More than 30 patients died after risks were not acted on in the decade following a controversial service redesign at a crisis-hit NHS mental health trust, according to an analysis by campaigners.
The report by the Campaign to Save Mental Health Services in Norfolk and Suffolk also logged nearly 20 patients of Norfolk and Suffolk NHS Foundation Trust (NSFT) who have died since 2013 after communication failures, while family concerns were ignored in 15 cases.
Longstanding concerns over mismanagement and poor care at NSFT were raised after a report from the auditors Grant Thornton last year revealed there were 8,440 “unexpected” deaths of patients of the trust between April 2019 and October 2022. The trust has had nine chief executives in 10 years and has been placed in special measures four times.
The campaigners’ new report analysed 86 deaths of NSFT patients that were reported by local or national media since the service redesign in 2013, as well as prevention of future deaths (PFD) notices written by coroners.
The report categorised the 86 deaths into different factors that were publicly reported, with “risk not acted on” appearing most frequently (31 cases), followed by “poor communication” (19 cases), and “expressions of suicide ignored” and “family concerns ignored” (15 cases each). Some cases had more than one factor.
In 2013 senior managers at NSFT implemented a “radical redesign” of services that cut beds, reduced the number of consultant psychiatrists, and replaced primary care mental health teams with new teams that proved harder to access. Campaigners warned at the time that the changes would lead to worse patient care.
“The radical redesign was driven by the coalition government’s austerity programme where they cut 20% of NSFT’s budget,” Mark Harrison, chairman of the campaign, told the Observer. “They closed the homelessness team, broke up the crisis team, took NSFT workers out of GP surgeries. They made many of their most experienced staff redundant. And they made the others reapply for their jobs, where they either downgraded them or they added extra responsibilities for the same money.
“This is what led to the increased rate of unnecessary deaths. The campaign predicted that all those measures would result in increased deaths, and they did – and NSFT has never recovered from it.”
Analysing coroners’ PFD notices, the report identified six cases since 2020 where coroners raised concerns about staffing issues.
Last week, two more PFD reports were issued following inquests into the deaths of NSFT patients, one warning of failures in risk assessments by the trust and the other detailing a string 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 numbers of deaths at NSFT, those with the power to act remain subdued on the matter, hence our keenness to meet the police’s threshold of commencing an investigation into NSFT,” the campaign’s report concluded.
Sheila Preston’s son, Leo Jacobs, was diagnosed with paranoid schizophrenia in 1998, but his service provision went downhill after the 2013 service redesign. The workload of community nurses shot up, and family carers such as Preston were sidelined.
“The radical redesign is when everything went wrong,” she told the Observer. “And everything’s got worse since.”
About 18 months before he died, Leo said he didn’t want to see his family any more. His behaviour became increasingly erratic and paranoid. But a restructure of nursing teams in late 2016 brought disaster. “Everybody was given a different patch. His nurse, who used to visit him every two weeks, had to say goodbye and he got a new nurse,” she said.
But the change was implemented during school half-term. Leo’s new nurse went on holiday and was ill when he came back. 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 see Leo?’ And he said no. And this was the Monday after he died on the Sunday.”
During that time he had been ‘cuckooed’ – county lines drug dealers had moved into his flat.
“I’ve read his diary,” said Shelia. “He said, ‘I wish I could get rid of these people’.”
Leo died of a drug overdose – it is not known whether it was intentional. He was 38. Preston believes if the nurse had been visiting, they would have seen what was happening.
“He wasn’t seen for two months. They didn’t see him, they just forgot about him basically. When they changed over, it was inefficiently managed and he wasn’t seen, and he was cuckooed and robbed of his money.”
She spoke to the Observer in a personal capacity, but she previously spent nine years as a governor at NSFT, where she sought to speak on the side of service users, and has recently returned to the role. NSFT’s new strategy involves another restructure, which she fears will have the same poor outcome.
“There’s very few deaths on wards – a handful,” Preston said. “Most of the deaths are in the community because people are not treated at the inception of these serious mental health issues. They’re not treated properly at the beginning. So they go in and out, in and out of hospital, each visit into hospital puts them back two steps in their so-called recovery.”
An NSFT spokesperson said: “We offer our sincere condolences to all families and carers of people who have lost loved ones. We can assure all families and carers that we are working hard to learn from these incidents and do our very best to ensure they are minimised in future.”
The trust said it was improving its collection and use of mortality data, had reduced its nursing vacancy levels through new recruitment, was reviewing PFD reports since 2013 and was working on waiting times, record keeping and carer involvement.
