Whistleblower raises alarm over ‘inadequate’ investigation into 60 suicides

Cambridgeshire and Peterborough Foundation Trust originally said it would carry out the review of more than 60 patient suicides internally. But following criticism, it U-turned on this decision and last month agreed to an externally-led process.

The overarching review was prompted after an internal investigation by a senior trust clinician, carried out in July 2021, concluded the record of a patient who died by suicide was wrongly altered, with a care plan added to their notes the day after their death.

In a letter to the mother of the patient, 33-year-old Charles Ndhlovu, chief executive Anna Hills said the external review “will not focus on reinvestigating individual cases, however it will enable us to identify themes and issues common to more than one of the individuals, which we need to address to take forward our work on suicide prevention”.

Ms Hills also revealed a new investigation into Mr Ndhlovu’s case had been carried out. She said it concluded his records were not altered after all, directly contradicting the conclusion of the original investigation, which helped trigger the wider review.

The letter, seen by HSJ, stated: “We could see the record had been accessed after Charles’ death but could not see that any changes had been made, which I hope provided you with some reassurance.”

The trust has not commented publicly on the original finding of the investigation into Mr Ndhlovu’s case before now, despite widespread media coverage over the last five months of the allegations the records were inappropriately changed.

But Des McVey, a consultant nurse and psychotherapist who carried out the first investigation, said he stood by his original findings.

Mr McVey told HSJ: “When I completed my review it was clear on the Rio website [the electronic patient record system] that Charles’s care plans were created on the day after his death. For them to report to his mum that there was no change is concerning.”

Mr McVey, who left the provider by mutual consent last year, also criticised the trust’s decision not to conduct full investigations into other cases, saying: “They need to fully investigate each case otherwise the review will be completely inadequate and the trust will not learn the vital lessons it needs to ensure nothing like this ever happens again.”

The trust declined to directly address these comments.

In a statement, the trust said it continues to “refine the terms of reference and the parameters of the thematic review”, and it is in the process of appointing an external body and chair to carry it out.

As previously reported, HSJ has seen emails in which the trust gave assurances to Mr McVey that it would carry out an investigation of suicide cases in June 2022, after he had presented trust bosses with his findings of what he maintains was the tampering with Mr Ndhlovu’s record.

But more than a year later, the trust has not yet finalised how the review will be carried out.