“(brief summary of matters of concern) 1”

The coroner’s concerns

(brief summary of matters of concern) 1. The adequacy of Norfolk and Suffolk NHS Foundation Trust’s (NSFT) Integrated Delivery Team (IDT) decision making concerning the discharge of a patient from mental health services in circumstances where a failed engagement has occurred. 2. The adequacy of NSFT’s Crisis Rehabilitation Home Treatment Team (CRHTT) response to an urgent referral, in particular; risk assessment, safety planning and decision making concerning the downgrading of referrals. 3. Adequacy of the NHS England Patient Safety Incident Response Framework (PSIRF) to address serious incidents concerning patients and the implementation of this framework by NSFT. I received evidence from NSFT concerning the measures which that organisation had undertaken to address my concerns. This evidence included the following: a. Care Group communication has improved across the Trust. b. Skills Training on Risk Management (STORM), covering suicide and self-harm awareness training, was being implemented across the Trust. c. Staff were being engaged concerning waiting lists and expectation management and how to present these to patients in a positive manner. d. The downgrade policy concerning crisis line referrals had been changed in 2023 to make the circumstances concerning a downgrade clearer and what was expected of nursing staff involved in these decisions. Regulation 28 – After Inquest Document Template Updated 30/07/2021 This evidence has not allayed my concerns. I remain concerned that many of the measures outlined by NSFT are prospective and have not been introduced. I note: i. STORM training continues to be rolled out, although the evidence from a number of witnesses questioned the effectiveness of the rollout in reaching all staff. ii. Whilst the downgrade policy concerning urgent referrals has been tightened up, key parts of the process, such as the handover document between shifts, is still to be introduced. iii. The Trust SOP addressing the downgrading of urgent referrals, which I was told was revised in 2023, has not been provided to the Court and has not been implemented by the Trust. iv. Changes to the way the Trust investigates incidents such as Ellie’s, including the use of a screening tool to determine how the PSIRF process is implemented, the requirement to retain recordings of calls and which statements are to be taken to inform serious patient incident investigations, are still to be introduced by the Trust. v. The failure by NSFT to preserve important evidence, in the form of recordings of calls between Ellie and the NSFT crisis call handler, at a time when it was on notice that this evidence would be important and relevant for the conduct of the Inquest, remains a concern.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2024-0184

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0