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Man with mental health issues dies after failings by two NHS trusts

A vulnerable patient with suicidal thoughts was found dead in a river after being let down by two trusts in East Anglia, an investigation by the Parliamentary and Health Service Ombudsman found.

The man went to Norfolk and Norwich University Hospitals NHS Foundation Trust, with his partner, because he was feeling suicidal and admitted as an acute patient. He was on the ward for more than 16 hours without adequate support.

He was eventually assessed by a doctor and then waited all night for the crisis team from the neighbouring trust, Norfolk and Suffolk NHS Foundation Trust, to see him and they did not attend until 9am the following morning. He was assessed by a mental health nurse who discharged him and recommended he attend his GP surgery and get counselling.

He was found dead three days later.

Parliamentary and Health Service Ombudsman Julie Mellor said:

"It is unacceptable that a vulnerable man received such little support when he so desperately needed it.

"A bit more time, care and attention by the Trusts may have resulted in a different outcome for him."

The Parliamentary and Health Service Ombudsman found the initial treatment completed by the Norfolk and Norwich University Hospitals NHS Foundation Trust was inadequate. However the decision to not detain the man under the Mental Health Act was reasonable.

Norfolk and Suffolk Trust's crisis team's failure to attend the man was unreasonable particularly given the length of time he waited to be assessed. The eventual assessment and discharge completed by the mental health nurse was not comprehensive.

The man's partner, Trezza Azzopardi said:

"Norfolk and Norwich Hospital Trust's behaviour has been arrogant, dismissive and shambolic. They have compounded my distress by their complete lack of respect for me or my partner.

"They would have continued to ignore me if not for the fact that I contacted the Ombudsman Service. In its findings, the Ombudsman Service has vindicated me in my belief that the Trusts had failed my partner and myself."

The Ombudsman Service recommended both Trusts apologise to the woman and tell her the lessons they learned from her complaint. They were asked to submit action plans to meet their obligations under the NHS Mental Health Crisis Concordat – a set of standards patients should receive in crisis care.

Julie Mellor said: "It is absolutely crucial both Trusts learn from their mistakes and implement our key recommendations."

The Parliamentary and Health Service Ombudsman investigates complaints from individuals about UK government departments, and other public organisations, and the NHS in England. It carries out adjudications independently, without taking sides, providing a final decision on people's complaints. The Ombudsman Service investigates 4,000 cases a year and upholds around 42 per cent.

Notes for editors

  1. For further info contact: Ben Miller on 0300 0614324
  2. The coroner's inquest reached a narrative verdict, which is a statement surrounding someone's death, without attributing the cause to an individual.
  3. NHS Trusts are expected to work within the new Mental Health Crisis Concordat (HM Government, 2014). The crisis concordat is jointly developed between professional groups and NHS Trusts. The concordat provides quality statements, including standards to receive help in a crisis with the same urgency as physical health problems. The concordat also asks for a 'local declaration' in which the standards are implemented locally between key agencies.
  4.   Both Trusts agreed to consider the recommendations of the concordat, working jointly with organisations tasked to assist implementation, such as NHS England, to plan strategies to ensure they work within the concordat and the good practice recommendations.

Contact: Ben Miller

Phone: 0300 0614324


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