8,000 'unexpected' deaths at Norfolk and Suffolk NHS trust

The figure has emerged in an independent audit of Norfolk and Suffolk NHS Trust, which provides mental health care in the region.

The trust has struggled with poor performance for several years, having been in special measures four times in the last decade, and there have growing concerns about the number of people who might have taken their own lives while in its care.

The report was commissioned by the integrated care boards of Norfolk and Suffolk - which oversee local NHS organisations - to investigate this issue.

It was unable to find a precise number.

Instead, it identified 8,440 'unexpected deaths', defined as where a patient has "not been identified as critically ill or death is not expected" but who has died within six months of being in the trust's care.

It will include suicides, and cases where an inquest could not reach a ruling of suicides, and other deaths - but also those where a person has unexpectedly died by causes such as heart attack, stroke and accidents.

It has provided a figure - which is not included in the report - of 259 people known to have taken their own lives within six months of being in its care, since 2018.

It was not able to explain the huge discrepancy between the figures but has been accused of "corporate gaslighting" by campaigners, for its poor data management, for not explaining the higher figure and instead citing a lower one.

Caroline Aldridge (Image: Archant 2021)

Caroline Aldridge, who has closely monitored deaths in the trust since her son Tim died in 2014, said: "The report is deeply upsetting because instead of demonstrating that the trust has listened to bereaved relatives' concerns and focussed its energy on being transparent, it has sidestepped the question of how many have died.

"The report does show that the scale of deaths is worse than feared and it highlights some shockingly poor practice and governance of mortality data.

"This leaves relatives wondering if their loved ones are included in the figures and how anyone can ever know.

"People are dying due to mental illness in plain sight and nobody has noticed or cared that the trust has lost count of patient deaths."

In total, since April 2018, 11,379 people have died within six months of being in contact with the trust.

Of these, 689 deaths were 'expected'. These include - but are not limited to - people who have life-threatening illnesses or whose death may have been due to the frailty of old age.

But the auditors say that "multiple changes in presentation and methodology" cast doubt over the figures NSFT had provided.

The report, which was carried out by auditor Grant Thornton, highlighted several inconsistencies in the way NSFT gathered its mortality data.

It reads: "The trust does not adopt a consistent reporting standard and has frequently changed both the methodology and presentation of mortality data in its board reports.

"Over eight consecutive board reports, information and the method of presentation changed six times.

"This has led to confusion in both the classification of mortality and the number of deaths which form part of the trust's mortality statistics."

Another issue identified was that the trust had been keeping records across four separate systems - which did not always tally up with one another.

Stuart Richardson, chief executive of NSFT (Image: NSFT)

Stuart Richardson, chief executive of NSFT, said: "Our thoughts are very much with those families and friends who have lost their loved ones and may feel upset by the publication of this review of how we process data.

"We are very sorry that the trust has not previously had the systems and processes in place for the collection, processing and reporting of mortality data that would be rightly expected."

He added that the trust has put an action plan in place that would look to improve recording and reporting going forward - which would also look to address the prior discrepancies. 

The plan includes establishing a committee for sharing learnings from deaths and relying more on automated recording systems.

Tracey Bleakley, chief executive of NHS Norfolk and Waveney, said: "As local health and care systems, we will support the trust to make the necessary improvements required to be assured in future about the trust's mortality data."