Poor data leaves trust unable to report on avoidable deaths

However, the review into how Norfolk and Suffolk Foundation Trust collects, processes and reports mortality data made no conclusions on the number of avoidable deaths – the issue which had originally prompted the probe. 

Local NHS leaders argued the review’s purpose was focused on auditing the trust’s processes, and this had been delivered. But a local MP, Clive Lewis, accused it of “explicitly dodg[ing] the big questions”. 

The report, which looked at data from between April 2019 and October 2022, has however raised concerns about the number of patients dying soon after being discharged.

The review by Grant Thornton – titled Norfolk and Suffolk Foundation Trust’s Mortality Recording and Reporting (see PDF attachment below) –  did not make a judgement on whether any of these deaths were either avoidable or expected.

It said: “For 1,953 patients whose death is considered part of the trust’s mortality reporting, the date of death is within one month of discharge. This includes 278 patients whose date of discharge is the same day as the day they died. Of these, 158 were informed via NHS Spine, 112 via community teams, and 6 through inpatients teams.

“Given the number of patients who die within a month of discharge, more work is needed to understand this cohort, ensure this data is accurate and act on any learning.”

The trust said the patient discharge dates were often automatically recorded as the date on which they died, such as in cases where the patient was receiving community care. It said this is appropriate and standard practice.

The review was commissioned following years of accusations from campaigners and local MPs that the trust has a high number of avoidable deaths. The trust’s quality challenges have been so great that system leaders have considered splitting it up.   

Campaigners have long claimed around 1,000 people have died unexpectedly under or shortly after leaving the trust’s care  since 2012 – a figure the trust has always rejected, although it has never offered its own estimate.

Grant Thornton’s report covers a significantly shorter period. The local integrated care systems, which commissioned the review, told HSJ they felt there would be “diminishing returns in looking back further [than 2019] given diminishing data integrity and organisational memory over time”.

More needed to be done to improve data quality

On the overall quality of NSFT’s mortality data, the review said the “process for determining the categorisation of death as expected or unexpected, which is a key aspect of mortality reporting, is not clear or auditable”.

Auditors were therefore “unable to provide assurance over the mortality data reported”.

The report described the trust’s disjointed web of mortality reporting systems, reliant on often manual processes which significantly increases risk of human error, and concluded they were not fit for purpose.

The trust said it was already making strides to address this. The review acknowledged some improvements had been made, although it added far more needs to improve.

The report said: “The governance structures in place at the trust are in line with national requirements, but operational understanding of this governance was unclear.

“More needs to be done to establish end-to-end oversight of the mortality data production and reporting process for all mortality, and to assure the board that mortality data reported is accurate.

“Based on the evidence seen as part of our review, more work is also required to support services to use the data available in order to ensure it is accurate and to understand key messages.”

Trust says ‘sorry’ but insists progress is being made

NSFT chief executive Stuart Richardson told a media briefing: “We are sorry our processes and systems historically have not accurately recorded the information that is required. But we are pleased that Grant Thornton can now see we do have good governance within the organisation… We have made some progress as an organisation but we still have a lot to do.”

The CEO said the trust understood this was not about numbers but about lives and that the board was “happy to meet with any family which has experienced a loss”.

The review was carried out on behalf of the Suffolk and North East Essex, and Norfolk and Waveney integrated care boards at the trust’s “request”.

The ICBs said in a joint statement: “[The review] shows very clearly that there are significant improvements required to be assured in future about the trust’s mortality data. As local health and care systems, we will support the trust to make the necessary improvements, ensuring all actions from the detailed action plan are met.”

Local MP: Review ‘explicitly dodged the big questions’ – we need a public inquiry

Clive Lewis, the Labour MP for Norwich South, which is in the trust’s catchment area, criticised the report as “thousands of expensively commissioned words which explicitly dodge the big questions to which we still desperately need answers”.

Mr Lewis added: “Just how many people in the care of NSFT have needlessly died? And how bad is the trust compared to its peers across the country?

“We need to make a decisive break from that legacy of failure. And that still means an independent public inquiry into the system-wide breakdown of local mental healthcare.”

Campaigners and bereaved families, whose concerns about avoidable deaths sparked the mortality review, called for changes to the trust’s leadership.

They added: ”It is clear that NSFT do not know how many of their service users have died or even their cause of death and Grant Thornton were also unable to establish this due to conflicting and contradictory data…

“We have repeatedly warned of this scandal and neither NSFT nor the commissioners or regulators listened.”