Norfolk and Suffolk NHS Foundation Trust

PFD Addressee
Reports: 38 Earliest: Sep 2013 Latest: 26 Nov 2024

100% 2-year response rate (above 83% average). 53% of classified responses show concrete action taken.

Response Status (last 2 years, 3 reports)
Responded 3
AI Classification
Action Taken 53%
Action Planned 32%
Noted 15%
Disputed 0%
Based on 47 classified responses
PFD Reports Received by Quarter
PFD Reports
38 results
Benjamin Goodrum
All Responded
2017-0362 8 Dec 2017 Norfolk
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Although there was evidence of good communication with Mr Goodrum, the coroner noted that no one person took overall responsibility for him after his allocated co-ordinator left.
Action Taken (AI summary) The Trust has implemented a new recruitment system (TRAC), engaged a partner organization to promote career opportunities through social media, and has action plans for 'hotspot' areas.
Brian Stannard
All Responded
2017-0394 14 Nov 2017 Norfolk
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Nursing home staff were inadequately equipped to manage a patient with complex mental and physical ill health, particularly regarding self-harm risks. Incomplete record-keeping, potentially due to high workload, and underutilised computer systems also raised concerns.
Action Planned (AI summary) The Trust is engaged in a program to improve record-keeping, including risk assessments and care plans, with active monitoring at all levels. They are also working with business change and training specialists to develop staff use of the Lorenzo electronic patient record system and with system suppliers to improve its performance.
Rachel Edwards
All Responded
2024-0220 27 Feb 2017 Suffolk
Alcohol, drug and medication related deaths
Concerns summary (AI summary) The report notes Rachel was informally admitted.
Action Planned (AI summary) The Trust will assess medications prescribed upon discharge, which will continue across the Trust. The Trust is planning the technical changes required to build electronic bridges between different elements of the health system, but there is no confirmed date for completion.
David Read
All Responded
2017-0031 8 Feb 2017 Norfolk
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) After an initial urgent referral and a cancelled appointment, a new appointment for mental health services was scheduled after a delay of over 16 weeks, during which time the patient died.
Action Taken (AI summary) Norfolk and Suffolk NHS Trust has fully staffed its team and made amendments to practice. If a service user does not attend an appointment the team will have a phone call to rearrange an appointment instead of sending a letter. The clinical team leader monitors cases that have an appointment pending on a daily basis.
Christopher Higgins
All Responded
2015-0480 24 Dec 2015 Norfolk
Suicide
Concerns summary (AI summary) Inconsistent mental health observation practices, inadequate patient escort protocols during police transfers, unassessed safety risks in the environment, and poor inter-agency agreements for A&E assessment of detained patients led to unsafe conditions.
Action Taken (AI summary) The Trusts have worked together to develop a process for ensuring that patients under the care of mental health services who require acute care have a clear pathway which includes agreed communication channels between clinicians. A flow-diagram has been developed and is being used. The Trust updated its Observation and Engagement of Service Users policy and communicated changes to staff. Additional height bars were added to a railing on the disabled access ramp and the Trust has decided to enclose the ramp, with work scheduled for completion by the end of March 2016. The hospital has worked with Norfolk and Suffolk NHS Foundation Trust to develop a referral pathway to ensure inpatients from the local mental health facility can access care and treatment in the Emergency Department in a timely manner. A written pathway and flow diagram has been developed for staff.
Thomas Thurling
All Responded
2015-0309 6 Aug 2015 Norfolk
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inadequate monitoring of medication changes, including lack of awareness and delayed reviews, coupled with the absence of a Care Co-ordinator during a period of mental health deterioration due to staff shortages, posed significant risks.
Action Planned (AI summary) The Trust is sharing the issue of monitoring medication changes with a range of leads, including Pharmacy and those leading Triangle of Care; clinical services have been directed to consider how they are consistently meeting guidance for covering staff absences.
Barbara Mayer
All Responded
2015-0113 23 Mar 2015 Norfolk
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Carer fatigue was not followed up, inconsistent crisis team contacts prevented establishing trust, and urgent help was delayed due to increased demand. Treatment options were also not adequately discussed with the patient.
Action Planned (AI summary) The Trust is implementing the 'Triangle of Care' model and nearing completion of the first stage of this multi-year plan. Localities are reviewing their escalation plans for services such as CRHT and the Dementia Intensive Support Teams.
Robert Anstice
Historic (No Identified Response)
2015-0014 16 Jan 2015 Norfolk
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Critical recommendations for support and care coordination were not actioned, and communication breakdowns meant team members were unaware of appointments. The patient was discharged despite difficulties in engagement and unmet practical needs.
Joanne Nobbs
All Responded
2014-0560 4 Dec 2014 Norfolk
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths
Concerns summary (AI summary) A correlation between the deceased's deteriorating physical and mental health was noted but not investigated, and a care plan was not revised despite the deceased no longer engaging with mental health services.
1 response from Norfolk and suffolk NHS Trust
Ann Wells
Historic (No Identified Response)
2014-0401 11 Sep 2014 Norfolk
Hospital Death (Clinical Procedures and medical management) related deaths
Graeme Kidd
Historic (No Identified Response)
2014-0337 23 Jul 2014 Norfolk
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Locum doctors lacked access to vital electronic records and awareness of mental health services, while GPs faced referral barriers due to mandatory physical checks. Additionally, patients lacked essential medication advice in the prescribing doctor's absence.
Jamie Barlow
Historic (No Identified Response)
2014-0153 7 Apr 2014 Suffolk
Community health care and emergency services related deaths
Concerns summary (AI summary) There was a lack of effective inter-agency working, clear protocols for police assistance, and a joint mental health assessment framework for high-risk patients.
Matthew Dunham
Historic (No Identified Response)
2013-0229 12 Sep 2013 Norfolk
Mental Health related deaths
Concerns summary (AI summary) Failures in mental health care included delayed emergency referrals, unclear team roles, inadequate assessment of suicide risk, and critical breakdowns in information sharing and coordination among professionals.