8 Feb 2026 Elise Kay Louise Sebastian · Prevention of Future Deaths report Essex
View report summary
Concerns raised 3
Failure to maintain staff observation of the Oxevision monitor during WiFi disruption View source Oxevision system failing to operate reliably because of WiFi coverage difficulties View source Lack of staff training in use of the Oxevision system View source
This report raised 28 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Elise Kay Louise Sebastian · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Elise Kay Louise Sebastian tied a fatal ligature in her room on Longview Ward on 17 April 2021 and died two days later in hospital. The principal concerns included inadequate and falsified observations, insufficiently trained and staffed ward personnel, poor communication about ligaturing and self-harm, medication-recording errors, failures involving Oxevision, and other care and record-keeping deficiencies.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to maintain staff observation of the Oxevision monitor during WiFi disruption
Wider context from the report “1. Mental Health Trust Staff on Longfield Ward:
a. Elise was neurodiverse and staff were not trained in Autism
b. were inexperienced. The majority were new bank and agency staff with limited experience working with detained children, and this matter had been raised by the Care Quality Commission about other Trust services in January 2021.
c. Did not have sufficient staffing to conduct observations required by the doctors for patients on the ward. This was known to the mental health Trust management and had been raised by the ward manager. During the time of Elise’s admission, the staff member allocated for observations was required to conduct approximately 66 observations within an hour. This was not logistically possible. Management knew that staffing allocation on Longview Ward was not sufficient to conduct the required levels of observations to keep the patients safe. Evidence was heard during the inquest that there are still observations that are not being conducted either as required or at all within the Trust and remains an ongoing concern. Datix reporting incidents are not always raised.
d. The mental health Trust implemented a system called Oxevision with a Project Board to assist with the planning and roll out of the new system. There were difficulties with the roll out on St.Aubyns ward who were part of the pilot, due to WiFi coverage and the Oxevision system not operating correctly.
e. The clinical management at the Trust Project Board meeting overseeing the roll out for Oxevision, required that ward staff implement a procedure where the Oxevision fixed monitor in the ward office be observed by a member of staff whilst the WiFi problem was resolved. This did not happen on Longview Ward.
f. The Trust Project Group had reports that WiFi was not working and any issues were required to be reported as incident reports on Datix forms but these were not being completed. The Trust Project Board did not question why they were not receiving the Datix forms with the known issues. There was no oversight of what was required to ensure that the roll-out was operating appropriately and/or what the Project Board expected in the interim whilst the WiFi difficulties were being investigated.
g. Not all the Trust staff on the ward were trained to use the Oxevision System.
h. There was disputed evidence about the volume on the fixed terminal for Oxevision in the office about whether the alert volume could be turned down or ‘muted’. It was established that there was no incident unrelated to Elise’s death where a doctor did turn this volume down on the ward.
” Source location Elise Kay Louise Sebastian · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Oxevision system failing to operate reliably because of WiFi coverage difficulties
Wider context from the report “1. Mental Health Trust Staff on Longfield Ward:
a. Elise was neurodiverse and staff were not trained in Autism
b. were inexperienced. The majority were new bank and agency staff with limited experience working with detained children, and this matter had been raised by the Care Quality Commission about other Trust services in January 2021.
c. Did not have sufficient staffing to conduct observations required by the doctors for patients on the ward. This was known to the mental health Trust management and had been raised by the ward manager. During the time of Elise’s admission, the staff member allocated for observations was required to conduct approximately 66 observations within an hour. This was not logistically possible. Management knew that staffing allocation on Longview Ward was not sufficient to conduct the required levels of observations to keep the patients safe. Evidence was heard during the inquest that there are still observations that are not being conducted either as required or at all within the Trust and remains an ongoing concern. Datix reporting incidents are not always raised.
d. The mental health Trust implemented a system called Oxevision with a Project Board to assist with the planning and roll out of the new system. There were difficulties with the roll out on St.Aubyns ward who were part of the pilot, due to WiFi coverage and the Oxevision system not operating correctly .
e. The clinical management at the Trust Project Board meeting overseeing the roll out for Oxevision, required that ward staff implement a procedure where the Oxevision fixed monitor in the ward office be observed by a member of staff whilst the WiFi problem was resolved. This did not happen on Longview Ward.
f. The Trust Project Group had reports that WiFi was not working and any issues were required to be reported as incident reports on Datix forms but these were not being completed. The Trust Project Board did not question why they were not receiving the Datix forms with the known issues. There was no oversight of what was required to ensure that the roll-out was operating appropriately and/or what the Project Board expected in the interim whilst the WiFi difficulties were being investigated.
g. Not all the Trust staff on the ward were trained to use the Oxevision System.
h. There was disputed evidence about the volume on the fixed terminal for Oxevision in the office about whether the alert volume could be turned down or ‘muted’. It was established that there was no incident unrelated to Elise’s death where a doctor did turn this volume down on the ward.
” Source location Elise Kay Louise Sebastian · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of staff training in use of the Oxevision system
Wider context from the report “1. Mental Health Trust Staff on Longfield Ward:
a. Elise was neurodiverse and staff were not trained in Autism
b. were inexperienced. The majority were new bank and agency staff with limited experience working with detained children, and this matter had been raised by the Care Quality Commission about other Trust services in January 2021.
c. Did not have sufficient staffing to conduct observations required by the doctors for patients on the ward. This was known to the mental health Trust management and had been raised by the ward manager. During the time of Elise’s admission, the staff member allocated for observations was required to conduct approximately 66 observations within an hour. This was not logistically possible. Management knew that staffing allocation on Longview Ward was not sufficient to conduct the required levels of observations to keep the patients safe. Evidence was heard during the inquest that there are still observations that are not being conducted either as required or at all within the Trust and remains an ongoing concern. Datix reporting incidents are not always raised.
d. The mental health Trust implemented a system called Oxevision with a Project Board to assist with the planning and roll out of the new system. There were difficulties with the roll out on St.Aubyns ward who were part of the pilot, due to WiFi coverage and the Oxevision system not operating correctly.
e. The clinical management at the Trust Project Board meeting overseeing the roll out for Oxevision, required that ward staff implement a procedure where the Oxevision fixed monitor in the ward office be observed by a member of staff whilst the WiFi problem was resolved. This did not happen on Longview Ward.
f. The Trust Project Group had reports that WiFi was not working and any issues were required to be reported as incident reports on Datix forms but these were not being completed. The Trust Project Board did not question why they were not receiving the Datix forms with the known issues. There was no oversight of what was required to ensure that the roll-out was operating appropriately and/or what the Project Board expected in the interim whilst the WiFi difficulties were being investigated.
g. Not all the Trust staff on the ward were trained to use the Oxevision System.
h. There was disputed evidence about the volume on the fixed terminal for Oxevision in the office about whether the alert volume could be turned down or ‘muted’. It was established that there was no incident unrelated to Elise’s death where a doctor did turn this volume down on the ward.
” Source location Elise Kay Louise Sebastian · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Install additional routers and tablets and establish paper-record fallback procedures for Oxevision connectivity failures.
Verbatim wording from the response “▪ WiFi solution identified by IT, with an additional routers installed (July 2021). Additional tablets were also provided to the ward” Source location 2026-0078 - Response from Essex University Partnership Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Approve and circulate Oxevision procedures, provide staff training, establish user competencies and implement Oxevision audits.
Verbatim wording from the response “• Oxevision SOP approved and circulated to staff” Source location 2026-0078 - Response from Essex University Partnership Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Retrain clinical staff in Oxevision and observation use in accordance with the relevant procedures and policy.
Verbatim wording from the response “Again, all clinical staff are being retrained or trained in the use of Oxevision and observations. In line with the Oxevision SOP and the Therapeutic engagement and supportive observation policy.” Source location 2026-0078 - Response from Essex University Partnership Trust
Open published response
19 Dec 2023 MORGAN-ROSE HART · Prevention of Future Deaths report Essex
View report summary
Concerns raised 2
Failure to ensure in-person checks after bathroom alerts View source Failure to use Oxevision only as an adjunct to face-to-face observations View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Essex Partnership University NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Essex Partnership University NHS Foundation Trust
Configure Oxevision bathroom alerts to repeat audibly and visually at three-minute intervals until the bathroom is exited.
View source
Essex Partnership University NHS Foundation Trust
Review and update Oxevision and observation procedures to align terminology and clarify alert-reset functionality.
View source
Essex Partnership University NHS Foundation Trust
Train and retrain clinical staff in Oxevision, electronic observations and supportive-observation requirements.
View source
Essex Partnership University NHS Foundation Trust
Monitor Oxevision use through ward spot checks, DATIX review and maintained training records.
View source
Essex Partnership University NHS Foundation Trust
Circulate and reinforce the Therapeutic Engagement and Supportive Observation policy across all wards.
View source See 2 more actions
×
AI-generated summary
MORGAN-ROSE HART · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Morgan-Rose Hart, who was detained on a female mental health ward, died on 12 July 2022 after being found unresponsive with a ligature around her neck. The report identified concerns about missed and falsified observations, failures to complete physical welfare checks after bathroom alerts, inadequate escalation of risk, shortcomings in investigation and record keeping, and insufficient suitable placements for people with autism and mental health and self-harm risks in Essex.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure in-person checks after bathroom alerts
Wider context from the report “(4) Bathroom alerts – Evidence was heard that an Oxevision alert is triggered if a person is in the bathroom for more than 3 minutes and staff are required to complete an in-person check . Morgan-Rose was left in the bathroom unobserved for approximately 50 minutes . It was not clear from the evidence how the Trust proposes to ensure compliance in respect of this duty .
” Source location MORGAN-ROSE HART · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to use Oxevision only as an adjunct to face-to-face observations
Wider context from the report “(6) Staff entries in patient observations sheets should have given rise to a concern that some staff may have been using Oxevision not just as an adjunct to face-to-face observations, but instead of them . This remains a concern .
” Source location MORGAN-ROSE HART · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Configure Oxevision bathroom alerts to repeat audibly and visually at three-minute intervals until the bathroom is exited.
Verbatim wording from the response “Configuration changes to the Oxevission system have been implemented. This will ensure that bathroom alerts continue at 3 minute intervals until an individual has exited the bathroom. This includes the reset functionality of a repeatable and audible and tile illumination of an alert with timer continuation after each successive reset of the alert in 3-minute intervals.” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update Oxevision and observation procedures to align terminology and clarify alert-reset functionality.
Verbatim wording from the response “A clinical review of the SOPs for Oxevission and Oxevission Observations to align terminology and produce updated versions of the SOPs has been implemented. This includes ensuring the continuity of terminology in the SOP and all communications mirroring system based terms and wording.” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train and retrain clinical staff in Oxevision, electronic observations and supportive-observation requirements.
Verbatim wording from the response “All clinical staff are being retrained or trained in the use of Oxevission and observations. In line with the Oxevission SOP and the Therapeutic engagement and supportive observation policy.” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor Oxevision use through ward spot checks, DATIX review and maintained training records.
Verbatim wording from the response “DATIX data reflects that staff are using Oxevission in adherence to policy and responding to alerts which has resulted in no harm. The Inpatient Leadership team continue to spot check ward practice and review DATIX data.” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Circulate and reinforce the Therapeutic Engagement and Supportive Observation policy across all wards.
Verbatim wording from the response “The review of the Therapeutic Engagement and Supportive Observation policy has been completed and circulated to all staff.” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.