NSFT publish Learning from Deaths report
Norfolk and Suffolk NHS Foundation Trust (NSFT) have today published an in-depth report covering all deaths across Norfolk and Suffolk from the period 1 April 2019 to 31 October 2023.
In publishing this report, the Trust does not underestimate how much pain and trauma bereaved families and relatives have been through. The Trust sincerely apologises that we may have added to this pain by not accurately recording the circumstances surrounding the loss of their loved ones, and not being able to show our learning and improvement from each and every death.
The report fulfils the commitment made by NSFT Chief Executive, Caroline Donovan, when she arrived at the Trust in November 2023, to investigate deaths and publish the findings, involving hundreds of staff reviewing thousands of records. It is part of the Trust’s wider programme to improve patient care and services and be open about the problems it is addressing.
The report reviews deaths of people in Norfolk and Suffolk, who had received care from NSFT. This includes those under the care of the Trust within six months of their death which aligns with the national guidance. The report provides evidence about the quality of NSFT services and how they must be improved.
Key themes from the report include staffing, record keeping, communications between NHS teams and with patients and families and waiting times for services.
This new analysis has produced important learning for the Trust and the wider health and care system. The analysis was actively supported by both Norfolk and Waveney Integrated Care Board and Suffolk and North East Essex Integrated Care Board, along with both Integrated Care Systems covering Norfolk and Suffolk.
The in-depth analysis screened all 12,503 deaths from 2019 to 2023. The Trust 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 the 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 the Trust to improve care to prevent future deaths.
The analysis shows a number of common themes:
- 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.
The Trust appointed a new experienced Chief Executive, Caroline Donovan, in November 2023. Caroline has led on the development of a revised Trust strategy with a very clear and detailed improvement plan to become safer, kinder and better. Having reviewed both the Grant Thornton and the Forever Gone report, Caroline commissioned this extensive review of every single death to ensure there was a proper record of the cause of each death and a review of common themes. Caroline was also completely committed to ensuring openness and transparency for families and our communities. This plan has been and will continue to be subject to scrutiny by partners, patients, carers, families and regulators.
At the heart of the improvement plan is an essential need to improve care and improve the culture in NSFT. Some progress has been made including reduction in waiting times for assessment and treatment and 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. However, there is so much more to do.
A Learning from Deaths group has been established 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 Trust priorities.
Caroline Donovan, Chief Executive at Norfolk and Suffolk NHS Foundation Trust, said: “Today’s report marks a crucial milestone for us and more importantly, for bereaved families and relatives who were rightly concerned about whether the Trust had a record of the death of their loved ones. We now know who every person is, whether they were in our care or not, and what happened to them.
“This report is a detailed analysis that tells us that of the 6,385 patients who were under the care of NSFT within the last six months of their death, the vast majority (92%) of people died from natural causes, such as dementia or cancer and 418 people died from an unexpected unnatural death. This includes all deaths by suicides, over the four-and-a-half-year period.
“Every death is a death too many and every person who has died has a family whose lives have been devastated from their loss.
“During the period our review covers coroners issued 14 Prevention of Future Deaths notices to the Trust indicating there was more we should do to prevent future deaths.
“There is also 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 partners across our integrated care systems.
“We will learn from and use this evidence to deal with problems and improve care.
“This report rights a wrong. 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.
“We now investigate and report on patient deaths, in public, to every board meeting.
“I do not underestimate how much pain and trauma bereaved families and relatives have been through and sincerely apologise that the Trust may have added to this pain by not accurately recording the circumstances surrounding the loss of their loved ones.
“Every single person’s death has now been thoroughly examined by teams of clinical and non-clinical staff. We have identified recurring themes linked to unexpected, unnatural deaths. These themes will, and in many cases have already, led to Trust wide improvements.
“These findings 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.
“The report highlights clear themes, including understaffing, poor record keeping, weak communication between NHS teams and with patients and families and long waits.
“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 is broadly in line with the England average and in Suffolk is slightly higher.
“Almost half the total deaths in the analysis were of people either not receiving care or treatment, or were in the care of other services.
“We are sharing the report with our partners across the NHS to support wider learning and improvement.
“I would like to share my sincere gratitude with 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.”
“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 9:00 and 17:00 Monday to Friday.
Tracey Bleakley, Chief Executive, NHS Norfolk and Waveney Integrated Care Board, said “I am pleased with the progress being made at NSFT as we work towards improving mental health outcomes and experiences for our local communities across Norfolk and Waveney.’’
“This vital piece of work has only been made possible by the collaboration and commitment from many different organisations across Norfolk and Waveney and I would like to extend my thanks to all of our partner organisations, including primary care and the Voluntary Community and Social Enterprise sector for their help and support.”
Dr Ed Garratt OBE, Chief Executive, NHS Suffolk and North East Essex Integrated Care Board, said: “Every death is one too many and we recognise how difficult this report will be for the bereaved families affected by it. We believe that NSFT have made significant progress in understanding their mortality data and have better processes now in place for the future. NSFT and the local ICBs are committed to learning from deaths to support improvement and transformation across Norfolk and Suffolk.”
Trevor Stevens, father of Tobi Stevens, said: “I am encouraged that the Trust is listening to families, and I am more confident that they will act on what we tell them.
“It’s still early days, but I feel my involvement is valued. I will watch closely to make sure the Trust keeps improving and keeps involving families.”