In September last year CHARM wrote to the Greater Manchester Integrated Care Partnership asking the leadership to commission an independent audit of preventable deaths (see letter here), similar to the one conducted in Norfolk and Suffolk commissioned by the Integrated Care Board in Norfolk & Suffolk, following a campaign by activists (see background below).
Our aim is to ensure transparency, accountability, and the co-production of an action plan to address the issue of preventable deaths in the City Region. As you will be aware the Trust is one of the highest recipients of PFD certificates in the country alongside Pennine Care and the GMICP. We are very concerned about what this means for the wider issue of other preventable deaths of people using services in Greater Manchester.
To address these concerns, we formed a working group that has met with the Norfolk and Suffolk Campaign re. PFD’s (they had conducted their own analysis that led to the independent audit).
Following this meeting we decided to carry out our own analysis based on the same criteria they used. This work has been completed and we have now analysed 34 coroners reports on preventable deaths by mental health service users. We found a clear growth in the numbers of people dying for avoidable reasons.
You can read the report here:
CHARM Technical Report on PFDs
Background
1. The Norfolk and Suffolk NHS Foundation Trust (NSFT) faced significant scrutiny regarding its handling of patient deaths. An independent review by Grant Thornton, covering April 2019 to October 2022, revealed that NSFT had recorded 8,440 deaths during this period but lacked detailed information on the circumstances surrounding many of these deaths. This absence of comprehensive data hindered the Trust’s ability to determine how many deaths were avoidable.
2. In response to these findings, NSFT acknowledged deficiencies in its mortality data collection and reporting processes. The Trust has committed to implementing improvements, including standardizing mortality reporting, developing data-sharing agreements with partner organisations, upgrading technology systems for better data integration, and establishing a Learning from Deaths Committee to oversee these initiatives.
3. The audit into preventable deaths at the Norfolk and Suffolk NHS Foundation Trust (NSFT) was significantly influenced by persistent efforts from mental health campaigners and bereaved families. These advocates highlighted systemic issues within the trust, including unsafe staffing levels, poor record-keeping, and inadequate responses to safety warnings. Their advocacy brought to light the trust’s failure to act on multiple Prevention of Future Deaths reports issued by coroners since 2013, which warned that more patients could die unless safety issues were addressed.
4. The independent review by Grant Thornton covered the period from April 2019 to October 2022. This review revealed that NSFT had recorded 8,440 deaths during this timeframe but lacked detailed information on the circumstances surrounding many of these deaths, hindering the trust’s ability to determine how many were avoidable. The findings from this audit underscored the critical importance of accurate data collection, transparent reporting, and robust governance within healthcare institutions to ensure patient safety and maintain public confidence.
5. Manchester generates the largest number of PFD reports outside of London https://preventabledeathstracker.net/reg-29-addressee-tracker-database/ Since 2003 GM Integrated Care Board etc has received 93 PFDs, 78 of these have been issued in the last 6 years. It has been issued with the 5th highest number of PFDs in the country. It is the first regional organisation after NHS, CQC, Dept of Health, HM Prisons and is listed above the Home O(ice. GMMH and Pennine Care are listed in the top 30 of recipients (19th and 21st). Pennine care have been issued with 40 PFDs, 29 of these in the last 6 years. GMMH have been issued with 36 PFDs, 25 of these in the last 6 years.
