Investigation Put In Place To Create Recommendations For Unexplained Deaths

An investigation has been carried out into the first England NHS mental health service that was put under special measures after it recorded its highest number of unexpected deaths.

After Norfolk & Suffolk Foundation Trust (NSFT) recorded 157 deaths in 2015-16 compared to 88 deaths in 2012-13, the trust instructed Verita to carry out an investigation into the rise.

Verita is an independent team of investigative consultants who work with organisations in a variety of sectors throughout the UK.

The investigation said that NFST was not doing enough to establish why the deaths were happening.

The trust commissioned the report after existing statistics showed it had a higher number of deaths than other mental health trusts in the UK. But Verita said data collection was not standardised across the UK which made for “limited means for making meaningful comparisons.”

The report concluded: “Overall the trust's investigation process meets national requirements, but analysis or wider exploration of service and care management problems could be improved."

Verita also recommended improvements to the consistency of internal reports into each death, improvements with support and engagement with bereaved families, alongside an urge for better evidence that the trust's board had discussed each unexpected death.

The report in total contains 13 recommendations for how the trust can improve its investigations into patient deaths and its communication with affected families, and calls for more national data to be collected by health authorities.

Michael Scott, chief executive of the trust, said: “All of the recommendations made are already, or will be, acted upon.

The trust was placed in special measures by the Care Quality Commission in February 2015.

Guy Forster, Partner and head of medical negligence at Irwin Mitchell’s Cambridge office, said:

Expert Opinion

“It is alarming to see the rising numbers of unexpected deaths within the mental health services and the on-going issues identified in relation to care provided to patients in Norfolk and Suffolk.

“The fact that the NHS Trust involved has commissioned this investigation of the delivery of its service is to be welcomed but clearly there remains much more to be done.

“We have seen first-hand how problems in the delivery of mental health services can have disastrous consequences for the welfare of patients and their families. We very much hope the actions identified are completed as a matter of urgency to reduce the number of avoidable deaths and improve the safety of the service as a whole.”
Guy Forster - Partner

If you or a loved one has suffered due to professional or clinical negligence from a mental health practitioner, or at worst your loved one has died, we can help you to claim compensation. Visit our Mental Health Negligence Claims page for more information.