Improving Together: Learning from Deaths to help us become safer, kinder and better - CEO Caroline Donovan's Blog - 22 July 2024
I’d like to focus my blog this week on a vitally important programme which I have given the highest priority to since I joined you as Chief Executive of NSFT in November 2023. The publication of our in-depth report covering all deaths across Norfolk and Suffolk from the period 1 April 2019 to 31 October 2023 has been a herculean effort by many colleagues to complete this vitally important review. I am hugely grateful to the many people who have supported this work including so many of you as well as our partners.
Every death is a death too many and every person who has died has a family whose lives have been devastated from their loss. We must recognise how much pain and trauma bereaved families have been through Families have told us that the Grant Thornton report last year showing that we did not have an accurate record of every cause of death, and not being able to show our learning and improvement has contributed to their grief. We have sincerely apologised for this.
I can now confirm that every person’s death has now been reviewed and for clarity we now know that during the four and a half year period of the review, for the 6,385 patients who met the criteria, 92% people died through natural causes eg heart attack or stroke and 7%, equating to 418 people died by unnatural unexpected causes, such as suicide or substance misuse.
There is learning for us from deaths that have happened by natural causes as we know that people with a serious mental illness die 15 years younger than the general population. We need to continue to work with partners in support of reducing this inequality. From the 418 people who sadly died through an unexpected, unnatural death, we had 14 Prevention of future Deaths notices. One PfD is a death too many; we need to truly prioritise ensuring we understand if care could have been improved then ensure we put learning into practice. We have of course already made some improvements and our trust wide improvement plan also supports some of the themes as you will see through the report your have all been sent.
The report fulfils the commitment we made to investigate every death and publish the findings, involving hundreds of staff reviewing thousands of records; a key programme of work which is part of our Trust wide programme to improve patient care and services and be open about the problems we are addressing.
Before we published the report on Thursday last week, myself, Zoë Billingham and Gary O’Hare, met extensively with a wide range of partners, talking them through in detail many aspects of the review, including what it found and what actions we have and will take. Our briefings included:
- NHS England
- ICBs – Norfolk and Waveney and Suffolk and North East Essex
- Care Quality Commission
- Members of Parliament
- All staff briefing
- Council of Governors briefing
- Service User and Carers briefing
- Campaign to Save Mental Health Services in Norfolk and Suffolk briefing
- Healthwatch and HOSC briefing
- In-depth media interviews with BBC, ITV, Eastern Daily Press and The Health Service Journal.
Key findings from the report
The report reviews deaths of people in Norfolk and Suffolk, who had received care from NSFT, which includes those under the care of our Trust within six months of their death which aligns with the national guidance.
The in-depth analysis screened all 12,503 deaths from 2019 to 2023. We decided to extend the time period of the original Grant Thornton review of deaths by an additional 12 months to make sure all deaths were reviewed from April 2019 up to the launch of our new Trust digital system for recording, analysing and learning from all deaths of patients in touch with NSFT, in November 2023.
Of these 12,503 deaths:
- 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%
During this period, there were 14 Prevention of Future Deaths Notices issued from Coroners instructing our Trust to improve care to prevent future deaths.
Learning from Deaths
Our analysis shows a number of common themes from the report. These are:
- 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
At the heart of the improvement plan is an essential need to improve care and improve the culture in NSFT.
Working with our bereaved families and carers
Absolutely vital to all this work is making sure we work with our bereaved families and carers. I would like to express my sincere gratitude to 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.
A Learning from Deaths group was established in December 2023, with membership from partners, patients, carers, bereaved families and Healthwatch. The group has overseen the review of deaths and is making sure learning and improvement is at the heart of our Trust priorities.
Co-production with service users and carers is extremely important. This is one of our 12 large scale change programmes across our Trust. We are about to launch a new Service User and Carer Council which will put the voice of our service users, families and carers right at the heart of everything we do. The Chair will be elected by the Council and they will sit as an attendee at our Board of Directors meetings. We will also have a Service User and Carer Council operating in each of our five localities, making sure that at locality level, our service users, families and carers are directly influencing our work, improvement and transformation at every level.
We have worked with a number of bereaved families who have helped inform how we report on learning from deaths, including presentation of our learning from deaths report and monthly reports. An easy read version of our full learning from deaths report is also available on our website.
I am also pleased that we have two Family Liaison Officers working for NSFT since January 2023. Their work and support to our service users, families and carers is crucial and a step in the right direction – but we have much more work to do.
It is vital that our bereaved families continue to be supported and know that a range of support is available. 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 9:00am and 5:00pm Monday to Friday.
ICB commissioned support is also available to provide support to people who may be affected as a result of reading this report. If you live in Norfolk, please contact:
- Norfolk and Waveney Mind bereavement support service, providing support to individuals who are bereaved by suspected suicide – email suicidebereavement@norfolkandwaveneymind.org.uk or call 0300 330 5488
If you live in Suffolk, please contact:
- Victim Support Suffolk – Bereaved by Suicide service – email SNEE.bereavedbysuicide@victimsupport.org.uk or call 01473 322683.
Communication
A big area we must focus on is improving our communication and culture, ensuring partners, staff, our service users, families and carers are at the heart of all we do. Improved communication within across our leadership teams is a crucial part and I want to reflect on our latest Senior Leadership Team (SLT) workshop which took place on 12 July in Norwich. The session was led by Chris Link, the external facilitator who is supporting our Board, executive and Senior leadership development and focused on our leadership and culture in NSFT.
We heard from Professor Oliver Shanley OBE, Chair of the Independent Review of Greater Manchester Mental Health NHS Foundation Trust and Priscilla Nzounhenda, Deputy Lead Nurse and our Listening into Action Lead. Oliver and Priscilla led a brilliant session on the findings of the review into the care and treatment provided by Greater Manchester Mental Health NHS Foundation Trust which examined failings in services and questions about the organisation’s failure to escalate concerns and mitigate against patient harm, raised by patients, their families, and staff.
The session focused on three key questions:
- How does our SLT group step up to lead, to create a truly Well Led, high quality and safe organisation of which we can be proud?
- Where am I in this? In what way am I responsible? What can I do to make things different? And
- What’s it like being on the receiving end of me? And what is our collective leadership style/behaviour and how might we consciously change our impact?
The day was another vital part of our work to reflect on our senior leadership team values, behaviours and clearly links into the work we must continue to focus on to help us become a safer, kinder and better organisation in the future.
We have a number of large-scale change programmes linked to this important theme where we are taking direct action, with much more to be done. We are working hard as a Trust to improving openness and transparency, significantly strengthen our co-production with service users, families and carers and improve contact and experience with our services.
Listening into Action is helping us to change the culture of our organisation, with many quick wins already established and taking place. Our Think Family Pioneer Team is one example of how we are changing the way we work with and support our service users, families and carers, along with 11 clinically led transformation teams to support change at scale.
Our new locality structure which will be operational from October 2024 will help drive consistency and significantly strengthen clinical leadership at each of our five localities across Norfolk and Suffolk.
I am pleased we have developed and launched our new Trust values – TALK; we are a Team, we are Accountable, we Learn and improve and we are Kind – to each other, our partners, service users, families and carers.
Waiting times
The findings in the report 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.
We have seen a 34% reduction in the number of patients waiting 18 weeks or longer for treatment since April 2024 and eradicated over 52-week waits for Children and young people waiting for assessment and in Suffolk for treatment.
We have also invested £55m in a new hospital, The Rivers Centre, with 85 beds to open in autumn 2024.
This is a step in the right direction, but we have much more work to do to improve access and waiting times.
Record keeping
As a Trust, we have revised and strengthened our discharge policies, an important piece of work we did in Autumn 2023.
We are also working hard to make sure we complete a 72 hour follow up post in-patient discharge. In May 2024, follow up to in-patient discharge was 91%. Our performance against 7-day follow up for people discharged from hospital is consistently above 90%, with 91% in June 2024. We do need to ensure that 100% of people receive follow up support within both three days and seven days following their discharge. And we must aim for this to happen in all cases.
We have also implemented a Clinical Harm Review Standard Operating Procedure (SOP). GPs identify priority for assessment and if we change this priority, we have a second clinician make a thorough check. Our STORM (Skills Training On Risk Management) being enhanced, along with enhanced clinical audits – record keeping, physical health, care plans and restrictive practice.
We must make sure that every service user has a clear care plan and safety plan shared with families and carers and transparent through our Lorenzo system.
Growing, valuing and retaining our workforce
We have seen an improving picture of staffing with a net increase of 100 nurses and 34 doctors in the last year and a 5% reduction of staff leaving the organisation.
We also now have over 100 medical trainees with us and their recent feedback scores are positive. For team working, NSFT 92% vs 76% national average, teaching and learning – NSFT 82% vs 67% national average and quality of care – NSFT 84% vs 73% national average. Our overall staff turnover at NSFT has also reduced from 17% to 12% in last 2 years and sickness rates have reduced in the last 2 years from 5.93% (May 2022) to 5.5% (May 2024).
Supporting our staff is vitally important. In terms of supervision taking place, we have seen a 12% increase from 68% to 80% (Sept 2023 to May 2024), a shift in the number of appraisals taking place with a 12% increase from 73% to 86% (Sept 2023 to May 2024). Our mandatory training completion currently sits at 91.6% (July 2024).
There is a detailed section in the full report which focuses on these core themes, along with improvements we have made in the last 12 months. However, as I have said, there is so much more we need to do.
Mortality data in England
Unfortunately, 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, 10.6 per 100,000 people is broadly in line with the England average of 10.5 per 100,000 people and in Suffolk, slightly higher at 11.1.
Next steps to support continued learning
We have 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 our partners across our integrated care systems.
But I made it clear last week, when speaking with the many people I briefed on our learning from deaths work that 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. Equally, we cannot do this alone and that’s why it is vital we work closely, with our partners across our integrated care systems.
The Learning from Deaths report will be discussed on Thursday 25 July at our Board of Directors meeting in public. The full report and link to join the event is available on our website.
Thank you for everything you continue to do – our staff, partners, service users, families and carers.
Until next time,
Caroline