NSFT say they've fully established number of patient deaths
Their analysis screened all 12,503 deaths from 2019 to 2023
Last updated 19th Jul 2024
An NHS Mental Health Trust in Suffolk has said it's now fully established the number of patients, who died under their service, between 2019 and 2023.
The Norfolk and Suffolk Foundation Trust's 'Learning from Deaths' report, comes after a report last year from the accounting firm- Grant Thornton found that they'd lost track of the numbers.
How did this come about?
The report was initiated by the NSFT's recently appointed Chief Executive, Caroline Donovan and aims to investigate deaths and publish the findings, involving hundreds of staff reviewing thousands of records
The numbers in more detail:
The analysis screened all 12,503 deaths from 2019 to 2023:
• 6,118 patients were not in receipt of care from NSFT in the last six months of their life
• 6,385 patients were under the care of NSFT within the last six months of their life and met the scope of the review
Of the 6,385 patients who were under the care of NSFT within the last six months of their life:
-92% of people died from natural causes, such as heart disease or cancer
-3,598 deaths were expected due to natural causes – 56%
-2,293 unexpected deaths due to natural causes – 36%
-418 unexpected unnatural deaths – 7%
-76 deaths unknown – 1%
The NSFT say this shows a number of common themes:
• Communication with patients and carers and between teams needs strengthening.
• Waiting times are too long and there are too many barriers to accessing services.
• Record keeping and processes are inconsistent.
• The Trust needs to grow, value and retain its workforce.
"We will learn from and use this evidence to deal with problems and improve care"
Caroline Donovan, Chief Executive at Norfolk and Suffolk NHS Foundation Trust, said:
“Today’s report marks a crucial milestone for us and more importantly, for bereaved families and relatives who were rightly concerned about whether the Trust had a record of the death of their loved ones. We now know who every person is, whether they were in our care or not, and what happened to them.
“This report is a detailed analysis that tells us that of the 6,385 patients who were under the care of NSFT within the last six months of their death, the vast majority (92%) of people died from natural causes, such as dementia or cancer and 418 people died from an unexpected unnatural death. This includes all deaths by suicides, over the four-and-a-half-year period.
“Every death is a death too many and every person who has died has a family whose lives have been devastated from their loss.
“During the period our review covers coroners issued 14 Prevention of Future Deaths notices to the Trust indicating there was more we should do to prevent future deaths.
“There is also more to learn from people who have died prematurely due to having a serious mental illness, learning disability or autism. This work needs to be done with partners across our integrated care systems.
“We will learn from and use this evidence to deal with problems and improve care.
“This report rights a wrong. We can’t learn from these sad outcomes and experiences, and we can’t assess our performance and quality if we don’t know what’s happening to the people in our care.
“We now investigate and report on patient deaths, in public, to every board meeting.
“I do not underestimate how much pain and trauma bereaved families and relatives have been through and sincerely apologise that the Trust may have added to this pain by not accurately recording the circumstances surrounding the loss of their loved ones.
“Every single person’s death has now been thoroughly examined by teams of clinical and non-clinical staff. We have identified recurring themes linked to unexpected, unnatural deaths. These themes will, and in many cases have already, led to Trust wide improvements.
“These findings endorse the actions we have taken to change and will add to our improvement programme. We have taken urgent action to employ more clinicians and nurses, ensure mandatory training happens, and to reduce waiting times.
“The report highlights clear themes, including understaffing, poor record keeping, weak communication between NHS teams and with patients and families and long waits.
“Mortality data for mental health Trusts is not collected on a national basis, so it is not possible to compare death rates of people who have sadly died under the care of NSFT with other organisations. Suicide data of the whole population (who may or may not have been under the care of NSFT) is collected on a national basis and reported through Office of National Statistics. The data shows that the rate of suicide in Norfolk is broadly in line with the England average and in Suffolk is slightly higher.
“Almost half the total deaths in the analysis were of people either not receiving care or treatment, or were in the care of other services.
“We are sharing the report with our partners across the NHS to support wider learning and improvement.
“I would like to share my sincere gratitude with the bereaved families and carers who have been working with us, for their invaluable challenge and support to help us get this right. We will continue to work closely with them to make sure we proceed to learn and become a safer, kinder and better organisation of the future.”
“If bereaved families would like to get in touch with us to ask anything at all as a result of this report, they can contact our dedicated Family Liaison Officers by email at flo@nsft.nhs.uk or telephone on 01603 518850 between 9:00 and 17:00 Monday to Friday.
Statement from 'Campaign to save Mental Health Services in Norfolk and Suffolk':
"The aim of this piece of NSFTs work is to learn from deaths. We want to hope that this is what the Trust is doing and that the reviewing of ‘legacy deaths’ was not taken forward to prove people wrong or for continued reputation protection.
"We want to be assured that the right questions are being asked, for the right reasons of patient safety and protection of lives of some of the most vulnerable in our society, and that this isn’t another way of the Trust attempting to spin the narrative of a mental health provider that has been failing for over a decade".