Sister's disappointment after inspectors found factors contributing to death of Norwich man Neil Jewell continued at mental health trust
PUBLISHED: 09:43 03 November 2017 | UPDATED: 16:13 05 November 2017
The family of a man who died under the care of the region's mental health trust say they are devastated failings in the way he was cared for appear to have continued since his death.
Norfolk and Suffolk Foundation Trust’s then-chief executive Michael Scott assured Christine Welfare that changes would be made following the death of her brother Neil Jewell, 42, of Philadelphia Lane, Norwich, on January 17 2014.
An inquest in April found failings in the way Mr Jewell - who was sectioned under the NSFT - was cared for, including how he was observed after being tranquillised.
Despite being assured changes would be made, Mrs Welfare said the latest report into the trust - which put it back into special measures - showed no such improvements.
An NSFT spokesman said work is “already well underway to address each and every issue raised” and that part of its urgent action plan is to ensure improvements are made consistently across the trust.
Mrs Welfare, who lives in Aylsham with husband Edward, said: “I was really devastated to read the report, especially with regard to the continuing unsafe restraint, tranquilisation and seclusion. It really makes me feel physically sick inside to know that these poor vulnerable people are being treated in this way. The report goes on to mention that food and water and medical checks are still not being done. Surely this contravenes a person’s human rights, as I still believe my brother’s were.”
Mr Jewell was diagnosed with paranoid schizophrenia in his late teens/early 20s.
Mrs Welfare raised a number of issues with how her brother was looked after over the years. But in January 2014 a combination of factors saw him sectioned.
He was taken to West Suffolk hospital, and then to Ipswich Hospital, laid face down on an ambulance stretcher with his arms and legs restrained. He was placed in a seclusion room at Ipswich Hospital’s Woodlands Unit.
Mrs Welfare said: “Neil had been successively rapidly tranquillised, locked in seclusion throughout the night without access to water, and left lying face down on a mattress on the floor, as it was felt he needed to sleep.”
It was only on January 12, when the duty nurse became aware Mr Jewell had not moved from his face down position for more than 10 minutes, that they entered the room, as observations had been carried out over CCTV.
When they turned him over he was unresponsive. And by the time a crash team arrived and managed to restore Mr Jewell’s heart beat, he had been left too long without oxygen to his brain.
In the most recent Care Quality Commission report, inspectors said: “Restrictive practices, particularly seclusion, long term segregation and rapid tranquilisation [at NSFT] particularly in acute services must be reduced.”
They added: “Physical health checks required following rapid tranquilisation had not been undertaken as required.”
Trust figures showed in the 12 months to March 2017, restraint was used on 2,350 occasions, 538 of these were face down. This was down by 4pc since the last inspection but remained high.
Rapid tranquilisation was used on 564 times during the same period, a “significant increase” since the last inspection.
Mrs Welfare said: “When my husband and I met with Michael Scott and Jane Sayer after Neil’s inquest, they talked about going ‘back to basics’ then, as nursing had been in Michael’s early career.
“Staffing and finance is a huge and ongoing issue - on the one hand the government says the NHS has been given the resources, but obviously how it is divided out does not have a parity with a hospital’s needs.
“We were assured that the new IT system would provide the much needed support and ensure continuity, particularly when patients are transferred out of area. This too seems to be failing and not adequate.
“How much money was wasted on this? What research was done initially in sourcing this system?”
She added: “At the conclusion of Neil’s inquest, the coroner, Dr Peter Dean, wrote to the trust specifically with regard to training, rapid tranquilisation and medical checks for patients in seclusion. How can these ongoing issues be acceptable? Why did it take the CQC to point this out when it was a specific area we were assured was being addressed?”
“All staff working in the trust do an amazing job and are passionate about it, but you cannot build on shaky foundations.
“The government really needs to look at its strategy - it can change its thinking and it’s never too late to change and look at how things could work well again if they went back to basics too. Patients and their families have been badly let down once again.”
An NSFT spokesman said: “This was an extremely sad situation in 2014, and the patient’s family and friends have our deepest sympathy.
“We did take on board the recommendations of the coroner and we unreservedly apologised to the family. The care provided was not acceptable and is not the standard of care we would offer to patients in our services today.
“The trust’s board actioned an urgent response to the findings in the recent CQC report. Work is already well underway to address each and every issue raised. Improvements have previously been made, and part of our urgent action plan is to ensure that those improvements have been made consistently across the whole of our trust and new ways of working are fully embedded. We are determined to ensure that our mental health services continue to improve in what we all recognise as an increasingly demanding environment in the NHS and in social care.”