Norfolk & Suffolk trust records its highest number of unexpected mental health deaths
An NHS mental health service, which was the first in England to be placed in special measures, has recorded its highest number of unexpected deaths.
Norfolk & Suffolk Foundation Trust (NSFT) recorded 157 deaths in 2015-16, compared to 88 deaths in 2012-13.
Verita, which the trust instructed to carry out the investigation, said NSFT was not doing enough to establish why the deaths were happening.
NSFT said any recommendations were "already, or will be, acted upon".
'One too many'
The trust commissioned the report after existing statistics showed it had a higher number of deaths than other mental health trusts in the UK.
Figures for previous years included 105 deaths in 2013-14, but Verita said data collection was not standardised across the UK, which meant there was "limited means for making meaningful comparisons" about death rates.
It concluded: "Overall the trust's investigation process meets national requirements, but analysis or wider exploration of service and care management problems could be improved."
It also recommended improvements were made to the consistency of internal reports into each death, support and engagement with bereaved families should be improved and there needed to be better evidence that the trust's board had discussed each unexpected death.
Michael Scott, NSFT chief executive, said: "The safety of our service users is paramount and one avoidable death is one too many - that is why we commissioned this investigation."
A parallel report carried out by NHS England's Nursing and Quality Directorate concluded that since April 2015 NSFT had reported deaths in line with the new NHS Serious Incident framework and "investigated in a timely and appropriate manner".
The trust was placed in special measures by the Care Quality Commission in February 2015.