An independent report has found that a mental health trust was failing to record patient mortality data consistently and accurately
"We had been consistently flagging up concerns about inconsistencies and poor quality of the mortality data at NSFT for years. The message conveyed to bereaved families is that their loved ones are of so little value that their deaths are not even worthy of being recorded properly.” Bereaved relatives of patients at Norfolk and Suffolk NHS Foundation Trust (NSFT)
Campaigners in Norfolk and Suffolk are calling for a public enquiry into the way mental health trusts record patient deaths.
The call comes after auditors Grant Thornton published an independent report into Norfolk and Suffolk NHS Foundation Trust (NSFT) that criticised the trust’s chaotic data collection. The report said this was a national problem.
In its report, Grant Thornton investigated the way NSFT monitored and recorded the deaths both of inpatients and patients in the community. It concluded that NSFT was unable to “provide assurance” of its figures, saying there was a gap between data entered on internal systems and those presented in reports to the board. It said that of the 11,379 deaths of people in contact with the trust over five years, it was not possible to determine the number that could have been avoided. The report noted that the “quality and consistency of mental health data is a recognised national challenge” adding: “National guidelines over mortality reporting for mental health trusts are not as clear and defined as those in place for acute trusts.”
The report made a number of recommendations to the trust including improving the recording of mortality data, introducing standardised reporting structure, engaging with clinical staff in the production of mortality data, improving partnership working with other organisations such as the integrated care board, and establishing clear governance in relation to mortality reporting.
Caroline Aldridge, whose son Tim died in 2014, has written to health secretary Steve Barclay calling for an enquiry. The letter was also signed by campaigners Anne Humphreys and Labour member of Norfolk County Council, Emma Corlett.
In the letter, the parents wrote: “If a Trust cannot even count, let alone identify, who has died and why, they are not in a position to learn and improve. From the bereaved relatives and mental health campaigners’ perspectives, the casual and chaotic practice that Grant Thornton reveal into their audit of NSFT is not a surprise. We had been consistently flagging up concerns about inconsistencies and poor quality of the mortality data at NSFT for years. The message conveyed to bereaved families is that their loved ones are of so little value that their deaths are not even worthy of being recorded properly.”
The parents also said in the letter that they believed that other trusts’ handling of mortality data is “similarly flawed” and that this “reflects a whole system failure.” They added: “Whether by acts of commission or omission, the corruption of data within the NHS is totally unacceptable and it must be exposed and addressed.”
Stuart Richardson, the chief executive of NSFT, said: “We are very sorry that the trust has not previously had the systems and processes in place around recording mortality data that people rightly expect.
“The Grant Thornton report makes recommendations which clearly set out what we need to do – and this work is already under way, with external support and oversight from our NHS partners.
“We will regularly publish consistent information with mortality figures that will be independently audited, comparable over time, and discussed in public at our board meetings.”
Although the government is not holding an enquiry into the recording of patient deaths, it has commissioned an independent rapid review into how data and evidence is used in mental health inpatient settings.
It is shocking to read the Grant Thornton report into the chaotic data collection at an NHS trust. Proper, consistent reporting of mortality data should be an absolute minimum requirement, and we agree with campaigners that an inability or unwillingness to do this shows a lack of care and respect towards patients and their relatives. Although the government has decided against commissioning a public enquiry, we hope that its rapid review into the use of data in mental health settings will go some way to addressing the issue of how mortality data is recorded.