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Campaigners have taken their fight for a public inquiry into a failing mental health trust to Parliament.
Bereaved relatives of those who died while in the care of the Norfolk and Suffolk NHS Foundation Trust (NSFT) are calling for the Government to step in.
They are demanding to know how many patients have died since a "radical redesign" of the trust's services in 2013 and they want an independent statutory public inquiry to investigate why the system is failing.
It comes after the trust was slammed by the health watchdog earlier this year. The Care Quality Commission rated it inadequate and served it with a "warning notice" to improve.
Inspectors found services were not safe, effective or well-led.
They said staffing levels were often unsafe, waiting lists were long and not managed properly and patient records were inaccurate.
The CQC’s report said that 115 “unexpected or potentially avoidable deaths” were reported between September 1, 2019 and September 30, 2021.
The trust has published an improvement plan and says it is determined to make progress.
But bereaved parents, including Caroline Aldridge, say urgent action is needed. Her son, Tim, died in 2014 when he was 30.
For years he had struggled to get the right help from the trust, even though his mother worked there.
Mrs Aldridge said: "I lived with this fear that there would be a knock at the door and someone would tell me he had died.
"Even though I worked for the trust and I was part of the system, I still couldn't seem to work out how it was that someone like Tim could get the help he needed.
"Police knocked on the door at half past six one morning. I just knew straight away that this was what I'd been dreading.
"But nothing prepares you for it. Nothing prepared me for the shock. Nothing prepared me for how much I just miss him."
Stuart Richardson, Chief Executive of the trust, said: "We know we need to do more for people who are waiting for our services.
"We are continuing to work closely with our patients, service users, staff and partners to drive sustainable improvements and build strong foundations for the future.
"We are focusing on five key areas – safety, timely access, engaging with staff, governance and leadership and changing services to meet people’s needs – so that we can make sure everyone in Norfolk and Suffolk receives the mental health services they deserve."
Mrs Aldridge has written a book about her son's struggle to navigate the mental health system. It's called 'He Died Waiting'.
"Any of us could become unwell at any time and need (mental health) services," she said.
"I look at my grandchildren and I think what would we want for them so that they aren't going through what we went through?
"That would break my heart to think that everything that happened to Tim, nothing had changed and that if my grandchildren needed some help it wouldn't be there and the same would happen.
"I think if people stopped and thought about if this was my son, my daughter, my wife, my husband, my mother... what would I want for them?"
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