Former Norfolk mental health nurse says local provider needs to make service safer
"There are people who are falling through the gaps"
Last updated 9th May 2024
A local decision-maker and former mental health nurse in Norfolk is telling us the county's local mental health provider needs to be challenged on how it's making its services safer.
It's as senior figures from the Norfolk and Suffolk Foundation Trust face scrutiny from Norfolk County Council today, on their new plan to record patient deaths.
"There are people who are falling through the gaps"
Emma Corlett is County Councillor for Town Close, Norwich: "They NSFT need to get out there and see for themselves, not just within their own services, the people who are on mental health waiting lists.
"Data is useful up to a point, but it doesn't tell the human story.
"There are people who are falling through the gaps and then there are those who are in plain-sight of services, with their families are saying they need help, but nothing is happening.
"There needs to be intense scrutiny of people who are ending up dead, after having recent contact with crisis services."
What is the NSFT doing to improve its handling of data?
The Norfolk and Suffolk Foundation Trust says one of its "core transformation and improvement programmes" focusses on learning from deaths.
The NSFT says it'll do this now by:
-Collecting, analysing and reporting on deaths; involving the creation of a new electronic system for mortality information collection, analysis and reporting.
-Ensuring that learning through improvements to clinical practice;reviewing all Prevention of Future Deaths reports from 2013 to identify themes and ensure learning and improvement.
-Working with service users, carers and bereaved families;detailed work with service users, families carers and bereaved families who sit on our Learning from Deaths Action Plan Management Group.
The Trust says it's also developed a more accurate and mainly automated system to record deaths, in a robust and timely way, while also publishing this data on a bi-monthly basis and discussing it at every board meeting.
The report groups the number of deaths for each reporting period into five groups:
Expected natural – This is a death which has a clear natural cause.Examples may include a death linked to a neurological disease, such as Parkinson’s or dementia, frailty or old age, cancer and organ failure.
Unexpected natural – Deaths in this category are when a loved one passes away unexpectedly but from natural causes. This could be as a result of contracting an infection or respiratory illness or infectious diseases. It can also include illness such as cancer.
Unexpected unnatural – If the death of a loved one is placed into this category, the cause is linked to reasons where the individual may have decided to take their own life and their death was intentional. Examples include hanging, drug toxicity, drowning, a fall and injuries from an external cause.
Unable to obtain cause of death – In an unfortunate number or small cases, it is very difficult from the information available or shared with us to determine the actual cause of death, even after in depth screening is done. We will always try to identify a cause of death to categorise the deaths so we can learn from any deaths to help improve the outcomes and experiences for our service users, families and carers.
Awaiting cause of death – in some cases, we still await the cause of death from our official source of information at the point of publication of our reports. Where this is the case, we will include the cause in future reports.
What the latest published data shows:
Between November 2023 to 31 January 2024
Expected natural cause of death: 147 deaths, 34% as a percentage of all deaths during the period
Unexpected natural cause of death: 209 deaths, 48% as a percentage of all deaths during the period
Unexpected, unnatural cause of death: 15 deaths, 3% as a percentage of all deaths during the period
Unable to obtain/awaiting cause of death: 66 deaths, 15% as a percentage of all deaths during the period.
"Crucial to our transformation and improvement work"
Caroline Donovan, Chief Executive of Norfolk and Suffolk NHS Foundation Trust, said:
“I am pleased with the commitment, focus and determination of our staff who continue to work hard to ensure mortality data collection, analysis and reporting continues to be one of our top priorities as a Trust.
“I am particularly pleased that we have liaised very closely with a number of service users, carers and bereaved families to gain some very clear and vital thoughts on how we report this data, including the language used, through to the format and presentation.
“The collection, analysis and reporting of mortality data continues to be overseen by our Governance and Safety advisor, Gary O’Hare who will continue to work with our mortality team and wider organisation to ensure we embed this vital new way of working, which is crucial to our transformation and improvement work.
“I would like to share a personal thank you to our service users, families, carers and staff who have enabled us to develop such a robust system and process to support us on our journey to become a safer, kinder and better organisation. We will continue to work together to ensure clear and co-designed collection, analysis and reporting of mortality data across the Trust.”
The Background:
Campaigners claim there have been 8,440 deaths of patient or service-users between April 2019 and October 2022 at the NSFT.
The provider said it ‘did not recognise’ that figure.
Following this, campaigners wrote to the chief Constables of Norfolk and Suffolk Police in December 2023 asking them to investigate and prosecute the deaths at NSFT, including making an assessment if the threshold for a charge of corporate manslaughter has been reached.
It's after they became concerned at the number of deaths and repeated patterns from previous Prevention of Future Death reports (PFD).
Prior to this, a report by accountancy firm Grant Thornton in June 2023 found that the trust had lost track of the number of patient deaths.
The findings revealed 1,953 patients had died within one month of being discharged.
The report said: "Given the number of patients who die within a month of discharge, more work is needed to understand this cohort, ensure this data is accurate and act on any learning.
"The trust is currently working with GPs through Primary Care Networks to try to improve the capture of cause of death to inform this insight."
Data also found that out of 3,261 patients, 37% had a discharge date recorded after their date of death.
The majority of people were in old-age psychiatry or adult mental illness specialities, and 2,699 of them were aged over 65.
The Care Quality Commission (CQC) rated NSFT as “Requires Improvement” in February 2023.
It comes after the provider have previously been ‘inadequate’ by the CQC for a fourth time in April 2022.
When and where will this meeting take place?
Norfolk Health Overview and Scrutiny Committee will meet at 10am until 1pm, today in County Hall.
You can read their full agenda here.