In 2022 the Norfolk and Suffolk Mental Health Foundation Trust failed a Care Quality Commission Inspection for the fourth time since its ill considered and disastrous reconfiguration in 2013, the only Mental Health Trust in the country to have so abjectly failed in its responsibilities to provide an efficient and effective mental health service for so long.
Its failure was inevitable once it had gone ahead with a
massive reconfiguration of service provision 10 years ago. It disbanded
locality based community mental health teams, relocating them in a few
centralised locations, inevitably meaning that those teams were less responsive
to community needs, and had to travel further to have face to face contact with
services users, making the service innately less efficient.
They also had the brilliant idea of encouraging the most
experienced staff to take early retirement or redundancy, then expecting them
to re-enlist on lower pay grades. Not only was this very expensive, but it left
a huge shortfall in expertise, with an expectation that lower paid and less
experienced staff would take on larger caseloads with more responsibility.
Then to top it all, the Trust systematically closed many
inpatient beds, making it necessary to use expensive private hospitals to
provide an often inferior service many miles away.
Throughout the 25 plus years that I worked in
multidisciplinary community mental health teams, I always maintained that you
could close beds, or reduce community based staff, but to do both would result
in disaster. The Norfolk and Suffolk Trust proves the evidence of the truth of
that.
The Trust has continued to perform with dazzling
incompetence. In June 2023 it was revealed that a report into patient deaths in
the Trust had been toned down in an attempt to deflect attention away from the
failings of senior management. In the first draft, it was said that there had
been "poor governance" in the way deaths data was managed, with
governance also being called "weak" and "inadequate".
But the final report released to the public did not have
these descriptions.
It was then discovered that the Trust had presented grossly inadequate statistics relating to the number of children known to the Trust
These showed that more than 4,000 children were on waiting lists for mental
health assessments, with more than 1,000 apparently waiting longer than a year,
but they had included 3,000 other cases, mainly adults with ADHD.
While the current management in the Trust appears incapable
of doing anything to improve its performance, early evidence for chronic
mismanagement goes back at least two decades, to a time when the Trust was then
known as the Norfolk and Waveney Mental Health Partnership NHS Trust.
A prime example is the case of Richard King.
On 7th August 2004, Richard King stabbed his stepfather,
John West, 11 times, killing him.
Richard King had a diagnosis of paranoid schizophrenia and
had been a patient of the Trust since 1991.
He was first assessed under the Mental Health Act in
December 2002, when he was detained under s.2 for assessment. He was discharged
after only three days.
Between then and 2004 there were a total of 8 admissions to
hospital, mainly informal, but some under s.2 or s.3 of the Mental Health Act.
He frequently reported paranoid delusions, and there was increasing concern
about the safety of his wife and others.
On 15th July 2004, Richard’s social worker, who was also an
Approved Social Worker, the predecessor to an AMHP, received a call to say that
his wife was very upset and Richard had locked her out of the house. She
visited, and as she knew him well, she was able to calm the situation somewhat.
Richard agreed to an informal admission, and the social worker, accompanied by
a police officer, and with a police car following, took him to hospital.
After a few days, Richard was allowed home leave at his
request. He was in contact with the home treatment team during that time. After
11 days he was discharged without being seen by doctors at the hospital.
Less than two weeks later he killed his stepfather.
On 21st January 2005, he was found guilty of the murder of
John West and was detained under s.37/41 Mental Health Act.
The Norfolk and Waveney Trust arranged for what was
described as an independent inquiry into this serious incident. The Inquiry
reported in June 2005.
One of its key conclusions was this:
“It is very probable that Richard King would not have been
in a position to kill Mr West had he been correctly admitted under Section 3 of
the Mental Health Act 1983 in July 2004. This would have allowed for a proper
risk assessment and a mental state examination to be completed to the required
standard during the course of admission. It would also have prevented the
discharge being enacted without the patient being seen. He would not have been
discharged or given leave until it was considered safe to do so.”
A daylong meeting was subsequently held in which all of
Norfolk’s Approved Social Workers were present, to feed back the findings of
the report and make practice recommendations in response to its conclusions.
This is where I make a confession. I know exactly what
happened at this meeting, and the reaction of those present because I was
there. I was one of those ASW’s.
The ASW’s were not happy about the recommendations. It was
felt that undue blame was placed on the ASW and on the community nurse who had
been involved in Richard King’s care in the community, while little was said
about the role of psychiatrists in allowing him to be discharged without having
been seen.
It was considered that the ASW who had arranged for
Richard’s informal admission had acted competently and in accordance with the
letter and spirit of the Mental Health Act, seeking the least restrictive
option. The ASW’s home visit was not initiated as part of a Mental Health Act
assessment, and since Richard had agreed to an informal admission, there had
been no need to conduct a formal assessment. Even if such an assessment had
taken place, it would have been unlikely that detention under s.3 would have been
considered at that point. It might have been more usual to admit under s.2 for
assessment.
Unison, the local government union, described the report as“flawed”, contained factual errors and misunderstandings, and had unfairly
scapegoated social workers.
The local MP was also highly critical of the report, and Indeed,
there was so much dissatisfaction that eventually, a properly independent
inquiry was convened.
This report, entitled “Looking Through the Reeds”, was
published in June 2008.
The report is too long to comment at length on its
findings. However, the report noted that the social worker “did not regard
herself as working within an effective team given the reception she received
when arriving at the hospital and the subsequent abrupt discharge, without
consultation with the community staff.” It also noted that an internal
investigation had found that the social worker “had not breached departmental
policies and procedures or acted unlawfully in failing to use the Mental Health
Act on this occasion.”
The Inquiry further concluded that “We are not in agreement
with findings of the previous panel in this regard. A s.3 could have been
arranged at any time if Richard King had tried to leave the hospital. It was
not.”
This inquiry also considered at length the nature and
substance of the first inquiry.
It noted that the first inquiry was not independent of the Trust,
and it did not comply with the appropriate guidance.
In relation to the first inquiry’s laying blame at the door
of the social worker, the second inquiry was clear:
“We cannot agree with the inquiry’s conclusion, that had
Richard King been detained under s.3 he would probably have spent longer in
hospital and would not have been given early home leave. Scrutiny of previous
admissions would have demonstrated that his admissions were, with one
exception, extremely short whether voluntary or involuntary. He had left the
hospital without leave on other admissions. In our view, the panel reached its
opinion on this point against the weight of the evidence.”
The second inquiry was also critical of the way that the
Trust handled the aftermath of the murder of John West.
It observes:
“Several members of staff that we interviewed told us how
they were affected by criticism from the first inquiry and were not given any
formal support to help them cope with the devastating effect of public
criticism. While some moved to different posts and some were told of
competencies that should be achieved, no one received any specific training to
address deficits in their practice. Several felt victimised… There was no
indication that the Trust had helped staff to prepare for the external inquiry and
support them through the process.”
After all these years has the Norfolk and Suffolk Mental Health Foundation Trust learned the lessons of the past sufficiently to make the profound changes to its performance needed? In view of ongoing criticism and scrutiny by the press and the BBC, right up to when I posted this video in September 2023, I fear not.
