Jane Bush

Private and Confidential  
Ms J Lake 
Senior Coroner for Norfolk 
Norfolk Coroner Service 
County Hall 
Martineau Lane 
Norwich 
NR1 2DH 

Dear Ms Lake 

Trust Management 
1st Floor Admin 
Hellesdon Hospital 
Drayton High Road 
Hellesdon 
Norwich 
NR6 5BE 

14 December 2021 

I write in response to the Prevention of Future Deaths received following the tragic death of Mary Bush 
in August 2020. I know that you will be sharing this response with Mary’s family and I would like to take 
this opportunity to express to her family again how very sorry we are for the loss of Mary. 

I have shared your concerns with our children’s, families and young people’s leadership and wider team. 
I have collated below the response to each point with the actions we have taken already, and future 
actions to strengthen our offer to young people across the age range. 

1.  Mary was referred to the mental health team in November 2019 and was assessed in January 2020, 

some three weeks later than should have been.  

The demand for specialist mental healthcare from the Children’s, Families and Young Persons Service 
(CFYP) remains high and is increasing during the pandemic. The week ending 10th December saw a 
25% rise in the number of accepted referrals; Norfolk and Suffolk have the highest referral rate into 
CFYP services nationally (NHS Benchmarking Network). The waiting time between referral and 
assessment for routine cases is longer than the Trust’s target of 28 days. Exceeding the target wait to 
assessment is not service-wide.  

Several teams in the CFYP Care Group are assessing referrals within the targeted waiting times but two 
teams are not. The Central Youth Team has problems meeting the target and so is part of a waitlist 
initiative to increase capacity of the clinicians and reduce the number of those waiting for assessment 
and waiting for treatment. Assessment capacity has been increased by supplementing existing clinicians 
with clinicians recruited from a private agency. Two agency nurses have been working on assessments 
and their contracts are being extended through until May 2022 to continue to address the demand.  

2.  There was a delay in Mary receiving psychological therapy. She was still on the waiting list at the 

time of her death.  

The backlog of children and young people who are awaiting treatment has been a concern for some time 
and continues to be the focus of our efforts. Again, the Central Youth Team has the largest waiting list.  
Third sector partners, MAP, Ormiston Families, and the YMCA all have capacity and have agreed to 
work with some of those waiting for treatment. For those young people waiting for specific treatment, 
such as therapies, the teams are looking to address this by exploring options such as employing 
Assistant Psychologists to provide brief interventions including managing emotions and anxiety or 
providing webinars available to young people at their convenience. 

CFYP successfully bid for funding to resource a project that will develop an online service we can offer 
service users. Digital packages have been used successfully by other NHS Trusts such as those  

Working together for 
better mental health 

Trust HQs: Hellesdon Hospital, Drayton High Road, Norwich NR6 5BE 
                  Endeavour House, 8 Russell Rd, Ipswich IP1 2BX 

  www.nsft.nhs.uk 

 
 
    
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Ms Lake re MB 

 - 2 - 

researched and trialled by Cambridge and Peterborough NHS Foundation Trust. We are learning from 
them as we develop our provision of digital interventions including applications such as 1:1 therapy 
(25yrs and under), also computer ‘games’ which target childhood anxieties (7-11yrs) and provide 
Cognitive Behaviour Therapy (12yrs plus). 

3.  The evidence was that at the date of inquest, there continued to be a delay in service users receiving 

psychological therapy. Evidence was heard that balancing capacity and demand, which has 
increased, remains a challenge.The cases referred are of increasing complexity, as in Mary’s case.  

and  
4.  Some steps have been taken in an effort to deal with this, such as specific risk assessment  

training, focusing on intervention treatment plans to aid capacity and throughput, reviewing the skill 
mix of staff.  

The CFYP Care Group embarked on a service development strategy that is seeking to address the 
ongoing demand versus capacity imbalance. Work has been completed to establish the demand and 
capacity imbalance and a business case was submitted to the Norfolk and Waveney Clinical 
Commissioning Group (CCG) in June 2021. The CCG has now agreed, December 2021, the  
additional funding to recruit six additional staff to the Central Youth Team. Interviewing to those posts  
is in progress.   

To improve staff retention, the demand and capacity project included the development of job plans for all 
staff, skill mix review and needs analysis for training. This project has already improved staff morale and 
is likely to improve recruitment and retention in the future.  

The Trust has secured funding for Clinical Associate Psychologists, four of which will be joining the 
Norfolk youth team. It is hoped that this initiative will be extended into the children’s team if supported 
through the University of East Anglia who would be providing the training needed. 

5.  However, there is the ongoing issue of recruitment and retention of suitably skilled staff by the Trust 

and the ability to resource this to enable the Trust to function effectively. 

There is a national recruitment problem for mental health services. We have changed the way that we 
attract new staff, adverts are written specifically to emphasise the opportunity for development and 
innovation which is ongoing within the service line. This is to encourage and attract the staff we need to 
support our vision for improvement. We have added relocation incentives to all our difficult to recruit 
posts as locality does appear to be a barrier for some. We are also offering remote and/or hybrid 
working where appropriate for the service. 

The national expansion of mental health training provision is very welcome but is not an instant solution 
as the training takes time and demands a high level of supervision offer from existing qualified staff. To 
support the pace of expansion while still addressing our unmet need for service users, CFYP has 
recruited senior nurses and a Clinical Nurse Specialist to support the service development. Interviews to 
recruit to two Consultant Clinical Psychologist posts will take place on 20th December 2021. All senior 
staff recruited will work with service users and expand the skills mix available in teams.  

I hope that these actions provide reassurance that the Trust is doing all that it can to improve our 
response to the demand for children’s and young people’s mental health services. We, as part of the 
wider integrated care system, continue to review and revise our approach to meeting the needs of the 
county’s young people as a partnership. 

Yours sincerely, 

Chief Executive 

Working together for 
better mental health 

Trust HQs: Hellesdon Hospital, Drayton High Road, Norwich NR6 5BE 
                  Endeavour House, 8 Russell Rd, Ipswich IP1 2BX 

  www.nsft.nhs.uk