The report from an independent review into how data relating to deaths is processed and reported at Norfolk and Suffolk NHS Foundation Trust (NSFT) has been published today (28 June 2023).
The review, called Norfolk and Suffolk Foundation Trust’s Mortality Recording and Reporting, was commissioned by NHS Norfolk and Waveney, and NHS Suffolk and North East Essex integrated care boards at NSFT’s request.
Stuart Richardson, Chief Executive Officer at NSFT, said: “Firstly, our thoughts are very much with those family and friends who have lost their loved ones and who may feel upset by the publication of this review on how we process data. We are very aware of the anguish of those who have lost their loved ones, and we are deeply committed to working with them as we continue to learn lessons from the past and make improvements at NSFT.
“We welcome the independent Grant Thornton report published today and accept its recommendations in full. We’re grateful to our local integrated care boards for commissioning this review on our behalf and to the team who carried it out.
“We are very sorry that the Trust has not previously had the systems and processes in place for the collection, processing and reporting of mortality data that would be rightly expected from a high performing organisation.
“We are pleased Grant Thornton found strong governance around the recording of all patient safety incident deaths including suicides. Data quality, performance reporting, and governance all form vital elements of the improvement work that is well underway across the organisation – which was recognised by the Care Quality Commission with an overall improved rating in February 2023.”
The improvements underway across NSFT include:
- ensuring we have standardised reporting across NSFT for mortality, from our clinicians to our Board so that meaningful comparisons can be drawn over time
- developing data sharing agreements with our partners so that all organisations in our care systems can better understand and learn from deaths, to help address inequalities in our communities’ health
- upgrading the technology and systems our clinicians need to automatically update service user records with information from outside the Trust, for example the information shared by their GP. This will mean we have systems that talk to each other and provide robust and meaningful data on which to base decisions
- embedding a new Learning from Deaths Committee chaired by the Trust’s Medical Director for Quality with oversight from the Trust Board.
He added: “The report notes that the Trust is reliant on and needs the support of other NHS providers to make cause of death information available to meaningfully categorise deaths. It is also clear where health and care organisations across Norfolk and Suffolk could better work together to tackle the physical health inequalities amongst those with mental health needs by seeking to improve their access to physical health services. This can’t be achieved by NSFT alone and we look forward to working closely with our partners in physical healthcare to make this a reality.
“In addition, we take this opportunity to call for more work to be done at a national level to unify language, definitions and categorisations of deaths so that data is comparable across all mental health and learning disability trusts.
“We have made significant improvements across NSFT over the past year and remain committed to continuous learning and improvement. Improving our data processing and reporting is very much part of that.”
“We reiterate our commitment to continue to work with families and those that have lost loved ones to continue to learn lessons from the past. As a first step, we are re-examining our source data and are publishing today updated information for the past five years that describes the number of deaths relating to people in our care or six months after discharge.
“We want to assure those families that their loved one's deaths do matter to us, and we know each one is a much-loved individual and not an anonymous number. By listening and working together with openness and transparency, we are confident we can make the improvements we all want to see.
Notes to editors:
The independent review was carried out by Grant Thornton – an independent audit and consulting company – and took place between October 2022 and January 2023. The audit team reviewed mortality data recording and reporting between April 2019 and October 2022. They looked into how the Trust processes and reports data relating to deaths of people cared for in its inpatient and community services, and those who died within six months of discharge from its care.
The report’s key findings:
- understanding of individual patients and clinical management of incidents is good but more work is required to maximise the use of mortality data to inform how services could improve
- methodology for mortality reporting is in line with the expectations of national guidance, where it exists, and the processes in place in peer organisations, however our implementation requires further work to improve the reliability and usefulness of the information we produce
- mortality data management process is unclear and uses multiple systems to record and produce the data
- governance structures are in line with national requirements but more needs to be done to establish end-to-end oversight of the mortality data production and recording process, and to assure data accuracy for the Board
Insufficient information for the Trust to meaningfully categorise deaths
- The Trust has strong governance in its approach to deaths resulting from patient safety incidents – on site incidents are followed up, as well as suicides where the coroner has notified the Trust
- The auditors note the Trust is often reliant on other NHS providers for cause of death information and more needs to be done to provide access to this information. As well as actions the Trust can take, the auditors note NSFT will need to be supported by the Integrated Care Boards and other healthcare organisations in Norfolk and Suffolk to make this information available
Opportunities for improving physical health inequalities amongst those with mental health needs across Norfolk and Suffolk
- The auditors note the benefits if providers across the system can come together to address the Trust’s challenges in accessing information for some patients. This information would help health and care organisations to better address the physical health challenges and health inequalities faced by people with mental health needs
Problems with consistency and data in language nationally
- The auditors note that the quality and consistency of mental health data is a recognised national challenge and that national guidelines for mortality reporting for mental health trusts are not as clear and defined as those for acute trusts
- They acknowledge that this lack of detailed national guidance limits the opportunity for mortality data comparisons and provides a challenge for the Trust in applying a nationally consistent process.
- Overview of NSFT mortality data for the past five years [pdf] 146KB
- Read the full report here.