Mental health patient hanged themselves in Norfolk inpatient unit

PUBLISHED: 09:13 24 January 2018 | UPDATED: 09:35 24 January 2018

Mental health. Pictured: A young man experiencing depression sits by a window. Picture: Newscast Online

Mental health. Pictured: A young man experiencing depression sits by a window. Picture: Newscast Online


A patient is believed to have hanged themselves at a psychiatric ward in Norfolk despite the mental health trust being ordered to remove all points which would make it possible.

Julie Cave, Norfolk and Suffolk NHS Foundation Trust (NSFT) chief executive. Photo: NSFT Julie Cave, Norfolk and Suffolk NHS Foundation Trust (NSFT) chief executive. Photo: NSFT

Norfolk and Suffolk Foundation Trust’s (NSFT) associate director of operations Ian Young told colleagues at a meeting last month there had been a death on a ward at a medium secure unit on November 29, 2017.

And although an inquest had not yet been held, minutes of the meeting said: “it appeared to be related to the use of a ligature”.

The trust was told it had to remove all ligature points in its most recent inspection by the Care Quality Commission (CQC), where it was placed into special measures.

A ligature point is anything which could be used to attach a cord, rope or other material.

And the CQC said three-quarters of people who kill themselves while of a psychiatric ward do so in this manner.

NSFT were told by inspectors that “since 2014, there had been an inconsistent approach to ligature point management at the trust”.

Since 2016 the trust had identified 1,004 ligature points, which were fixed at a cost of £2.2m.

A further 287 points will be fixed by April, at a cost of £800,000. And by the end of March points in the community areas will also be remedied, at a cost of £400,000.

NSFT chief executive Julie Cave said: “Due to patient confidentiality, and as this matter will be heard at an inquest, it is not appropriate for our trust to comment any further on the sad death of this service user. However, naturally, our thoughts are with their family and we offer our sincere condolences for their loss.

“The aim remains clear, to make our buildings as safe as we possibly can for our service users. No trust could honestly claim it can remove every ligature point. So where ligature risks remain our staff are made fully aware of these and are supported to manage the environment safely to protect our patients.

“Teams are also made aware of any service users who may be at particular risk of self-harming through ligaturing, so they can be appropriately monitored to help protect them as much as possible.

“Having these clear processes embedded in our teams, and testing them every step of the way, is how we will achieve what we need to and every effort is being made to keep the risks to a minimum.”

The Samaritans are available to talk 24 hours a day by calling 116 123.

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