Norfolk and Suffolk NHS trust fails to allay coroners' concerns over two deaths

Ellen Woolnough died in July 2022, following an attempt to take her own life

A mental health trust has failed to allay concerns over the death of two patients where there were missed opportunities, said new reports.

Ellen Woolnough, 27, died in July 2022 and Paul Templeton, 65, died in 2023. Both were patients of Norfolk and Suffolk NHS Foundation Trust (NSFT).

Two coroners have said evidence of actions taken since the deaths "did not allay concerns".

The trust said it was "working really hard" to learn from past deaths.

An inquest in February found there had been a "missed opportunity" to engage Ms Woolnough, known as Ellie, before her death.

While in a separate inquest a jury found Mr Templeton, who had been an inpatient at Woodlands mental health unit, had been let down by a failure to recognise actions that made him a suicide risk.

'Missed opportunities'

Ms Woolnough, from Ipswich, had struggled with her mental health since the age of six and was later diagnosed with emotionally unstable personality disorder.

On 20 July 2022, she attempted to take her own life and was subsequently admitted to hospital, where she died eight days later.

Dr Darren Stewart ruled her death a suicide, but raised concerns over NSFT's handling of Ms Woolnough, and its subsequent investigation.

In a prevention of future deaths report Dr Stewart raised multiple concerns including:

• The adequacy of discharge decision-making from the service where there has been a failed engagement

• The adequacy of NSFT to respond to an urgent referral, especially risk assessments, planning and decision-making regarding downgrading referrals

• The adequacy of the NHS England Patient Safety Incident Response Framework to address serious incidents concerning patients and the implementation of this framework by NSFT

Inquests into two recent deaths in Suffolk found issues with how NSFT's patients were treated

Dr Stewart said he had concerns that measures he was told would be implemented by the trust in light of Ms Woolnough's death had not been introduced.

This included a handover document between shifts for downgrading urgent referrals and changes to how the trust investigates incidents such as Ms Woolnough's death, including retaining recordings of calls.

He said a failure by NSFT to preserve important evidence, in the form of recordings of calls between Ms Woolnough and the NSFT crisis call handler, when it was on notice from the coroner's court, "remains a concern" he added.

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Ms Woolnough's parents, Lisa and James Woolnough, said NHS trusts need to be held accountable regarding assurances they make following inquests and prevention of future deaths report.

They said: "We, like many families who have endured this process, have a strong resolve that this really shouldn't happen to anyone else."

"This is not the first time NSFT have been told there are issues, that in the past after previous issues of [prevent of future deaths reports] they have made assurances they've learned from their mistakes, mistakes you know that had they truly have learned from there is a good chance your daughter would still be here.

"To be told [the trust] 'could have' and 'should have' provided a better service is of little comfort," they added.

An NHS spokesperson said: "The new Patient Safety Incident Response Framework was developed after thorough engagement with patients, families and the NHS, and requires compassionate engagement and involvement of those affected as part of an effective process of learning from patient safety incidents, backed up by more robust standards than existed previously."

'No reflection of findings'

Mr Templeton's mental state had deteriorated during 2022 and he had become "severely malnourished and dehydrated", which led to an eventual hospitalisation and detainment under the Mental Health Act.

He was staying at Woodlands House, run by NSFT, when he attempted to end his life on 14 April 2023, he died six days later.

An inquest jury in February concluded "initial and subsequent assessments seriously failed to recognise that Paul's prolonged choice not to eat or drink were in fact indications of 'action' to end his own life and therefore he should have been considered a suicide risk".

Paul Templeton was staying at the Woodland Unit, run by NSFT, when he died

Following the conclusion of the inquest, coroner Peter Taheri said he asked for evidence about action being taken to prevent future deaths related to "serious failures in risk assessment" as identified by the jury.

The trust's response, which said Mr Templeton did not present any self-harm or suicide risk other than food restriction, did "not allay my concerns", Mr Taheri said.

He said the trust's response did not "grasp, engage with, or show reflection in light of the jury's finding".

The trust said it was in the process or implementing changes including improving psychological, food and fluid recording, ensuring weighing of patients by the community and crisis team and morning physical health.

These actions did not "address the particular concern highlighted by the jury," Mr Taheri said.

'Comprehensive review'

An NSFT spokesperson said: "We can assure all families and carers that we are working really hard to learn from these incidents and do our very best to ensure they are minimised in future.

"As a trust, we are on a rapid, and much needed journey of improvement which has been strengthened by the welcome arrival of our experienced chief executive officer, Caroline Donovan."

"A comprehensive review of prevention of future deaths from 2013 to 2024 is underway to ensure improvements in practice have been made and learning is embedded across our clinical services," the spokesperson added.

NSFT must formally respond to both coroners reports by the end of May.