‘No Patient Should Ever Be Treated Like this Ever Again’

Ivan Ambrose suffers from autism, severe depression, severe anxiety, post-traumatic stress disorder (PTSD) and obsessive compulsive disorder (OCD). Unfortunately for him, he was an NHS patient in the worst mental health trust in England.

The treatment he received from Norfolk and Suffolk mental health trust caused him to have a severe panic attack and the revival of his PTSD, with flashbacks of excruciating interviews with a coordinator at the trust who didn’t understand and wasn’t trained to cope with his autism.

He also suffered from severe staff shortages at the trust and, when the consultant psychiatrist treating him retired, the trust couldn’t easily find him another and wanted him to go back and see the mental health coordinator who had previously failed him.

“Everything got more and more confusing, muddled and very distressing for me with the constant backwards and forwards of appointments being arranged and cancelled with different consultant psychiatrists,” Ivan said. “No patient should ever be treated like this ever again, whether autistic or not.”

Ivan’s experience is unfortunately not unusual in the mental health service.

The situation is particularly bad at Norfolk and Suffolk mental health trust. Since it was created in 2012 by merging two disparate trusts, Norfolk and Waveney and Suffolk, it has gone through six chief executives in 11 years, suffered staff shortages and been rated ‘inadequate’ by the Care Quality Commission, which inspects NHS trusts. It has also been in and out of ‘special measures’ four times. The CQC has recently slightly upgraded its rating to ‘requires improvement’.

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Worse than that, this particular trust was subject to an investigation by accountants and management consultants Grant Thornton, which found that nearly 2,000 patients had died within a month of being discharged – a number having committed suicide. So inadequate was the trust’s patient record-keeping, it could not provide an exact figure leading to concerns that it may have been underplayed and the report watered-down.

Tom Hunt, Ivan’s Conservative constituency MP for Ipswich, said he has “called for a public inquiry” and for the trust “to be put under a special administrative committee” because he has “lost confidence in its ability to care for the most vulnerable members of society”.

“I can confirm that it is not uncommon for these concerns to be brought to my attention,” he added. “Families have shared their personal accounts of the trust’s failings and the impact these have had on them, which are in many cases distressing.”

Hunt has also pressed ministers at the Department of Health and Social Care to take action.

Cath Byford, deputy chief executive officer and chief people officer at Norfolk and Suffolk NHS Foundation Trust, said: “We have made significant improvements across NSFT over the past year, which were reflected in the improved overall rating we received from the CQC in February.

“We welcome the independent Grant Thornton report and accept its recommendations in full.

“Our thoughts are very much with those who have lost loved ones and we are committed to working with them as we continue to learn lessons from the past. We are very sorry that the trust has not previously had the right systems and processes in place for collecting, processing and reporting mortality data and are addressing this as part of the wider improvement work which is currently taking place.”

It has also recruited more than 1,000 new staff members, but its failure to retain workers has meant this is only an increase of 331.

Meanwhile, the national picture for mental health is worsening.

The latest review of mental health services by the CQC last month revealed that there are 25 mental health trusts rated ‘inadequate’ and 201 rated ‘requires improvement’ in 2023 compared with 169 last year. That is more than a quarter of all trusts. Only 71 are rated ‘outstanding’.

The waiting list for people like Ivan requiring community mental health treatment currently stands at 1.2 million people – and that is the tip of the iceberg. The National Audit Office estimated in a report published earlier this year that there were about eight million people who had mental health problems but had not contacted the NHS about them. A particularly large increase was found among young people post-COVID, with the figures jumping from 10 to 26% among 17 to 19 year olds.

Mental health, alongside maternity care and the ambulance services, were the fastest declining services in the NHS, according to the CQC.

Ivan has now opted out of treatment by the trust despite a fresh offer from it promising a new specialist who understood autism and apologising for its “inappropriate and unacceptable treatment”. It will cost him £1,600 a year to pay for two monthly or monthly 30-minute consultations with a private psychiatrist and £385 for an initial assessment.

Left out of the King’s Speech

A Mental Health Act was one of the main priorities of former Tory Prime Minister, Theresa May, who held a Downing Street summit with leading psychiatrists to reform the law. A draft bill has been prepared and was on the stocks to be introduced in Parliament. However, as King Charles opened the new Parliament in November, the bill was quietly dropped from the Government’s legislative agenda.

Steve Brine, Conservative chairman of the all-party Commons Health and Social  Care committee yesterday criticised the government for not going ahead with it.

“It is disappointing that the government has failed to bring forward legislation to overhaul the Mental Health Act. The draft Bill, among its planned reforms, would outlaw the inappropriate detention of people with learning disabilities and autism. Without change, too many people will continue to be held in secure units, often for years at a time. These reforms are long overdue.”