
Sidle said: “Before the inquest I thought the trust might change, but now I have no doubt this will only be resolved by a public inquiry.” She said the trust’s operating staff told her privately that they agreed with the need for an investigation.
Sidle was deeply involved in the successful medication of her brother, a former climate change consultant from North Walsham, Norfolk, for many years before he relapsed last year. She is now keen to assist with any future investigations and is seeking a meeting with health ministers to express her concerns.
On the day her brother died, Sidle, a consultant at two London teaching hospitals, pushed for the trust’s archive of recordings of desperate calls she made to a newly qualified nurse who refused to answer her brother. “I knew those calls were important and that it was possible they would be deleted,” she said. Coroners have previously criticized the trust for removing or altering key evidence about patient deaths.
In a transcript of a harrowing phone call read out at Norfolk District Court, Sidle pointed out her brother was “acutely psychotic” and on the decline after claiming he had three days to live. On Friday, June 29, she told the nurse: “Sunday (July 1) will be day zero, I have no idea what he (Christopher) is going to do but I’m afraid it will be quite catastrophic.” On that Sunday, Christopher, 51, threw himself out of a taxi; he died of his wounds four days later.
The nurse had refused to reassess Christopher at his first unsupervised assessment and told Sidle there were no beds available. Desperate, Sidle emailed another nurse from the trust’s community team to express her extreme concern, but the email was not passed on. The last psychiatrist to see Christopher also raised “extreme concerns” with her manager about the trust’s refusal to admit Christopher, but it was too late to save him.
Despite the fatal mistakes in her brother’s care, Sidle showed compassion for the staff who gave evidence at the inquest, thanking them for their honesty and even hugging one of those involved. “I have forgiven all those people because they too are victims of a dysfunctional system. And Christopher would have wanted that,” she said.
It’s the dysfunctional system she can’t forgive and is determined to change. In her testimony to the coroner, Sidle complained of a “culture of complicity” where patient assessments were “corrupted” by knowledge of the trust’s lack of resources, particularly beds. “Aligning patient assessment with resource availability continues to mask an urgent need for significant increases in resources for acute psychiatric services,” she wrote.
She is also alarmed by a “nurse-led” model of care that enshrines patients’ freedom and “patients’ right to make bad decisions” – a phrase quoted to her by a member of the crisis team. She said this was against the medical ethos of ‘first do no harm’.
“Allowing patients to make poor choices and not take medications causes tremendous harm,” Sidle said. “One of the diagnostic criteria for psychosis is not realizing you are ill – so how can you decide whether you want treatment?”
She pointed to recent scientific articles comparing psychosis to a “a stroke of the mind” and say it will happen destroy the brain if untreated. “It is absolutely ridiculous to have a system where you allow patients to deteriorate to the point where they become acutely psychotic, and then you run out of beds because such patients often have to stay in hospital for months,” she said.
Sidle said patients with psychosis should receive drugs every three months in so-called depot injections, where the drugs are released slowly over time. These injections, which were denied to her brother, avoid the mood peaks and valleys associated with oral tablets and ensure medication is always taken. “If you give depots, you reduce the number of patients who become chronically psychotic,” she said.
Sidle claimed that catching the disease earlier would avoid the public sector costs associated with treating disruptive mental health patients. She added: “My pitch to ministers is that you can actually make people better and save money – that rarely happens in healthcare.”
Cath Byford, deputy director of NSFT, said the trust was on a “rapid and much-needed journey of improvement” and was committed to working with Sidle to help the business learn and improve.
She said: “We have previously outlined the actions we have taken since Christopher’s death, including further training for our staff, redesigning our triage tool and patient history recording systems to ensure our staff have the best possible provides care to our service users.”