Norfolk and Suffolk Mental Health Trust gets ‘accurate’ death figures

An NHS mental health trust says it has finally discovered how thousands of its patients died after it lost track of the numbers.

The Norfolk and Suffolk Foundation Trust (NSFT) analyzed 12,000 deaths over a four-year period.

Around half of these patients were in NSFT care in the last six months of their lives, with 418 deaths categorized as ‘unnatural and unexpected’.

The CEO said a lot of work still needs to be done to improve services. The parents of a woman who died in the trust’s care have described the responsibility as “extremely important”.

It found that the cause of death was not established in more than three-quarters of cases, with discrepancies between internal systems and board reports.

Hundreds of NHS staff were tasked with reviewing thousands of records under Caroline Donovan after her appointment last November.

The NSFT said it was the first time an NHS mental health trust had produced and published a report like this.

The new analysis examined 12,503 deaths from 2019 to 2023 and found:

The trust defined an “unexpected and unnatural” death as one where a patient “may have chosen to take their own life and their death was intentional”.

Ms Donovan said: “We now understand that each of these deaths is in excess of one per cent.”

She added: “We can use this information to learn and improve. We have already started this and it has been recognized by the Care Quality Commission (CQC). We need to do a lot more.”

Ms Donovan also confirmed that the trust had to save £17m this financial year.

She said it was part of a program of changes and that the quality of services would not be affected as additional staff would be recruited.

But the Norfolk & Suffolk Mental Health Crisis Campaign said: “Without a cash injection and more beds, the deaths will continue.”

The group added: “The NSFT communicates its work as redressing past wrongs, but the wrongs were largely preventable and survivors and the public are still concerned that they are not being held accountable for previous harm.

“We continue to call for a lawful public inquiry.”

Ellie Woolnough, from Ipswich, died in hospital in July 2022 after trying to take her own life eight days earlier in NSFT care.

Her parents, Lisa and James, described the trust that ultimately led to the death of their patients as “extremely important”.

Ms Woolnough added: “You have to know what’s working and what’s not working. You know where you’re doing well so you can work on that, or you know what’s not working well and then you can change it.”

Mr Woolnough highlighted that the trust had failed to heed concerns raised in prevention of future deaths reports compiled by coroners following patient inquests.

“You only regret a mistake when you do something to change it,” his wife said.