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Missed opportunities: What lessons can be learned from failings at the North Essex Partnership University NHS Foundation Trust

Our recommendations

We have only seen part of what has happened at NEP through our own investigations, which have looked at incidents that took place at single points in a much longer timeline.

As a result, we are not best placed to look at the much broader issues of overall culture and leadership at the Trust over the ten year timeline which potentially stretches to several years before the death of Mr R depending on any findings made in the HSE investigation. But it is clear from CQC’s inspection reports that NEP’s acute adult inpatient services have not consistently demonstrated the learning culture and leadership that is essential to improving the quality and safety of care.

What we have seen through the two investigations we have carried out paints a worrying picture. We acknowledge that there is evidence that some improvements were taking place at the Trust over some of the past decade. This was highlighted by CQC in the warning notice it issued in 2016, when the then Chief Inspector of Hospitals noted that, even following the inspection that led to the warning notice being issued they, ‘could see that much work had been done since our visit in August 2015 and that there were a number of areas of good practice at the trust. The majority of patients gave positive feedback about their care’.  

Despite these improvements it is also inescapable that year after year there was a repeated failure to recognise the seriousness of the ongoing risks to the safety of people using NEP’s acute adult inpatient service. This is particularly true in relation to the assessment and management of risks for fixed ligature points and sharing the learning from mistakes with staff, as CQC’s inspection reports highlight.

In light of what had happened in the cases we have investigated and the learning from the other inquiries, investigations and reviews over the years, NEP should have become a beacon of good practice for the NHS. The Trust’s leadership should have been driving a culture of learning and improvement to address the serious problems that had been repeatedly highlighted to it and they should have been putting in place clear oversight of the changes that were needed to achieve this. 

It does not appear this was the case. Instead serious repeat failings at NEP were still being identified in CQC’s December 2016 inspection report. It appears that it was only when EPUT was created that a real grip of the issues began to emerge, many years after the deaths of Mr Leahy and Mr R. 

The recently published NHS Long Term Plan notes that, ‘while some parts of the NHS have created and sustained the leadership cultures necessary for outstanding performance and the big service changes set out in this Long Term Plan, this is not yet commonplace.’ In our view, there are questions to answer about why learning did not take place at NEP for so many years and how the leadership of the newly merged EPUT has now started to drive improvement. 

NHS Improvement is uniquely well-placed to lead a review to answer these questions. Having recently come together with NHS England to operate as a single organisation, NHS Improvement supports service improvement and transformation both across local healthcare systems and within individual providers. NHS Improvement also has a system leadership role for patient safety across the English NHS. As part of this activity, it is leading on the development of a patient safety strategy for the NHS, which identifies mental health as a priority area for reducing patient harm.

Learning from a review of patient safety, culture and leadership at NEP and EPUT would be invaluable not only for the Trust itself  and the patients, families and carers who use its services, but also for the wider NHS as it strives to strengthen the safety and quality of care for people with a mental health problem, and achieve equal status between mental and physical healthcare.

In addition to the recommendations we have made to remedy the injustices in the individual complaints we received, we also recommend that NHS Improvement should conduct a review of what went wrong at the North Essex Partnership University NHS Foundation Trust and establish what should have happened instead and the learning that can be taken from this. 

In making this recommendation we recognise that the HSE investigation is yet to be completed and we also understand that the local Clinical Commissioning Group 
(North East Essex) is planning to undertake a Commissioner-led review into these cases. It is important that NHS Improvement’s review is timely, does not duplicate other investigative work already underway and draws on the other completed reviews and investigations.

We therefore recommend that the review does not commence until the HSE investigation and any related activity is completed and that its Terms of Reference take into account the views of ourselves, CQC, the Trust and the families and carers affected, as well as HSE and Essex Police. It should also take account of the local Commissioner-led review’s Terms of Reference to avoid unnecessary duplication.  

We would expect NHS Improvement’s review to consider the key features that have led to the apparent improvements recognised by CQC from when the Essex Partnership University NHS Foundation Trust was created.

Any good practice that can be identified from the merger should be widely disseminated.  
It should also include an assessment of whether there is specific learning that could contribute to existing initiatives on mental health safety improvement, as identified in NHS Improvement’s own consultation on the NHS safety strategy, including the ambition to prevent all inpatient suicides.  

In addition to being shared with the Secretary of State for Health and Social Care, the families of the young men that died and NHS leaders, the review’s report and any recommendations should be made public. It should also be shared directly with the Chairs of the Public Administration and Constitutional Affairs Select Committee and the Health and Social Care Select Committee so that Parliament can consider whether any further scrutiny is necessary.  

We are also aware that there have been calls for a public inquiry into what happened at NEP, including from the complainants in the cases in this report. The review should consider whether the broader evidence it sees suggests that a public inquiry is necessary. If this is the case, the review should also make a recommendation in relation to this to the Secretary of State for Health and Social Care.