Independent review of mortality – Norfolk and Suffolk NHS Foundation Trust

An independent review which examined the reporting of patient deaths at the Norfolk and Suffolk NHS Foundation Trust (NSFT), was published in June 2023.

The briefing below provides an update to this.

18 January 2024: Update on actions being taken in response to the review of mortality recording and reporting at Norfolk and Suffolk NHS Foundation Trust

On 18 January 2024, the Norfolk Health Overview and Scrutiny Committee (page 41 onwards) will discuss an update in relation to actions being taken following publication of the review of mortality recording and reporting in mental health services in Norfolk and Suffolk (June 2023). The same report will also be discussed in public at the Suffolk Health Overview and Scrutiny Committee on Wednesday 24 January 2024.

The update has been developed collaboratively by, Norfolk and Suffolk NHS Foundation Trust (NSFT), NHS Norfolk and Waveney Integrated Care Board (N&W ICB) and, NHS Suffolk and North East Essex Integrated Care Board (SNEE ICB).

Both ICBs continue to work very closely with NSFT, along with NHS England, providing support to ensure the recommendations and associated actions are completed.


In September 2022, Grant Thornton UK LLP were commissioned to undertake the review, following a procurement process. The 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, assessing mortality reporting at NSFT between April 2019 and October 2022.

It was not designed to investigate the circumstances of individual deaths or to compare the levels of mortality reported by or related to NSFT with other NHS trusts in the UK. The review report, along with a detailed action plan was published on 28 June 2023.

Caroline Aldridge, Anne Humphrys, and Emma Corlett published a comprehensive response to the mortality review report, ‘Forever Gone: Losing Count of Patient Deaths’ on 7 July 2023.

The response was subsequently presented to both ICB Boards and the NSFT Board in July 2023. A collaborative working group was established based on the key principles of co-production, which included membership from both ICBs, NSFT, Norfolk and Suffolk Healthwatch, and the authors of ‘Forever Gone: Losing Count of Patient Deaths’.

Progress made against the actions and timescales set out in the action plan

There has been a significant amount of work undertaken since the action plan was published and progress is being made. We are very grateful to the input from all parties. To improve NSFT management and reporting of mortality data, NSFT have developed a new system, which comprises two key components:

  • A Microsoft SharePoint list, which holds data on all patient deaths that have occurred during care at NSFT or within 6 months of discharge from NSFT services
  • A Microsoft PowerBI dashboard which displays the patient data and allows users to view the information according to a range of different perspectives, such as age, gender and ethnicity.

Work started on this new process in April 2023, and it was made live on the 6 November 2023 (covering deaths notified after the 1 November) and addresses many of the recommendations found in the review.

A before and after comparison is shown below, highlighting the benefits of the new approach.

Old mortality recording and reporting process

Diagram of the old mortality recording and reporting process

New mortality recording and reporting process

Diagram of the new mortality recording and reporting process

OldNewBenefit of process change
Mainly manual processLargely automated processReduced risk of transcription error
Time saving for staff in collating information
Deaths entered manually will be visible in our PowerBI dashboard the next day
Two sources of dataMultiple sources of dataA more complete and accurate set of mortality data
Run monthlyRun dailyMore regular and up-to-date reporting
Missing information can be quickly identified, and clinical systems updated overnight
Data in different placesData within a single placeEasier to manage
Mortality data can be combined with other sources for greater insight
Manual reportingAutomated reportingA single consistent reporting source (Power BI)
Time saving for staff to create reports
Greater accuracy of reporting
Potential for more interactive and insightful reports
Limited process documentationStandard Operating ProceduresAgreed approach and accountability
Enables complete overview of Trust’s end to end Mortality process
Limited audit controlAudit controlGood governance and visibility of all changes that are made

NSFT has also appointed Gary O’Hare, an experienced Board Chief Nurse and Chief Operating Officer who is supporting with improvements to patient safety and governance across the Trust. Gary’s experience and focus will ensure improvements are made, embedded and sustained within this important area.

There are three principal areas where actions continue beyond the initial date of delivery within the action plan:

  • Completion of the PowerBI dashboard. The dashboard is in place and functioning as expected, however we expect that there may be changes to the way the data is presented as part of the final sign-off of the new reporting mechanism.
  • Standard Operating Procedures (SOP) have been created for each area of the process, and a draft over-arching SOP that places each within the end-to-end process. Some minor changes are needed as part of the early life support of the new system and then the over- arching SOP can be signed off.
  • External verification (action 16) has not yet been sought as the new system is still in early life support. The intention is for the new system to be reviewed as part of the Trust’s Internal Audit schedule for 24/25.

The action plan was last updated on the 20 December 2023 by the Action Plan Programme Management Board (a copy of this is included with the papers for both the Norfolk and Suffolk HOSC meetings). The table includes progress to date, any outstanding actions, rationale for any delays and proposed completion dates.

Next Steps

The work of the Collaborative Working Group, which formed immediately after Boards heard directly from the authors of the Forever Gone report is to be commended for its commitment and focus on service improvement.

The Trust has established a new Learning from Deaths Action Plan Management Group which will replace the current internal executive led Action Plan Programme Management Board. In addition, the important discussions of the Collaborative Working Group will feed into the work of the new Trust Learning from Deaths Action Plan Management Group.

The group will have a significantly increased membership which will include NSFT Executives, service users, carers, including bereaved relatives, who will be recruited through existing NSFT networks, SNEE and N&W ICB Quality/Safety Representatives, both Healthwatch organisations and Public Health leads from the respective Local Authorities.

The Group will provide the governance framework for the reporting of progress to the NSFT CEO/Management Group, The Trusts Quality Committee, and through it, the Board as well as to the Quality Committees and Boards of the two ICBs.

Previous updates