Costessey deaths show need for inquiry into local NHS trust, say families | Norfolk

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The families of people who have died in the care of Norfolk and Suffolk mental health services have said the tragic case of a man believed to have killed himself and his family underlines the need for a statutory inquiry into the NHS trust.

Bartlomiej Kuczynski, 45, was found dead in his home in Costessey near Norwich along with his two daughters and their aunt, earlier this month. Just over an hour before he had made a 999 call expressing alarm about his mental state, and was told to seek medical help.

Norfolk and Suffolk NHS foundation trust (NSFT) has confirmed it had prior contact with Kuczynski before the killings. The trust was already being scrutinised over the unexpected deaths of 8,440 of patients or former patients in a three-and-a-half-year period.

In a statement, the trust said Kuczynski “was already known to our services” when he was taken to the Norfolk and Norwich hospital by police on 14 December. By the time a mental health specialist from the trust arrived to assess Kucyznski, he had already discharged himself.

NSFT has launched an “externally-led serious incident review” into its contact with Kuczynski.

The Campaign to Save Mental Health Services in Norfolk and Suffolk, whose members include people who have family members who killed themselves while under NSFT care, said the Costessey deaths highlighted the need for the trust to be disbanded and replaced and its failures to be subject to a statutory inquiry.

Its chair, Mark Harrison, said that the killings showed the system was not working: “We need change immediately because people are still dying.

“NSFT doesn’t have effective community services. It doesn’t have an assertive outreach approach, and the crisis team is not fit for purpose. All the things that would have supported him [Kuczynski] to live in the community safely, aren’t there because they got rid of them.”

The group, which was founded in 2013, claims to be the largest grassroots local mental health campaign in the UK, representing staff, service users and thousands of people who have lost loved ones in the care of the trust.

Harrison said the trust’s failures were rooted in budget cuts. He said: “It goes back to the austerity programme from 2010. They got rid of all the services that supported people in acute mental distress to live in the community.”

Harrison said he was wary of a trust-led review into its contact with Kuczynski. He said: “The worrying thing is that NSHT are going to lead their own inquiry, ie mark their own homework. I wouldn’t trust that.”

He contrasted the way Norfolk constabulary was being scrutinised by the Independent Office for Police Conduct over the incident after the force referred itself to the watchdog. “Where’s the external watchdog for the NSFT?” he asked.

The campaign is also alarmed by a decision by the police to stop attending emergency mental health calls, under an initiative known as “right care, right person” (RCRP). The approach has been championed by the Metropolitan police commissioner, Mark Rowley, who argues officers have been diverted from their core role of fighting crime.

Norfolk constabulary has been training staff on the policy since last summer, before a delayed planned formal launch next month.

Harrison said the force’s failure to attend Kuczynski’s home after his 999 call, and its advice to him to seek medical help, demonstrated the dangers of the policy.

He said: “The Costessey murders underline the recklessness of RCRP. Handing off people who are in acute mental distress ends up with people dying.”

On Monday the campaign called for RCRP to be “halted immediately” in a letter sent to Norfolk’s chief constable, Paul Sandford. It said: “We have serious concerns for the safety of our communities in the current climate of mental health provision in Norfolk and Suffolk. We fear that services in our areas are presently not robust enough to deal and manage any new change effectively without additional harm.”

It added: “It is clear that NSFT and other services are struggling to manage cases right now with well established policies and procedures. We believe that any change and additional strains on existing mental health services can only escalate and aggravate those in crisis.”

The letter described the trust as “one of the worst, if not the worst in the UK”.

NSFT had been rated “inadequate” by the Care Quality Commission (CQC) four times in the last eight years. But in its latest inspection it was moved up to “requires improvement”.

On Tuesday, a committee of Norfolk county councillors who oversee NSFT backed the campaign’s call for a statutory inquiry into the way deaths were reported and recorded at the trust. In a letter to the health secretary, Victoria Atkins, the committee expressed “continuing concerns” about its services and requested another CQC inspection.

NSFT has been approached for comment.