A review of mental health services in Cumbria will examine an apparent trend of patient suicides in connection to the local mental health trust, HSJ has learned.

The independent review, due to be published next month, is examining the issue after a coroner called for Cumbria Partnership Foundation Trust to be “assessed independently” after the deaths of a number of patients who had been treated by the trust.

Ian Smith, senior coroner for South and East Cumbria, raised concerns about the provider to national bodies last year.

Court room and documents

The coroner called for the review after the deaths of a number of patients who had been treated by the trust

He wrote to the Department of Health and the Care Quality Commission in November 2013 following the inquest into the death of Kathleen Rosemary Dixon.

Ms Dixon died as a consequence of her own actions on 19 December 2012 while suffering from an acute episode of mental illness.

Mr Smith said in his letter that the death mirrored “the circumstances in a number of other inquests”, and this troubled him “considerably”.

In these cases patients had either been resident in one of the trust’s hospitals, been released and then “almost immediately committed suicide”, or alternatively been assessed by the trust, released and “committed suicide very shortly” afterwards.

He said: “This is sadly sufficiently frequent to cause me concern as to whether it is one of those very unfortunate things that can occur or whether in fact it is a symptom of a deep rooted problem within the trust”.

“Since I am not qualified to come to a decision on that problem I am referring it to yourselves as I hope you will be able to do so,” he added.

The CQC’s response letter indicates that its local compliance manager had personally contacted Mr Smith to discuss the issue.

The regulator’s response said it was monitoring death rates at the trust and had spoken to Cumbria Clinical Commissioning Group, which had said it was “initiating an investigation into the apparent trend”.

In a joint statement, Cumbria CCG and Cumbria Partnership Foundation Trust told HSJ they had commissioned an independent review of adult mental health services in the county.

“Whilst the review was not commissioned specifically in response to the coroners’ regulation 28 [letter] given this work was already in progress we ensured it covered suicides and attitudes to risk management,” they said.

The report is in draft form and is due to be received by a newly formed mental health partnership group on 4 November.