Vulnerable man was failed by two NHS trusts days before he died, finds watchdog

A man who had expressed suicidal thoughts was failed by two NHS trusts in the days before he was found dead in a river, an investigation by the health service ombudsman has found.

Stephen Foster, 48, was found dead on 23 June 2011. Today, the ombudsman published the findings of an investigation into the care he received in the days before his death. The ombudsman launched the probe after being contacted by Foster’s partner, Trezza Azzopardi,  who has accused one of the trusts involved of “arrogant, dismissive and shambolic” behaviour.

The case

Days before his body was found, Foster went to Norfolk and Norwich University Hospitals NHS Foundation Trust with Azzopardi because he was feeling suicidal. He was admitted as an acute patient but was left on the ward for more than 16 hours without adequate support.

When he was eventually assessed by a doctor, Foster was then forced to wait all night to be seen by a crisis team from Norfolk and Suffolk NHS Foundation Trust – the region’s mental health provider – despite several phone calls to the team. He was assessed by a mental health nurse from the crisis team at 9am the following morning. He was discharged and told to visit his GP surgery to request counselling. He was found dead three days later. An inquest reached a narrative verdict.

The ombudsman’s findings

The ombudsman found that the initial care provided by the acute trust was “inadequate”. However, the decision not to detain him under the Mental Health Act was reasonable. The failure of the mental health trust’s crisis team to attend and assess Foster promptly was “unreasonable” and the eventual assessment and discharge completed by the nurse was not comprehensive, the investigation found.

Ms Azzopardi said: “Norfolk and Norwich Hospital Trust’s behaviour has been arrogant, dismissive and shambolic. They have compounded my distress by their complete lack of respect for me or my partner.

“They would have continued to ignore me if not for the fact that I contacted the ombudsman service. In its findings, the ombudsman service has vindicated me in my belief that the trusts had failed my partner and myself.”

Julie Mellor, the parliamentary and health service ombudsman, said that the trusts should apologise to Ms Azzopardi and submit action plans showing how they would meet their obligations under the government’s mental health crisis care concordat.

“It is unacceptable that a vulnerable man received such little support when he so desperately needed it. A bit more time, care and attention by the Trusts may have resulted in a different outcome for him,” she said.

The trusts’ reaction

Debbie White, director of operations at Norfolk and Suffolk NHS Foundation Trust, said that “significant investments” had been made to improve psychiatric liaison services since 2011.

“Last April, Norfolk also became the first county nationally to sign up to the government’s mental health crisis care concordat. We have met Ms Azzopardi to offer our sincere apologies and to underline our commitment to learn the lessons.”

In a statement, Norfolk and Norwich Hospital Trust said: “This is a case from 2011. The patient came to A&E on a Sunday afternoon having had suicidal thoughts for several days.

“Following initial nursing assessment, within three hours he was assessed by a doctor in A&E and an immediate referral was made to the mental health team at Norfolk and Suffolk Foundation Trust (NSFT). He was admitted to the hospital as a voluntary patient whilst he waited to be seen. Unfortunately the mental health team were not able to see the patient until the following morning. When they did, they found that he did not need to stay in hospital. He was advised to see his GP and to seek counselling for the emotional difficulties he was experiencing.

“Sadly the patient was found dead several days later. The Coroner did not find that the patient had committed suicide and it is agreed that the decision that he did not require detention under the Mental Health Act was reasonable.

“It is regrettable that the patient had to wait overnight to be seen by the mental health team. A&E and the acute hospital is not the ideal environment for patients with mental health needs and we support the target to which NSFT is aspiring that 90% of mental health patients in A&E should be seen by its experts within an hour of referral.

“Like other acute hospitals, this Trust does not offer specialist mental health services or employ psychiatrists. This service is provided by the Norfolk and Suffolk NHS Foundation Trust.”

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