Review into series of ‘unexpected deaths’ identifies service shortcomings

The internal review at Tees, Esk and Wear Valleys Foundation Trust followed a series of deaths between October 2019 and September 2020.

The trust has said the key findings included a lack of family involvement in discussing risks, increased waiting times for face-to-face therapy, and a lack of contact or reassessment for patients on waiting lists.

Eight of the 13 deaths, six of which were suspected suicides, were escalated to serious incident reviews, according to a freedom of information response received by HSJ.

However, when asked for the findings of the serious incident reviews, the trust said: “To break down the key issues and attribute any single one of them to an individual patient death would in itself lead to potentially identifying that person.”

The trust’s improving access to psychological therapies service assessed 11,839 people between October 2019 and September 2020.

It comes amid a series of separate investigations into concerns around the trust’s services.

Families and campaigners have been calling for a public inquiry into alleged “systematic failures” following the deaths of at least 14 patients under the trust’s care since 2016.

NHS England has commissioned an independent inquiry into the deaths of two of the patients — 17-year-olds Christie Harnett and Nadia Sharif — who died within two months of each other in 2019 at West Lane Hospital, where inpatient services previously run by TEWV were shut down by the Care Quality Commission.

There has also been a review into the trust’s affective disorder services in Stockton, following the suicide of one person who used the service in early 2020, which highlighted delays for patients trying to access treatment.

In March, the CQC downgraded five adult and intensive wards across three of TEWV’s hospitals to “inadequate”. The CQC criticised the trust’s leaders for failing to make sure staff could assess patient risk, and gave them a deadline in May to make sufficient improvements.

In a statement, TEWV said various improvements have been made to its IAPT services over the last six months, including increased capacity for initial assessment calls, adding that key waiting times have reduced.

It said families now have a greater input, while group support has been introduced for people waiting for individual therapy, and there are improved processes for maintaining contact with patients and reassessing risks.

The internal review highlighted that “every patient had a clear, robust safety plan in place with contingencies to manage increased risks should there be a deterioration”, the trust added.

Story updated at 11:37am, 15 April to reflect that six of the deaths which progressed to serious incident review were ’suspected’ suicides.