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.

Action Taken 53%

Action Planned 32%

Noted 15%

Disputed 0%

Based on 47 classified responses

PFD Reports

30 results

David Read

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

2015-0480 24 Dec 2015 Norfolk

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 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 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 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

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

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.

Joanne Nobbs

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