Independent review published on mortality reporting and recording at the Norfolk and Suffolk NHS Foundation Trust

28th June 2023

An independent review which examined the reporting of patient deaths at the Norfolk and Suffolk NHS Foundation Trust (NSFT), has today been published.

The review – Norfolk and Suffolk Foundation Trust’s Mortality Recording and Reporting – was undertaken by Grant Thornton on behalf of the NHS Suffolk and North East Essex and NHS Norfolk and Waveney integrated care boards (ICBs) at NSFT’s request to understand how the trust collects, processes and reports data relating to mortality.

This work reviewed mortality data recording and reporting at the trust between April 2019 and October 2022.

Ed Garratt and Tracey Bleakley, chief executives of the NHS Suffolk and North East Essex and NHS Norfolk and Waveney ICBs respectively, said: “On behalf of all system partners, our thoughts are with those family and friends who have lost their loved ones and may feel distressed by this review.

“The review was commissioned with the full cooperation of the Norfolk and Suffolk Foundation Trust to ensure that we can improve the collection, processing and reporting of data that related to people being cared for by the trust as an inpatient and in community settings and within six months of discharge. It shows very clearly that there are significant improvements required to be assured in future about the Trust’s mortality data.

“As local health and care systems, we will support the trust to make the necessary improvements, ensuring all actions from the detailed action plan are met.”

Ed and Tracey added: “This review was commissioned for a specific purpose, to provide an independent audit of the processes used by NSFT to collect and report data relating to mortality; it was not designed to investigate the circumstances of each individual’s death or to compare the levels of mortality reported by or related to NSFT with those in other parts of the country.”

Key findings included that NSFT has strong governance around the recording of all patient safety incident deaths, including suicides and that governance structures are in line with national requirements.

However, the review recommended that the reliability and trust in the data reported by NSFT would be improved by reducing the number of manual interventions of recording and reporting.

It also found that mortality data needs to have a clear, supervised, pathway throughout the trust with agreed formats of presentation.

The review added such issues have led to questions of clarity within public facing documents and reduced clinical relevance within the mortality information reported. This results in a lack of confidence of external stakeholders – including regulators and the public – in the data, and in the Trust’s understanding of it.

Going forward in implementing the necessary changes, the review recommended that NSFT will need to be supported by the ICB and the other healthcare organisations within the health system to make this information available.

Grant Thornton said its work across the NHS had shown that when data gets used its quality improves, meaning it more accurately reflects the patients treated.

It found the Trust has been working with NHS England since September 2022 to improve its processes, particularly in relation to mortality and added that governance structures in place at the trust are in line with national requirements.

In addition to the review, a detailed action plan has been published which includes core actions which will help strengthen and improve the quality of data reporting and management of data within NSFT.

Both NHS Suffolk and North East Essex and NHS Norfolk and Waveney ICBs will oversee delivery of this action plan and support NSFT as part of the wider mental health transformation programme.

The review and action plan will be presented to both ICBs’ board in July where a discussion will take place about the trust’s progress against these recommendations.


Notes to Editors

The review into NSFT’s mortality recording and reporting can be found here and the associated Action Plan can be found here.

For more information or to arrange an interview:

NHS Norfolk and Waveney Integrated Care Board (ICB) communications team via:

NHS Suffolk and North East Essex Integrated Care Board (ICB) communications team via: