Posted by A consultant neurologist whose brother died after a series of failures by an NHS mental health trust has warned there will be more avoidable deaths without fundamental reform of psychiatric care.
Dr Katie Sidle’s concerns about the refusal of Norfolk and Suffolk foundation trust (NSFT) to give her brother Christopher, who was psychotic, a crisis admission were repeatedly ignored in the days and weeks before his death last July, a coroner found this month.
“It’s dangerous – there is no doubt that unless they make major changes there will be more deaths,” Sidle, who specialises in neurological conditions that often present as psychosis, told the Guardian. “I could not have been more informed about his condition and history, and yet I couldn’t get help for my brother.”
The evidence at the inquest suggested Christopher’s case fell through gaps between the trust’s community and crisis team. The coroner highlighted a number of missed opportunities to save him, including “inadequate” assessments, uncirculated emails, failures to recognise his well-documented ability to mask symptoms and the insufficiency of telephone monitoring to ensure he took his medication.
Christopher was repeatedly refused help because he was assessed as capable of taking his own medication despite a history of not doing so.
The hearings convinced Sidle to back calls for a public inquiry into the trust, which has been in and out of special measures since swingeing budget cuts in 2013. An audit report last year found that between April 2019 and October 2022 there were 8,440 unexpected deaths of patients who were in the trust’s care or had been in the previous six months.
Sidle said: “Before the inquest I thought the trust might be capable of changing, but now I have no doubt this will only be solved by a public inquiry.” She said serving staff at the trust had privately told her they agreed with the need for an inquiry.
Sidle was closely involved in successfully medicating her brother, a former climate change adviser from North Walsham, in Norfolk, for several years before he relapsed last year. She is now keen to help with any future inquiry and is seeking a meeting with health ministers to raise her concerns.
On the day her brother died, Sidle, a consultant at two London teaching hospitals, insisted the trust archive recordings of desperate calls she made to a newly qualified nurse who refused to admit her brother. “I knew those calls were important and that it was possible they would get deleted,” she said. Coroners have previously criticised the trust for deleting or altering key evidence about patients’ deaths.
In a transcript of one harrowing call read to Norfolk coroner’s court, Sidle pointed out that her brother was “acutely psychotic” and on countdown after claiming he had three days to live. On Friday 29 June she told the nurse: “Sunday [1 July] will be day zero, I’ve no idea what he [Christopher] will do but I’m worried it will be pretty catastrophic.” On that Sunday Christopher, 51, threw himself from a taxi; he died from his injuries four days later.
The nurse, on his first unsupervised assessment, had refused to reassess Christopher and told Sidle that no beds were available. In despair, Sidle emailed another nurse from the trust’s community team to express her extreme concern, but that email was not passed on. The last psychiatrist to see Christopher also raised “extreme concern” with her manager about the trust’s refusal to admit Christopher, but it too late to save him.
Despite the fatal mistakes in her brother’s care, Sidle showed compassion to the staff who gave evidence at the inquest by thanking them for their honesty and even hugging one of those involved. “I forgave all those people because they are also victims of a dysfunctional system. And Christopher would have wanted that,” she said.
It is the dysfunctional system that she cannot forgive and that she is determined to change. In her evidence to the coroner, Sidle complained of a “culture of complicitness” where patient assessments were “corrupted” by knowledge of the trust’s lack of resources, particularly beds. “Fitting patient assessment to availability of resources continues to mask an urgent need for significant increase in resources to acute psychiatric services,” she wrote.
She is also alarmed by a “nurse-led” model of care that enshrines patient liberty and patients’ “rights to make bad decisions” – a phrase that was quoted to her by a member of the crisis team. She said this ran counter to the medical ethos of “first do no harm”.
“Allowing patients to make bad choices and not take medication is doing an immense amount of harm,” Sidle said. “One of the diagnostic criteria for psychosis is you don’t recognise you’re ill – so how can you make decisions about whether you want treatment?”
She pointed to recent scientific papers that liken psychosis to a “stroke of the mind” and say it will degrade the brain if left untreated. “It’s absolutely ludicrous to have a system where you allow patients to deteriorate to the point they get acutely psychotic, and then you have no beds because such patients often require months in hospital,” she said.
Sidle said patients with psychosis should be given drugs every three months in so-called depot injections, which release medication slowly over time. These injections, which were denied to her brother, avoid mood peaks and troughs associated with oral tablets and ensure drugs are always taken. “If you give depots you reduce the number of patients becoming chronically psychotic,” she said.
Sidle claimed catching the disease earlier would avoid the public sector costs associated with managing disruptive mental health patients. She added: “My pitch to ministers is that you could actually make people better and save money – that rarely happens in healthcare.”
Cath Byford, NSFT’s deputy chief executive, said the trust was on a “rapid and much-needed journey of improvement” and was committed to working with Sidle to help it learn and improve.
She said: “We have previously outlined the actions we have taken since Christopher’s death, including further training for our staff, redesigning our triage tool and patient history recording systems to ensure our staff deliver the best care they can for our service users.”