The failure of trust in NHS mental health services was responsible for more than thirty deaths in Norfolk and Suffolk

More than 30 patients died after a failure to respond to risks following a controversial redesign of services at a crisis-hit NHS mental health trust in the past decade, according to an analysis by campaigners.

The report of the Campaign to save mental health services in Norfolk and Suffolk also recorded almost 20 patients from the Norfolk and Suffolk NHS Foundation Trust (NSFT) who have died since 2013 after communication failures, while family issues were ignored in 15 cases.

Long-standing concerns about mismanagement and poor care at NSFT emerged after a report by accountant Grant Thornton last year found there were 8,440 ‘unexpected’ deaths among the trust’s patients between April 2019 and October 2022. The trust has had nine CEOs in ten years. years and has been placed in special measures four times.

The campaigners’ new report analyzed 86 deaths of NSFT patients reported by local or national media since the service was redesigned in 2013, as well as prevention of future deaths (PFD) written by coroner.

The report categorized the 86 deaths into various factors that were publicly reported, with ‘risk not acted upon’ the most common (31 cases), followed by ‘poor communication’ (19 cases), and ‘expressions of suicide ignored’ and ‘family members’ . concerns ignored” (15 cases each). In some cases there was more than one factor.

In 2013, senior managers at NSFT carried out a ‘radical redesign’ of services, reducing the number of beds, reducing the number of consultant psychiatrists and replacing primary care mental health teams with new teams that were proving more difficult to access. are. Campaigners warned at the time that the changes would lead to poorer patient care.

“The radical redesign was driven by the coalition government’s austerity programme, where they cut 20% of the NSFT’s budget,” Mark Harrison, chairman of the campaign, told the newspaper. Observer. “They closed the homeless team, broke up the crisis team and removed NSFT workers from GP practices. They have laid off many of their most experienced employees. And they made the others reapply for their jobs, either downgrading them or adding additional responsibilities for the same amount of money.

“This has led to the increased number of unnecessary deaths. The campaign predicted that all these measures would lead to more deaths, and they did – and NSFT never recovered from that.”

Analyzing coroners’ PFD notices, the report identified six instances since 2020 where coroners raised concerns about staffing issues.

Last week, two more PFD reports were released following investigations into the deaths of NSFT patients, with one warning of shortcomings in the trust’s risk assessments and the other detailing a range of concerns.

The campaign is calling for a public inquiry and police investigation into failings at the trust and the high number of deaths.

“It is astonishing that, despite the high number of deaths in NSFT, those with the power to act on this issue remain reluctant, hence our willingness to meet the police threshold to initiate an investigation into NSFT,” the campaign report concluded.

Sheila Preston’s son, Leo Jacobs, was diagnosed with paranoid schizophrenia in 1998, but his services went downhill following the service redesign in 2013. Community nurses’ workloads skyrocketed and carers like Preston were sidelined.

“The radical redesign is the moment when everything went wrong,” she told the newspaper Observer. “And everything has gotten worse since then.”

About 18 months before he died, Leo said he didn’t want to see his family anymore. His behavior became increasingly erratic and paranoid. But a restructuring of the nursing teams at the end of 2016 brought disaster. “Everyone got a different patch. His nurse, who visited him every two weeks, had to say goodbye and he was given a new nurse,” she says.

But the change was implemented during half the school year. Leo’s new nurse went on vacation and was sick when he returned. Leo should have been seen every two weeks, but instead he wasn’t seen at all.

“Two months later, when they all got together, the old nurse asked the new nurse, ‘Have you been to Leo?’ And he said no. And this was the Monday after he died on Sunday.

During that time he was ‘cuckooed’; drug dealers from the province had moved into his apartment.

“I read his diary,” Shelia said. “He said, ‘I wish I could get rid of these people’.”

Leo died of a drug overdose – it is unknown if this was intentional. He was 38. Preston believes if the nurse had visited, they would have seen what happened.

‘He hasn’t been seen for two months. They didn’t see him, they just forgot about him. When they switched, it was run inefficiently and he was not seen, and he was robbed and robbed of his money.

She spoke to the Observer in a personal capacity, but she previously spent nine years as Governor at NSFT, where she wanted to speak on the service user side, and has recently returned to this role. NSFT’s new strategy involves another restructuring, which it fears will have the same bad outcome.

“There are very few deaths in the wards, just a handful,” Preston said. “Most deaths occur in the community because people are not treated at the onset of these serious mental health problems. They are not treated well at first. So they go in and out of the hospital, in and out of the hospital. With every visit to the hospital they take two steps back in their so-called recovery.”

An NSFT spokesperson said: “We offer our sincere condolences to all the families and carers of people who have lost loved ones. We can reassure all families and carers that we are working hard to learn from these incidents and doing our utmost to ensure they are kept to a minimum in future.”

The trust said it was improving the collection and use of mortality data, had reduced the number of nurse vacancies through new recruitments, was reviewing PFD reports since 2013 and working on waiting times, record keeping and patient involvement healthcare providers.