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recurance

Kerry Hunter

23 Apr 2019 · Coroner Nigel Parsley · Suffolk

A similar concern from this report was raised again 1 time later. See the linked reports.

The coroner's concerns

  1. 1. lack of effective treatment for Borderline Personality Disorder

    “since [the deceased]'s death the Norfolk and Suffolk Foundation Trust have conducted a review of their treatment provision for individuals suffering from Borderline Personality Disorder (BPD)”
  2. 2. restricted access to treatment for Borderline Personality Disorder

    “the proposed requirement in the Norfolk and Suffolk Foundation Trust plan (which will require a BPD suffer to agree to a transfer to an Integrated Delivery Team before being placed onto the new service) may prevent some patients gaining the access to the treatment they clearly need”

Linked reports

Raised again laterEllen Woolnough28 Mar 2024 · 4 years 11 months later
Closely relatedConfidence 0.70 · moderate

This report

“Under the proposed new system, in order to access the Norfolk and Suffolk Foundation Trust Borderline Personality Disorder service, those suffering from the condition would have to agree”

Later report

“The adequacy of Norfolk and Suffolk NHS Foundation Trust's (NSFT) Integrated Delivery Team (IDT) decision making concerning the discharge of a patient from mental health services in circumstances where a failed engagement has occurred.”
Original on judiciary.uk ↗
Full chain: Restricted access to treatment for borderline personality disorder

Responses

2019-0137-Response-by-Norfolk-and-Suffolk-NHS-Trust.pdf ↗· Norfolk and Suffolk NHS Foundation Trust

Stated action

“The plan for the new Personality Disorder Service involves eight elements: 1. Clinically-led personality disorder leadership team supporting a change in culture and clinical practice at a senior level modelling consistency, accountability and leadership.”

Stated action

“2. Improved access and assessment that involves a needs-based screening process which works alongside diagnostic criteria to ensure people access the part of the pathway which will deliver the most benefit and prevent unnecessary admissions to hospital.”

Stated action

“3. Specialist personality disorder therapy teams comprising nurses, psychologists, psychiatrists, occupational therapists and social workers within local teams, delivering targeted interventions to those with the most complex needs and providing advice & consultation to their colleagues and the wider system.”

Stated action

“4. A breadth of training ranging from Knowledge and Understanding Framework (KUF) training for all staff, through to full Dialectical Behaviour Therapy training for the specialist teams.”

Stated action

“5. 72 hour inpatient protocol providing purposeful, formulation-driven, recovery-focused care packages concentrated on self-regulation and discharge.”

Stated action

“6. Needs-based interventions involving a framework of delivery that works with diagnosis to enable better management of people with personality disorder in standard community and inpatient pathways.”

2019-0137-Response-from-Norfolk-and-Suffolk-NHS-Foundation-Trust.pdf ↗· Norfolk and Suffolk NHS Foundation Trust

Stated action · April 2024

“Through service user involvement, we are co-producing as much of our patient-facing information about our pathways and interventions as possible. We have”

Stated action

“The trust continues to roll out a comprehensive training programme for NSFT staff in relation to PD/CEN. The main training for staff is our Knowledge and Understanding Framework, which is entirely co-produced and co-delivered. We also have a two-day dialectical behaviour therapy (DBT) skills course which any member of staff can attend.”

Stated action

“STORM training includes specific training on safety planning, and our Dialog+ care planning tool is used to collaboratively create a safety plan for every adult and working age adult under our care. Our Youth teams have formed their own safety planning documentation which is co-produced with our young service users.”

Stated action

“We are currently developing a specific offer for older adults with complex emotional need, supported by specific training.”

Stated action · April 2024

“We are currently reviewing our personality disorders and complex emotional need (PD/CEN) strategy for release in April 2024 after service user and carer consultation.”

Stated action

“We are recruiting to one specialist post to provide for people with these comorbidities in South and West Norfolk, and we have set up a working group in psychology to guide us as to evidence and Trust HQ: County Hall, Martineau Lane, Norwich, NR1 2DH Web: www.nsft.nhs.uk - 3 - best practice in relation to modifying our therapeutic offer.”
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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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