A top lawyer wants to share the tragic experiences of families she has represented with the boss of our region’s failing mental health trust – after it was plunged into special measures again.
Sharon Allison is a partner with Ashtons Legal and for over almost two decades she has worked on several cases involving the Norfolk and Suffolk Foundation Trust (NSFT).
She is calling for a change in governance at NSFT, and has invited new chief executive Antek Lejk to meet her and discuss the impact of “countless inquests” and investigations on relatives.
“All I can reflect on is the last 18 years of experience representing families who have lost loved ones,” Ms Allison said.
“During those years I’ve sat in countless inquests involving the NSFT. “I’ve seen the commitment and dedication of the staff, who are trying to deliver a service in a broken system.
She has represented families of patients such as Joe Ruler, who took his own life on an NSFT ward at Wedgwood House in Bury St Edmunds in 2010, and Jeremy Head, who was found hanged at the same unit four years later.
Changes were made at the unit following Mr Ruler’s death, including minimising ligature risks.
Coroner Peter Dean said he could not be sure if Mr Head had taken his own life, but his sister Joanna Clark felt a lot of questions had not been answered after the inquest.
Ms Allison added: “My experience is that I am seeing the same cases, happening at the same trust, just each time with a different devastated family.
“And at the end of the day, it is families who are paying the ultimate price.”
In the wake of a third damning CQC report, Ms Allison is now calling for trust leaders to investigate failings as a matter of urgency.
“The trust’s governance has to adopt true reflective practice,” she said. “That means they have to undertake proper investigations of their failings, which must be shared with all staff so they can learn and ultimately improve patient safety.
“I invite the new chief executive of NSFT to meet me, so I can share the experiences that have led to the ultimate tragic impact on so many families.”
Trust response
The quality of investigations at NSFT has improved, accordign to the new CQC report.
Deputy chief nurse Dawn Collins said: “We are committed to investigating all serious incidents thoroughly, and have a team of investigation and improvement managers to undertake this work alongside clinical staff from across a range of roles and specialties to aid effective analysis and to strengthen learning from incidents.
“When there are lessons to be learned, we strive to ensure they are shared with all the relevant staff by communicating them out in various ways.
“This activity includes contemporaneous assessment of the incident, identifying and, if necessary, implementing immediate learning before the full investigation is completed to safeguard other service users.
“Once fully investigated, the wider learning will be cascaded throughout the organisation.
She added: “For example, managers will share learning with teams and, in some cases, directly with individuals; we issue a monthly patient safety newsletter; and all investigations are reviewed post-completion by county-based review panels to make sure important lessons are not missed at both a strategic and locality level, further enhancing dissemination to from line team meetings.
“We acknowledge that learning does not consistently reach all relevant members of frontline staff.
“While we are not unique in this, this is something we are working to improve. We are determined to make progress.”
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