How many times do we have to hear the phrase ‘lessons will be learnt’ before anyone actually does learn those lessons?

Already in Special Measures, the Norfolk and Suffolk Mental Health Trust has announced that it has launched an independent investigation into the large number of unexpected deaths and suicides among patients, reportedly the highest in England, with 139 in 2014/15 and 112 so far in the first nine months of the 2015/16 financial year.

Families and staff have been calling for an investigation for the last three years, and have now been told that the results will be available in three months, although the terms of the investigation, and who will lead it, have yet to be agreed. If other such reports are anything to go by, I doubt that it will be published in full; a sanitised press release will be issued instead, so I can only hope that the media will get their FOIs in early and that the authors and relevant Trust leaders will be called to Parliament’s Health Committee for a grilling.

Meanwhile, during a local television interview in response to publication of the latest figures, the day before the investigation was announced, the CEO refused to take any responsibility, effectively saying problems were down to a lack of funding. He subsequently stated that ‘every death is already investigated to assure ourselves that it was not due to our service or care…and to ensure lessons are learnt.’  Given the shameful death rate, lessons certainly don’t appear to have been learnt.

For example, several years ago, a young neighbour of mine was in the care of this Trust’s predecessor at St. Clement’s Hospital in Ipswich. He was a delightful young man, well educated and interesting; he also had a job. However, periodic mental health episodes began to escalate when his medication was altered; his parents – retired lecturers – raised concerns with the hospital, but were ignored over many months. Eventually their son had to be sectioned and became an in-patient because of self-harm. Within days he had taken his own life in hospital.

His parents were again ignored when they asked how this could have happened, given his history of self-harm, and turned to me for help. I contacted the then CEO, who arrogantly dismissed my enquiry, telling me to mind my own business. When I reported back to the parents, they were too distressed to pursue the matter, so the truth was never made clear. Their son was merely another statistic.

Given the pressure for this new enquiry, I suspect that campaigning families and staff are only too well aware that these deaths can no longer be allowed to be brushed under the carpet; they know something is seriously wrong with the Trust’s culture, and they should be congratulated for their persistence.

Surprisingly, the scale of the problem doesn’t appear to be a priority on the Health and Wellbeing Board’s radar. It published a mental health strategy for consultation last year; one of the key points was ‘removing the barriers to communication’. Aha, I thought, that makes sense – until I read that it was all about communicating with the various public sector authorities, which have different IT infrastructures which don’t talk to each other.

As usual, the people at the core of the ‘strategy’ – the patients– are hardly mentioned. It is all top down theory, instead of bottom up.

Yet it is patients who are the most vulnerable, who suffer because they don’t know what to do, how to complain, or seek advice; they are scared of ‘authority’. Those with mental health problems are amongst the most vulnerable and their choices can be irrational; death may be accidental, or appear to be the best option, because they think no-one cares about them. We must be grateful that guns are not readily available in Britain, otherwise the death rate would surely be a great deal higher.

Consequently, one can only hope that the Norfolk and Suffolk Mental Health Trust’s investigation is truly independent, held in public, challenges a complacent leadership, and ensures that those who have failed will be held to account.

But will that really happen? Regrettably, it is doubtful if previous such investigations are anything to go by. It’s too easy for people at the top of so many public sector organisations to hide behind the impenetrable bureaucracies which are such a feature of their management, especially in the health service.

So, the Health and Wellbeing Board should closely observe the process, ensuring its genuine independence by insisting on being consulted about who will lead (one of the recently retired Crown Court judges in Suffolk would do an excellent, wholly impartial, job) and review the investigation rigorously, demanding full accountability, and real change without delay so that more people don’t lose their lives.

And, instead of the usual response to serious reviews: full of promises to address the issues identified in the investigation’s recommendations, but without any idea how to actually deliver the required improvements, so nothing happens; we need a costed programme, incorporating a revised management structure, and timelines, with regular monitoring. That is the only way to achieve real change, and quickly.

This is not about ‘funding’, (although the Government recognises that mental health does need more resources). It is about radically changing the culture with a strong leadership team, people who aren’t divorced from those staff members (and relatives) who know what needs to be done, but who no-one has so far listened to.

So, should anyone ‘move on’, their replacement must not be a carbon copy, because public appointments tend to be largely a closed shop. What is needed are inspirational leaders from outside the loop, with strong business/financial experience and an understanding of what customer care means; a fresh pair of eyes which are objective and sympathetic, people who actually listen. There is evidence across the public sector, as well as business, that such people can revolutionise an organisation, making it more responsive, efficient and focused; this is what the Norfolk and Suffolk Mental Health Trust so desperately needs.

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