Almost 2000 patients died within 1 month of being discharged from a trust specialising in mental health and learning disability care, an independent review has revealed. The review also said that the Norfolk and Suffolk Foundation Trust (NSFT) had lost track of figures for patient deaths.
The NHS Suffolk and North East Essex and NHS Norfolk and Waveney integrated care boards (ICBs) hired professional services firm Grant Thornton to review the way NSFT records deaths. The published review was based on data recorded by the trust between April 2019 and October 2022, which was collected by Grant Thornton between November 2022 and January 2023.
Between April 2019 and October 2022 the Trust recorded over 8000 unexpected deaths. The review found the cause of death had not been established in more than three quarters of those cases. The findings also revealed that 1953 patients had died within 1 month of being discharged. This includes 278 patients whose date of discharge was recorded as the same day as the day they died.
People who passed away under the care of NSFT, for example if they were receiving support in the community, had their discharge date backdated to the day of their death.
Questions Regarding Mortality Data
The report said: "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 is currently working with GPs through Primary Care Networks to try to improve the capture of cause of death to inform this insight."
Data also found that a further 3261 (37% of the total) patients had a discharge date recorded after their date of death. The majority of people were in old-age psychiatry or adult mental illness specialities, and 83% (2699) of them were aged over 65.
Grant Thornton's report said it was "unable to provide assurance over the mortality data reported at the trust". It added that the data management process was unclear, with multiple systems used, while the reporting of mortality to internal and external audiences was inconsistent.
Members of the Campaign to Save Mental Health Services in Norfolk and Suffolk have been calling for a public inquiry into NSFT since last year. A Care Quality Commission (CQC) report published in February 2023 said the trust requires improvement. The ruling was based on inspections carried out last September and November.
Ed Garratt and Tracey Bleakley, respective chief executives of the NHS Suffolk and North East Essex and NHS Norfolk and Waveney ICBs, said: "On behalf of all system partners, our thoughts are with those family and friends who have lost their loved ones and may feel distressed by this review.
"The review was commissioned with the full cooperation of the Norfolk and Suffolk Foundation Trust to ensure that we can improve the collection, processing and reporting of data that related to people being cared for by the trust as an inpatient and in community settings and within 6 months of discharge.
"It shows very clearly that there are significant improvements required to be assured in future about the trust's mortality data."
Grant Thornton said the NSFT has been working with NHS England since September 2022 to improve its processes.