Report expected from NSFT following probe into NDR death

The Norfolk and Suffolk Foundation Trust (NSFT) was criticised by the county’s most senior coroner after an inquest into the death of Christopher Sidle earlier this year. 

The 51-year-old from North Walsham died last July when he fell from a taxi on Norwich's Northern Distributor Road (NDR) during a psychotic episode.

A week-long inquest into his death heard that a series of “missed opportunities" and "inadequate care” at the NSFT led to his death. 

Mr Sidle had been rejected by the Trust’s crisis team on three occasions during the last months of his life - including just three days before he died on July 4, 2023. 

Following his inquest, senior coroner Jacqueline Lake said she would be issuing two Prevention of Future Deaths (PFD) reports. 

A PFD report is published by coroners following inquests when they feel organisations must take action to prevent other people from dying in similar circumstances.

When these are sent to organisations, they are given 56 days to respond outlining what they are doing to address the coroner's concerns. 

A report into Mr Sidle’s death was issued by Mrs Lake on March 25. A response from the Trust is expected to be published this week.

In her report, she stated that assessments carried out by the Crisis Resolution Home Treatment Team (CRHTT) were “inadequate” and that psychotic markers were “underestimated and/or missed” to provide appropriate care and treatment. 

Referring to one assessment carried out just days before he died, she said: “The assessment was carried out without discussion within the team, without reading Christopher's records... due to insufficient time being allowed by the team prior to the assessment.

“The assessment continued without knowledge of Christopher’s history and his ability to mask symptoms. 

“There was no formal monitoring of the assessment which was allocated on the basis of availability or assessor rather than experience or suitability. This was the assessor's first lone assignment. 

“The assessment was inadequate and was a further missed opportunity to provide appropriate inpatient care to Christopher, which more than minimally contributed to his death.” 

Continuing her report, she acknowledged that while the Trust had treated the circumstances surrounding Mr Sidle’s death seriously, she continued to have concerns regarding future deaths being prevented. 

This included the need for “full and proper assessments” of patients and a deeper understanding by the CRHTT with regards to the scope and limitations of other services available within the community team.” 

Mr Sidle’s sister, a consultant neurologist, has demanded an overhaul of NHS psychiatric care following her brother’s death. 

Dr Katie Sidle warned that there will be more avoidable deaths without fundamental reform of psychiatric care and major changes. 

She has backed calls for a public inquiry into the trust, which has been in and out of special measures since swingeing budget cuts in 2013.  

An audit report last year found that between April 2019 and October 2022, there were 8,440 unexpected deaths of patients who were in the trust’s care or had been in the previous six months. 

Cath Byford, NSFT’s deputy chief executive, said the trust was on a “rapid and much needed journey of improvement” and was committed to working with Dr Sidle to help it learn and improve. 

She said: “We have previously outlined the actions we have taken since Christopher’s death, including further training for our staff, redesigning our triage tool and patient history recording systems to ensure our staff deliver the best care they can for our service users.”

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