10 Oct 2025 Jillian Anne Steedman · Prevention of Future Deaths report Essex
View report summary
Concerns raised 13 Lack of information sharing between professionals involved in care and treatment View source Failure to complete discharge care plans, risk assessment and procedures View source Failure to learn lessons from the death View source Out-of-date information for aftercare planning, placement and risk assessment View source Failure to review placement appropriateness following crisis View source Absence of a contact list in the integrated plan View source Failure to complete required reviews during distress and crises View source Failure of visiting professionals to review care plans and risk assessments View source Failure of social worker to alert others to deficient or absent plans following crises View source Inappropriate care-home placement for patient needs View source Failure to review and update the s117 care plan View source Absence of Council investigation and clarity over investigative leadership View source Failure to inform the ongoing ECT consultant of mental health deterioration View source See 10 more concerns
Responses linked to these concerns
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AI-generated summary
Jillian Anne Steedman · 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
Jillian Anne Steedman died at Pitsea Station on 12 May 2023 after intentionally going into the path of an oncoming train, following a deterioration in her mental health. The report identifies concerns including failures in information sharing, risk assessment, care planning, escalation, crisis response, and review of her placement and support arrangements.
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. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of information sharing between professionals involved in care and treatment
Wider context from the report “(1) There was a lack of information sharing between professionals involved in the care and treatment of Jillian Steedman who was a complex mental health patient with a long history of treatment resistant mental disorder.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to complete discharge care plans, risk assessment and procedures
Wider context from the report “(4) The mental health Trust staff involved in the discharge and community care of Mrs Steedman were put on notice by a clinical lead on 16 March 2023 that the care plans, risk assessment and procedures relevant to the discharge had not been completed and were required in addition to the integrated plan that was attached to the email. These were never completed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to learn lessons from the death
Wider context from the report “(14) There was an absence of a Council investigation and confusion as to which organisation should take the lead following Mrs Steedman’s death and then dispute before the inquest on the Investigation Report provided by the mental health Trust at the inquest. This caused concerns that lessons have not been learned .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Out-of-date information for aftercare planning, placement and risk assessment
Wider context from the report “(11) The information for the aftercare planning and assessment presented for placement and risk for Mrs Steedman placed before the panel was significantly out of date . There was no review and the s117 care plan had not been updated since 13 September 2022.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to review placement appropriateness following crisis
Wider context from the report “(8) The appropriateness of the placement was not reviewed following a crisis on 15 April 2023 just a few days after admission.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Absence of a contact list in the integrated plan
Wider context from the report “(13) There was no contact list provided as part of the integrated plan , and Mrs Steedman requested that her social worker be contacted when she was in crisis on 15 April, and she stated she wanted to die and would throw herself in front of a train. This led to the call being diverted to mental health crisis and not directly to the FIRST team in accordance with the plan. The appropriateness of the placement in the care home was not reviewed at that time or when the care home management expressed concerns about Mrs Steedman’s risks of diverting a taxi.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to complete required reviews during distress and crises
Wider context from the report “(7) Visiting professionals did not complete the required reviews necessary when Mrs Steedman was distressed and experiencing crises .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Failure of visiting professionals to review care plans and risk assessments
Wider context from the report “(6) The mental health Trust staff and the local authority social worker were visiting Mrs Steedman. The integrated plan required significant visits for Mrs Steedman initially every day with out of hours support available with a slow taper off over weeks. None of the visiting professionals asked to review the care plans or risk assessments and any such scrutiny would have revealed these necessary documents had not been completed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Failure of social worker to alert others to deficient or absent plans following crises
Wider context from the report “(12) The social worker did not raise any alerts as to deficiencies or absence of plans following crises for Mrs Steedman.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Inappropriate care-home placement for patient needs
Wider context from the report “(5) Mrs Steedman was discharged to the care home on 11 April 2023 from mental health hospital following an admission of over 12 months and previously failed discharges. Evidence was heard Mrs Steedman was not appropriately placed in the Care Home based on her needs and the local authority were on notice that another care home had refused to admit Mrs Steedman due to her mental health. There was no review and the s117 care plan had not been updated since 13 September 2022.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to review and update the s117 care plan
Wider context from the report “(5) Mrs Steedman was discharged to the care home on 11 April 2023 from mental health hospital following an admission of over 12 months and previously failed discharges. Evidence was heard Mrs Steedman was not appropriately placed in the Care Home based on her needs and the local authority were on notice that another care home had refused to admit Mrs Steedman due to her mental health. There was no review and the s117 care plan had not been updated since 13 September 2022 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Absence of Council investigation and clarity over investigative leadership
Wider context from the report “(14) There was an absence of a Council investigation and confusion as to which organisation should take the lead following Mrs Steedman’s death and then dispute before the inquest on the Investigation Report provided by the mental health Trust at the inquest. This caused concerns that lessons have not been learned.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to inform the ongoing ECT consultant of mental health deterioration
Wider context from the report “(2) Mrs Steedman’s consultant responsible for ongoing Electroconvulsive Therapy (ECT) was not informed of her mental health deterioration . Previous adjustments to the frequency of ECT had proved beneficial.
” Open source report
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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 Work with EPUT to strengthen its incident response framework, including safeguarding, investigation handling and early Adult Social Care involvement.
Verbatim wording from the response “To ensure roles and responsibilities for investigating deaths are clear we have been working with our colleagues in EPUT to ensure that their Patient Safety Incident Response Framework (PSIRF) is robust. We have met with the EPUT lead in this area and have provided detailed comments on their PSIRF to ensure that safeguarding remains at the centre of the approach, patient safety investigations are appropriately dealt with, and, where Adult Social Care needs to be involved, we are engaged at the earliest opportunity. We will continue to work with EPUT as they further develop their PSIRF.” Source location Response from Essex County Council
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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 Revise the Section 117 policy to improve care delivery and incorporate learning from the death.
Verbatim wording from the response “We have also been working with system partners to improve the governance arrangements that support mental health care in our administrative area and are presently working on a revision to the Section 117 policy so that it supports the effective delivery of care in this important area and incorporates the learning from Mrs Steedman’s sad death. This work is ongoing, but we anticipate it will be completed within the next six months.” Source location Response from Essex County Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake a full review of community mental health social work arrangements, including joint-working arrangements, to clarify roles and responsibilities.
Verbatim wording from the response “In response to this PFD, we will undertake a full review of our community mental health social work arrangements, including the existing arrangements supporting joint working, to ensure roles and responsibilities are clear. We expect this work to take place over the next year and we are committed to ensuring that the outcome of this work is safer with better coordinated support for those using the service.” Source location Response from Essex County Council
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17 Apr 2025 Linda Sitch · Prevention of Future Deaths report Essex
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Concerns raised 4 Failure to ensure thorough, professional and adequately documented review of urgent referral grading View source Lack of robust service-level oversight and auditing of managerial decision-making View source Failure to respond substantively to safeguarding and carer’s assessment referrals View source Failure to conduct and document required review before downgrading referral priority View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 9
Action
Implement risk-priority matrices for carers’ assessments, reviews and safeguarding referrals.
Stated completedThe respondent said that this action was complete when they made their response on 28 April 2025. View source
Action
Conduct a scheduled audit of referral progression through allocation and consider issuing further guidance on priority decisions and allocation timescales.
Stated plannedThe respondent said that this action was planned when they made their response on 28 April 2025. View source
Action
Implement recommendations from the external end-to-end safeguarding-process review to improve safeguarding practice and the customer journey.
Stated in progressThe respondent said that this action was in progress when they made their response on 28 April 2025. View source
Action
Implement the improved supervision framework to support practice reflection, work-priority clarification, wellbeing, development and learning.
Stated completedThe respondent said that this action was complete when they made their response on 28 April 2025. View source
Action
Hold monthly locality quality, performance and accountability meetings to scrutinise performance data and work progression.
Stated completedThe respondent said that this action was complete when they made their response on 28 April 2025. View source
Action
Increase safeguarding triage capacity and screen every alert before progressing qualifying referrals for further enquiry.
Stated completedThe respondent said that this action was complete when they made their response on 28 April 2025. View source
Action
Introduce carers practice guidance and core practice guidance covering assessments, reviews, support planning and safeguarding.
Stated completedThe respondent said that this action was complete when they made their response on 28 April 2025. View source
Action
Refresh the Quality Assurance Framework and conduct eight annual audit cycles covering assessments, reviews, mental capacity and safeguarding, with findings reported to the Practice Governance Board.
Stated completedThe respondent said that this action was complete when they made their response on 28 April 2025. View source
Action
Create a data and insights team and provide weekly safeguarding and waiting-list performance reports with management oversight.
Stated completedThe respondent said that this action was complete when they made their response on 28 April 2025. View source See 6 more actions
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AI-generated summary
Linda Sitch · 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
Linda took her own life on 11 November 2023 after prolonged strain associated with caring for her husband, who had significant physical and mental health problems. Adult Social Care did not substantively respond to safeguarding and carer assessment referrals or the family’s escalating concerns before her death. The report raises concerns about inadequate oversight and the risk that urgent referrals could be inappropriately downgraded or insufficiently reviewed, potentially contributing to future deaths.
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. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure thorough, professional and adequately documented review of urgent referral grading
Wider context from the report “d. In contrast to this view, I remain concerned that ASC continues to lack a robust system to ensure sufficiently rigorous oversight, including active auditing, capable of identifying the kind of sub-optimal managerial level performance as has been brought to the fore in this case. A change in personnel and moves towards “embedding best practice” do not, in my opinion, sufficiently address this systemic lacuna given that the effectiveness of such changes will still rely very substantially upon the performance of any Team Manager and/or a Deputy Team Manager. There appears to me to be a continuing lack of robust Service level oversight of those managers themselves, (including the appropriateness of their decision making), absent which any sub-optimal performance by said managers may well not be identified.
e. Absent a sufficiently robust system for providing oversight and identifying and significantly mitigating (if not entirely removing) such individual human error, alongside, for example, the inclusion of simple auditable check lists of matters to be accessed, reviewed and documented whenever a referral is received, then there is a continuing risk of urgent future referrals being inappropriately graded as Priority 2 (and/or being downgraded from Priority 1) without the requisite thorough and professional review, adequately documented, being undertaken . This gives rise to a concomitant risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of robust service-level oversight and auditing of managerial decision-making
Wider context from the report “d. In contrast to this view, I remain concerned that ASC continues to lack a robust system to ensure sufficiently rigorous oversight, including active auditing, capable of identifying the kind of sub-optimal managerial level performance as has been brought to the fore in this case. A change in personnel and moves towards “embedding best practice” do not, in my opinion, sufficiently address this systemic lacuna given that the effectiveness of such changes will still rely very substantially upon the performance of any Team Manager and/or a Deputy Team Manager. There appears to me to be a continuing lack of robust Service level oversight of those managers themselves, (including the appropriateness of their decision making), absent which any sub-optimal performance by said managers may well not be identified .
e. Absent a sufficiently robust system for providing oversight and identifying and significantly mitigating (if not entirely removing) such individual human error, alongside, for example, the inclusion of simple auditable check lists of matters to be accessed, reviewed and documented whenever a referral is received, then there is a continuing risk of urgent future referrals being inappropriately graded as Priority 2 (and/or being downgraded from Priority 1) without the requisite thorough and professional review, adequately documented, being undertaken. This gives rise to a concomitant risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to respond substantively to safeguarding and carer’s assessment referrals
Wider context from the report “a. Although not determined to be probably causative of the death, by the date of Linda’s death ASC had failed to respond substantively or at all to the Adult Safeguarding Referral dated 29th September 2023; the referral for a Carer’s Assessment for Linda herself, received by ASC on 2nd October 2023; the concerns reiterated by Linda’s family when chasing the 2nd October referral on 16th October 2023 . These failures were explained as ‘human error’.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct and document required review before downgrading referral priority
Wider context from the report “b. The oral evidence of the ASC Service Manager at the inquest (though not mentioned in her statement prepared for the purposes of the inquest), confirmed that the Team Manager responsible for downgrading the Priority 1 status of the carer’s assessment referral on 2nd October to Priority 2, without recording a rationale , had likely done so without undertaking the required consideration of either the readily available ASG referral of the 29th September, or the Mental Health Act assessment of Linda herself from the previous year . She agreed that, had an estimated “ten minute” review of the “slim files” for both Linda and her husband been undertaken, as should have happened, the Priority level could not and would not have been reasonably downgraded . She accordingly accepted that, in fact, (and contrary to her witness statement) the decision to downgrade to Priority 2 was capable of being determined, by her as an ASC Service Manager, to be ‘inappropriate’.
” Open source report
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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 Implement risk-priority matrices for carers’ assessments, reviews and safeguarding referrals.
Verbatim wording from the response “• A new Risk Priority Matrix for carers assessments and reviews was implemented in 2023, which was being embedded throughout the year.” Source location Response from Essex County Council
Open published response
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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 Conduct a scheduled audit of referral progression through allocation and consider issuing further guidance on priority decisions and allocation timescales.
Verbatim wording from the response “Adult Social Care have scheduled an audit cycle within the next three months, specifically focused on how referrals are progressed when an initial referral is received, through to point of allocation. Following analysis and outcomes of this, we will consider issuing further practice guidance to confirm expectations about making good, defensible decisions around priority levels, including expected timescale for the allocation of work.” Source location Response from Essex County Council
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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 Implement recommendations from the external end-to-end safeguarding-process review to improve safeguarding practice and the customer journey.
Verbatim wording from the response “In Spring 2024, Adult Social Care commissioned an external review of the end-to-end safeguarding process. There were several recommendations, that we are implementing to improve the customer journey and safeguarding practice.” Source location Response from Essex County Council
Open published response
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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 Implement the improved supervision framework to support practice reflection, work-priority clarification, wellbeing, development and learning.
Verbatim wording from the response “Adult Social Care have also implemented an improved supervision framework in 2024. There are four main elements to supervision which are to:” Source location Response from Essex County Council
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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 Hold monthly locality quality, performance and accountability meetings to scrutinise performance data and work progression.
Verbatim wording from the response “Furthermore, there is a monthly quality, performance and accountability meeting (QPAM) within each locality area, where data information reports are scrutinised by service managers and directors, which ensures greater accountability and oversight of all work and what stage it is at.” Source location Response from Essex County Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase safeguarding triage capacity and screen every alert before progressing qualifying referrals for further enquiry.
Verbatim wording from the response “The Central Safeguarding Triage Team has undergone transformative change, which has included increasing the resource of the team, implementing an initial screening check of all safeguarding alerts raised and those which are deemed to meet the criteria for safeguarding are then progressed to a safeguarding concern for further enquiries. As a result of these changes, 96% are triaged for a decision as to whether to proceed to safeguarding section 42 enquiry within 72 hours, with outcomes shared back with referrers and next actions agreed. The remaining 4% take a little longer with continuous oversight, whilst waiting for information at the triage stage to enable decision making. Therefore, there are no longer significant delays in progressing safeguarding referrals received.” Source location Response from Essex County Council
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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 Introduce carers practice guidance and core practice guidance covering assessments, reviews, support planning and safeguarding.
Verbatim wording from the response “• New Carers practice guidance for Adult Social Care operational workers to support better and more timely outcomes for carers.” Source location Response from Essex County Council
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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 Refresh the Quality Assurance Framework and conduct eight annual audit cycles covering assessments, reviews, mental capacity and safeguarding, with findings reported to the Practice Governance Board.
Verbatim wording from the response “Alongside the Quality Control measures in place, Adult Social Care refreshed its Quality Assurance Framework in 2024 and there are now eight audit cycles in place throughout every year. These focus on care act assessments/reviews, carers assessments, mental capacity assessments and safeguarding. Audits are analysed and reports are presented to the Practice Governance Board.” Source location Response from Essex County Council
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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 Create a data and insights team and provide weekly safeguarding and waiting-list performance reports with management oversight.
Verbatim wording from the response “We are satisfied that Adult Social Care has robust oversight in place. We created a data and insights team in August 2024, who provide detailed reports on performance. Directors / service managers / team managers receive a weekly report in relation to safeguarding activity across all teams. There is also a weekly report which details people waiting alongside a dashboard, these have team manager / service manager and director oversight.” Source location Response from Essex County Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adult Social Care considers its existing reporting, scrutiny, supervision and governance arrangements sufficient to provide robust oversight of managerial decision-making.
Verbatim wording from the response “We are satisfied that Adult Social Care has robust oversight in place. We created a data and insights team in August 2024, who provide detailed reports on performance. Directors / service managers / team managers receive a weekly report in relation to safeguarding activity across all teams. There is also a weekly report which details people waiting alongside a dashboard, these have team manager / service manager and director oversight.” Source location Response from Essex County Council
Open published response
20 Feb 2025 Paul Stephen Collingridge · Prevention of Future Deaths report Essex
View report summary
Concerns raised 4 Inadequate Code of Practice guidance for calculating street works distances where standard reference points or markings are unavailable or variable View source Difficulties in calculating distances for roadworks set up in darkness View source Failure to place road works warning signs without obscuring visibility of joining traffic View source Absence of a requirement to notify fatalities within roadworks on permit applications View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Paul Stephen Collingridge · 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
Paul Stephen Collingridge, aged 28, died on 6 December 2022 from multiple traumatic injuries after his motorcycle high-sided near overnight roadworks and he was struck by oncoming traffic. The report raised concerns about the setting out and measurement of roadworks in darkness and on curved roads, the placement of a warning sign that obscured visibility, and the absence of a requirement to report a fatality on a retrospective permit application.
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. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate Code of Practice guidance for calculating street works distances where standard reference points or markings are unavailable or variable
Wider context from the report “(2) The Safety of Street Works Code of Practice sets out how to take measurements to set out street works that include utilising street furniture that are at set distances and standard road markings that have standard lengths on carriageways with specific road speeds.
a. Some carriageways do not have street furniture
b. Some of the road markings on the carriage where the fatal collision did not comply to standard lengths and therefore the markings can have variations.
c. The Code of Practice does not set out how to calculate the distance where there is road curvature where the road markings have differing lengths on opposing sides where the markings are delineated on bends in a carriageway.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Difficulties in calculating distances for roadworks set up in darkness
Wider context from the report “(1) Where Road Works Permits are required by utility companies these are often urgent to carry out vital repairs. This can mean that roadworks are set up in hours of darkness and may cause difficulties calculating distances as set out in the Safety at Street Works Code of Practice.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to place road works warning signs without obscuring visibility of joining traffic
Wider context from the report “(3) A road works warning sign was placed at the junction that joined the carriageway of a road that obscured visibility of traffic joining the main carriageway . Whilst this did not cause or contribute to this incident this was not in accordance with the Code of Practice .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Absence of a requirement to notify fatalities within roadworks on permit applications
Wider context from the report “(4) The fatal incident that occurred on 6 December 2022 was not notified on the retrospective permit application for roadworks on the following day. There is no requirement for a fatality within roadworks be notified on application for an application for a permit .
” Open source report
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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 Raise the absence of a Street Manager field for reporting serious incidents and unusual events with the Department for Transport.
Verbatim wording from the response “3. When applying for retrospective permission for street works there is no requirement for a statutory undertaker to notify the authority of any serious incidents that have occurred during the emergency period. There is a national database run by the Department for Transport named Street Manager. This is the way that all local authorities communicate with all statutory undertakers. That database does not have a data field to allow permit applicants to report incidents or unusual events. We will raise this with the Department for Transport. However, the involvement of the police in any fatal road accident already provides a communications channel, meaning that in practice ECC is notified quickly of any fatalities and can quickly take any necessary action that it has the power to take.” Source location Response from Essex County Council
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Department for Transport is responsible for reviewing and improving the Code’s guidance on distance calculations for curved carriageways.
Verbatim wording from the response “Regarding curved carriageways, the absence of specific guidance on distance calculation in the statutory Code of Practice is acknowledged. While this remains a broader area for review for the Department for Transport, Essex County Council is prepared to support any request from the Department of Transport to improve the Code to address such circumstances. There is an overarching duty for statutory undertakers to have a safe system of work and the training they have will cover this.” Source location Response from Essex County Council
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Statutory undertakers and their contractors are responsible for safely setting up emergency works and ensuring Code compliance.
Verbatim wording from the response “1. Road Works Permits and Setup in Hours of Darkness. All work is more difficult during the hours of darkness. Undertakers and those working on their behalf are responsible for ensuring emergency works are set up safely and are required to have a trained and qualified person on site to ensure compliance with the Code. ECC does not have the ability to inspect all emergency roadworks as that does not form part of the safety system.” Source location Response from Essex County Council
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Police involvement in fatal road accidents provides a communications channel that promptly notifies the authority and enables action within its powers.
Verbatim wording from the response “3. When applying for retrospective permission for street works there is no requirement for a statutory undertaker to notify the authority of any serious incidents that have occurred during the emergency period. There is a national database run by the Department for Transport named Street Manager. This is the way that all local authorities communicate with all statutory undertakers. That database does not have a data field to allow permit applicants to report incidents or unusual events. We will raise this with the Department for Transport. However, the involvement of the police in any fatal road accident already provides a communications channel, meaning that in practice ECC is notified quickly of any fatalities and can quickly take any necessary action that it has the power to take.” Source location Response from Essex County Council
Open published response
19 Dec 2023 MORGAN-ROSE HART · Prevention of Future Deaths report Essex
View report summary
Concerns raised 11 Delays and premature sign-off in Trust investigations View source Failure of investigations to identify and document material issues and limitations View source Failure to ensure complete therapeutic engagement records in patient observation sheets View source Omissions in required food and fluid chart recording View source Failure to maintain clear and consistent rules on patient belts View source Shortfall of appropriate inpatient and community placements for autistic people with mental health and self-harm risks View source Failure to escalate changes in leave risk View source Lack of accurate records of staff pass allocation and access View source Failure to ensure in-person checks after bathroom alerts View source Insufficient scrutiny of CCTV and staff observation records View source Failure to use Oxevision only as an adjunct to face-to-face observations View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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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.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Delays and premature sign-off in Trust investigations
Wider context from the report “(1) The Trust investigation was materially incomplete and there was a lost an opportunity to:
a. Understand concerns of the Family
b. Acknowledge errors and learn lessons from the circumstances of the death. The Director of Operations and Matron informed the Trust Senior Management that the PSII Report had omissions. The Trust evidence was that it was an early adopter of the new NHS investigation process. The lead investigator did not report on material issues as to how Morgan-Rose was observed on the ward and the report was significantly delayed . Evidence was there was a pressure to sign the report off although it remained incomplete and did not contain a note about the limitations.
c.
d. Escalate concerns about staff observations - About 2 weeks after the death the Matron received a report that staff observations had not been appropriately conducted. This prompted a review of CCTV from the afternoon of Morgan-Rose’s death. There was insufficient scrutiny of the CCTV that showed that multiple observations entries made on 6 July 2022 after 14:06 hours could not be correct.
e. Understand security issues on a locked mental health ward - It has not been possible to establish the identity of the person that reset the bathroom alert triggered for Morgan-Rose on 6 July 2022 at 15:31. The Trust does not have an accurate records of Trust staff pass allocation. The Trust investigation did not establish that staff borrowed each other's security passes. On the day of Morgan-Rose’s death a visitor pass issued had had access to the nursing office. The Trust was unable to provide the identity of this person.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Failure of investigations to identify and document material issues and limitations
Wider context from the report “(1) The Trust investigation was materially incomplete and there was a lost an opportunity to:
a. Understand concerns of the Family
b. Acknowledge errors and learn lessons from the circumstances of the death. The Director of Operations and Matron informed the Trust Senior Management that the PSII Report had omissions. The Trust evidence was that it was an early adopter of the new NHS investigation process. The lead investigator did not report on material issues as to how Morgan-Rose was observed on the ward and the report was significantly delayed. Evidence was there was a pressure to sign the report off although it remained incomplete and did not contain a note about the limitations .
c.
d. Escalate concerns about staff observations - About 2 weeks after the death the Matron received a report that staff observations had not been appropriately conducted. This prompted a review of CCTV from the afternoon of Morgan-Rose’s death. There was insufficient scrutiny of the CCTV that showed that multiple observations entries made on 6 July 2022 after 14:06 hours could not be correct.
e. Understand security issues on a locked mental health ward - It has not been possible to establish the identity of the person that reset the bathroom alert triggered for Morgan-Rose on 6 July 2022 at 15:31. The Trust does not have an accurate records of Trust staff pass allocation. The Trust investigation did not establish that staff borrowed each other's security passes. On the day of Morgan-Rose’s death a visitor pass issued had had access to the nursing office. The Trust was unable to provide the identity of this person.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure complete therapeutic engagement records in patient observation sheets
Wider context from the report “(5) Trust oversight of care – the quality of record keeping was acknowledged not to be appropriate by nurses and senior staff during evidence, yet had been signed off:
a. Observations sheets for vulnerable detained mental patients were signed off by nurses in charge as being appropriate despite an absence of any recorded therapeutic engagement
b. Omissions in the recording of food and fluid charts required by the Responsible Clinician for a patient who was losing weight with a diagnosis of Body Dysmorphic Disorder.
c. The Responsible Clinician’s evidence was that the absence of appropriate food and fluid charts for other patients was an ongoing issue on Chelmer Ward that had been raised with nursing staff
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Omissions in required food and fluid chart recording
Wider context from the report “(5) Trust oversight of care – the quality of record keeping was acknowledged not to be appropriate by nurses and senior staff during evidence, yet had been signed off:
a. Observations sheets for vulnerable detained mental patients were signed off by nurses in charge as being appropriate despite an absence of any recorded therapeutic engagement
b. Omissions in the recording of food and fluid charts required by the Responsible Clinician for a patient who was losing weight with a diagnosis of Body Dysmorphic Disorder.
c. The Responsible Clinician’s evidence was that the absence of appropriate food and fluid charts for other patients was an ongoing issue on Chelmer Ward that had been raised with nursing staff
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain clear and consistent rules on patient belts
Wider context from the report “(2) There was a dispute in evidence over whether it was or was not permitted for patients to have belts on Chelmer Ward, that has not been resolved .
a. Morgan-Rose was on 1:1 observation due to her high risk of self-harm that including ligaturing and a belt was in her possession
b. The Responsible Clinician and a Ward Manager providing support to staff gave evidence that at time that belts were not permitted
c. The Trust senior management stated that belts were permitted and referenced the policy. The Updated ward documentation ‘Handover Checklist’ approved in October 2023 contains belts on a list of prohibited items . The Trust has stated that this is not correct although this was part of the After-Action Review and is in current use.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Shortfall of appropriate inpatient and community placements for autistic people with mental health and self-harm risks
Wider context from the report “(7) There is a significant shortfall of appropriate placements for people with Autism who have mental health and self-harm risks in Essex both inpatient and the community .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate changes in leave risk
Wider context from the report “(3) Escalation of risk – Morgan-Rose attempted to secure unescorted leave on the morning of her death, her Responsible Clinician had only authorised escorted leave. This was not escalated to the nurse in charge and the Responsible Clinician was not informed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of accurate records of staff pass allocation and access
Wider context from the report “(1) The Trust investigation was materially incomplete and there was a lost an opportunity to:
a. Understand concerns of the Family
b. Acknowledge errors and learn lessons from the circumstances of the death. The Director of Operations and Matron informed the Trust Senior Management that the PSII Report had omissions. The Trust evidence was that it was an early adopter of the new NHS investigation process. The lead investigator did not report on material issues as to how Morgan-Rose was observed on the ward and the report was significantly delayed. Evidence was there was a pressure to sign the report off although it remained incomplete and did not contain a note about the limitations.
c.
d. Escalate concerns about staff observations - About 2 weeks after the death the Matron received a report that staff observations had not been appropriately conducted. This prompted a review of CCTV from the afternoon of Morgan-Rose’s death. There was insufficient scrutiny of the CCTV that showed that multiple observations entries made on 6 July 2022 after 14:06 hours could not be correct.
e. Understand security issues on a locked mental health ward - It has not been possible to establish the identity of the person that reset the bathroom alert triggered for Morgan-Rose on 6 July 2022 at 15:31. The Trust does not have an accurate records of Trust staff pass allocation . The Trust investigation did not establish that staff borrowed each other's security passes . On the day of Morgan-Rose’s death a visitor pass issued had had access to the nursing office. The Trust was unable to provide the identity of this person .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient scrutiny of CCTV and staff observation records
Wider context from the report “(1) The Trust investigation was materially incomplete and there was a lost an opportunity to:
a. Understand concerns of the Family
b. Acknowledge errors and learn lessons from the circumstances of the death. The Director of Operations and Matron informed the Trust Senior Management that the PSII Report had omissions. The Trust evidence was that it was an early adopter of the new NHS investigation process. The lead investigator did not report on material issues as to how Morgan-Rose was observed on the ward and the report was significantly delayed. Evidence was there was a pressure to sign the report off although it remained incomplete and did not contain a note about the limitations.
c.
d. Escalate concerns about staff observations - About 2 weeks after the death the Matron received a report that staff observations had not been appropriately conducted. This prompted a review of CCTV from the afternoon of Morgan-Rose’s death. There was insufficient scrutiny of the CCTV that showed that multiple observations entries made on 6 July 2022 after 14:06 hours could not be correct .
e. Understand security issues on a locked mental health ward - It has not been possible to establish the identity of the person that reset the bathroom alert triggered for Morgan-Rose on 6 July 2022 at 15:31. The Trust does not have an accurate records of Trust staff pass allocation. The Trust investigation did not establish that staff borrowed each other's security passes. On the day of Morgan-Rose’s death a visitor pass issued had had access to the nursing office. The Trust was unable to provide the identity of this person.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
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 .
” Open source report
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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 Develop a directly managed short-term service in South Essex for neuro-divergent young people.
Verbatim wording from the response “In South Essex, we are developing a similar short term service as the one referred to in Colchester. These services will be directly run and managed by the Council.” Source location Response from Essex County Council
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 Work with statutory partners, service providers and service users to identify housing needs and develop specialist care and support models.
Verbatim wording from the response “In addition to the specific developments noted above, the Council works closely with our statutory partners; the Borough & Districts and NHS along with service providers and people who use services to identify future housing needs and to develop specialist models of care and support.” Source location Response from Essex County Council
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 Repurpose Colchester accommodation into a four-bed short-term group home staffed by a multidisciplinary team.
Verbatim wording from the response “Alongside the solo provision, the Council is repurposing another accommodation in Colchester to be a group home. This will provide a 4 bedded short term (up to 6 months) placements, staffed by a multi-disciplinary team, to support neuro-divergent young people to live in the community.” Source location Response from Essex County Council
Open published response
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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 Develop a third solo children’s home through planning and a full rebuild.
Verbatim wording from the response “The Council has approval for four solo bespoke registered Children Homes to work with Children and Young people with high needs that struggle to live with other people for a variety of reasons.” Source location Response from Essex County Council
Open published response
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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 Operate an internally delivered solo bespoke children’s home in Colchester for young people with high needs.
Verbatim wording from the response “The Council has approval for four solo bespoke registered Children Homes to work with Children and Young people with high needs that struggle to live with other people for a variety of reasons.” Source location Response from Essex County Council
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 Submit capital bids for additional services for complex autistic young people with significant mental health issues, including single-person homes, move-on housing and preventative respite.
Verbatim wording from the response “Transforming Care Partnership:” Source location Response from Essex County Council
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 Establish a second Colchester solo children’s home through a tendered provider, subject to Ofsted registration.
Verbatim wording from the response “The Council has approval for four solo bespoke registered Children Homes to work with Children and Young people with high needs that struggle to live with other people for a variety of reasons.” Source location Response from Essex County Council
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 Improve relationships with residential providers to increase access to local placements.
Verbatim wording from the response “Residential Accommodation Strategy:” Source location Response from Essex County Council
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for commissioning hospital care rests with the NHS through Integrated Commissioning Boards and NHS England, not the Council.
Verbatim wording from the response “Essex County Council has a joint responsibility with three Integrated Commissioning Boards across Essex for meeting the health and care needs of the residents in Essex. This includes ensuring that there is a sufficient supply and range of specialist community placements and other forms of support for people with autism and co-existing mental health needs.” Source location Response from Essex County Council
Open published response
19 Feb 2023 Molly Ann Sergeant · Prevention of Future Deaths report Essex
View report summary
Concerns raised 13 Lack of escalation when assessment and discharge planning requests are not answered View source Lack of assessment of section 117 needs for discharge View source Delayed appointment of a social worker View source Failure to act on appropriate social care referrals View source Lack of understanding of section 117 Mental Health Act rights and entitlements View source Discharge planning that compels a choice between family members and changes homelessness status View source Lack of understanding of changing child-in-need assessment rights during detention View source Failure to conduct required assessments during detention View source Lack of appreciation of autism diagnosis and suicide risk in decision-making capacity View source Insufficient assessment of the impact of autism diagnosis in discharge planning View source Delayed diagnosis of autism View source Excessive key worker or care co-ordinator workload View source Insufficient consideration of autism diagnosis in relation to suicide risk during discharge planning View source See 10 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Molly Ann Sergeant · 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
Molly Ann Sergeant, aged 17, was found deceased on 16 October 2020 after hanging, having left a note. The report identifies concerns about delayed autism diagnosis, insufficient assessment and discharge planning, failures in social-care assessments and coordination, and a lack of understanding of her aftercare rights and chronic suicide risk.
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. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of escalation when assessment and discharge planning requests are not answered
Wider context from the report “(4) Lack of escalation to Essex County Council when there was a failure to respond to requests for assessment and attendance at discharge planning meetings and the key worker/care co-ordinator carrying too heavy a workload as a consequence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of assessment of section 117 needs for discharge
Wider context from the report “(6) A lack of understanding of section 117 Mental Health Act rights and potential for consideration for entitlements to meet Molly’s needs related to her mental health disorder, by Essex County Council:
a. compelling Molly to choose between family members as part of her discharge planning and then as a consequence changing Molly’s status during her detention from homeless.
b. Lack of assessment for any s117 needs to facilitate discharge
c. Lack of appreciation of the impact of Molly’s autism diagnosis in a background of chronic suicide risk on decision-making and Molly’s potential to understand the decisions being made.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Delayed appointment of a social worker
Wider context from the report “(5) Essex County Council did not:
a. act on appropriate referrals to social care by Essex Partnership NHS Trust
b. conduct required assessments of Molly during her detention
c. did not appoint a social worker until after Molly was discharged
There was a lack of understanding of the impact of Molly’s detention on her right to assessment as a child in need and how this changed during her detention under the Mental Health Act.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to act on appropriate social care referrals
Wider context from the report “(5) Essex County Council did not:
a. act on appropriate referrals to social care by Essex Partnership NHS Trust
b. conduct required assessments of Molly during her detention
c. did not appoint a social worker until after Molly was discharged
There was a lack of understanding of the impact of Molly’s detention on her right to assessment as a child in need and how this changed during her detention under the Mental Health Act.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of section 117 Mental Health Act rights and entitlements
Wider context from the report “(6) A lack of understanding of section 117 Mental Health Act rights and potential for consideration for entitlements to meet Molly’s needs related to her mental health disorder , by Essex County Council:
a. compelling Molly to choose between family members as part of her discharge planning and then as a consequence changing Molly’s status during her detention from homeless.
b. Lack of assessment for any s117 needs to facilitate discharge
c. Lack of appreciation of the impact of Molly’s autism diagnosis in a background of chronic suicide risk on decision-making and Molly’s potential to understand the decisions being made.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Discharge planning that compels a choice between family members and changes homelessness status
Wider context from the report “(6) A lack of understanding of section 117 Mental Health Act rights and potential for consideration for entitlements to meet Molly’s needs related to her mental health disorder, by Essex County Council:
a. compelling Molly to choose between family members as part of her discharge planning and then as a consequence changing Molly’s status during her detention from homeless .
b. Lack of assessment for any s117 needs to facilitate discharge
c. Lack of appreciation of the impact of Molly’s autism diagnosis in a background of chronic suicide risk on decision-making and Molly’s potential to understand the decisions being made.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of changing child-in-need assessment rights during detention
Wider context from the report “(5) Essex County Council did not:
a. act on appropriate referrals to social care by Essex Partnership NHS Trust
b. conduct required assessments of Molly during her detention
c. did not appoint a social worker until after Molly was discharged
There was a lack of understanding of the impact of Molly’s detention on her right to assessment as a child in need and how this changed during her detention under the Mental Health Act.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct required assessments during detention
Wider context from the report “(5) Essex County Council did not:
a. act on appropriate referrals to social care by Essex Partnership NHS Trust
b. conduct required assessments of Molly during her detention
c. did not appoint a social worker until after Molly was discharged
There was a lack of understanding of the impact of Molly’s detention on her right to assessment as a child in need and how this changed during her detention under the Mental Health Act.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of appreciation of autism diagnosis and suicide risk in decision-making capacity
Wider context from the report “(6) A lack of understanding of section 117 Mental Health Act rights and potential for consideration for entitlements to meet Molly’s needs related to her mental health disorder, by Essex County Council:
a. compelling Molly to choose between family members as part of her discharge planning and then as a consequence changing Molly’s status during her detention from homeless.
b. Lack of assessment for any s117 needs to facilitate discharge
c. Lack of appreciation of the impact of Molly’s autism diagnosis in a background of chronic suicide risk on decision-making and Molly’s potential to understand the decisions being made.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient assessment of the impact of autism diagnosis in discharge planning
Wider context from the report “(2) There was insufficient assessment for discharge planning purposes of the impact of Molly’s recent diagnosis of Autism by Essex Partnership NHS Foundation Trust
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Delayed diagnosis of autism
Wider context from the report “(1) Molly had a delayed diagnosis of Autism . Molly was diagnosed during her detention at the St. Aubyn Centre when she experienced a mental health crisis and detained under the Mental Health Act.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Excessive key worker or care co-ordinator workload
Wider context from the report “(4) Lack of escalation to Essex County Council when there was a failure to respond to requests for assessment and attendance at discharge planning meetings and the key worker/care co-ordinator carrying too heavy a workload as a consequence .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient consideration of autism diagnosis in relation to suicide risk during discharge planning
Wider context from the report “(3) There was insufficient consideration given to the impact of Molly’s delayed diagnosis of Autism on her chronic high risk of suicide in her discharge and discharge planning in a background of Molly not accepting her diagnosis.
” Open source report
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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 Require Child and Family Assessments and continued Social Care involvement for every young person admitted to a Tier 4 inpatient bed.
Verbatim wording from the response “There is now agreement that there will be a Child and Family Assessment for every young person admitted to an in-patient Tier 4 bed. This has been in place since January 2022 but has been re-emphasised to the Children and Families Hub and all operational social work teams since the Inquest. The initial communication stated that any young person admitted to a psychiatric in-patient unit is a child in need (by definition) and will receive a Child and Family Assessment. There is a specific audit being undertaken this Spring 2023 by our Professional Standards Unit to ensure that these are always taking place. The expectation is that the Young Person will have an allocated social worker throughout their stay as an in-patient.” Source location Response from Essex County Council
Open published response
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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 Audit whether Child and Family Assessments are consistently completed for young people admitted to Tier 4 inpatient beds.
Verbatim wording from the response “There is now agreement that there will be a Child and Family Assessment for every young person admitted to an in-patient Tier 4 bed. This has been in place since January 2022 but has been re-emphasised to the Children and Families Hub and all operational social work teams since the Inquest. The initial communication stated that any young person admitted to a psychiatric in-patient unit is a child in need (by definition) and will receive a Child and Family Assessment. There is a specific audit being undertaken this Spring 2023 by our Professional Standards Unit to ensure that these are always taking place. The expectation is that the Young Person will have an allocated social worker throughout their stay as an in-patient.” Source location Response from Essex County Council
Open published response
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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 Maintain the pan-Essex Section 117 protocol setting out multi-agency care planning processes, including accommodation responsibilities.
Verbatim wording from the response “There is a pan-Essex SET Section 117 Protocol which was published in April 2022. This highlights the primary purposes of Section 117 and is intended to articulate a clear process by which multi-agency care planning in the context of Section 117 should be undertaken. It makes clear reference to the provision of accommodation issues within the Section 117 arrangements. It is currently a 26-page document.” Source location Response from Essex County Council
Open published response
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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 Operate weekly multi-agency oversight meetings for autistic and learning-disabled young people in Tier 4 inpatient beds and coordinate safe discharge responsibilities.
Verbatim wording from the response “There are now weekly partnership meetings (from April 2022) at Senior Management level which specifically look at autistic young people and those with learning disabilities in Tier 4 (inpatient) beds. This meeting is chaired by the Director for Commissioning and Policy, Essex County Council and has representation from the Learning Disability / Autism Health Equalities Team ( including Commissioners and Case Managers), the Assistant Director of the Provider Collaborative ( Mental Health), Regional NHS England representation , ECC’s Head of Permanency and Placements, ECC’s Director from Children and Families, the Head of Individual Placements ( Health) and the Matron for the local Tier 4 beds.” Source location Response from Essex County Council
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 Deliver Section 117, Section 85, mental health and autism awareness training and awareness-raising for Children and Families staff.
Verbatim wording from the response “In relation to training and awareness-raising sessions across Children and Families in respect of Section 117, Section 85 and autism awareness, there has been extensive mental health training that has taken place throughout 2021 and 2022 and the dates of this training were previously submitted to the Coroner. Further Section 117 training sessions took place in January 2023 and further courses are due to take place in May and July 2023. The Essex Social Care Academy is currently working on additional commissioning options in relation to further mental health training and autism awareness” Source location Response from Essex County Council
Open published response
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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 Complete the draft Section 117 practice guidance and produce a Thinking Practice Tool to support Section 117 planning.
Verbatim wording from the response “The draft Section 117 practice guidance will be completed in the Spring 2023, and a “Thinking Practice Tool “will be produced to assist staff in relation to the issues involved in Section 117 planning.” Source location Response from Essex County Council
Open published response
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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 Develop and publish internal Section 117 guidance covering duties, processes and the Section 117 Panel.
Verbatim wording from the response “There is also an internal Section 117 guidance working group which has been developed by the Leads for Mental Health within ECC. This is due to be published in Spring 2023. This will cover Section 117 duties and responsibilities, the Section 117 process, the Section 117 Panel.” Source location Response from Essex County Council
Open published response
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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 Operate a monthly Mental Health Resolution Forum to resolve liaison issues between Children and Families, EWMHS and Tier 4 specialist commissioning.
Verbatim wording from the response “There is a Mental Health Resolution Forum which meets monthly – this focuses on liaison and resolution issues between Children and Families, EWMHS and Tier 4 Specialist Commissioning. Core agencies are represented at Director / Head of Service level. This was established in 2018” Source location Response from Essex County Council
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The acknowledged shortcomings were not causation or contributory factors in Molly’s death.
Verbatim wording from the response “It is not our view that these shortcomings, which we have fully acknowledged and have taken significant steps to ensure do not happen again, were causation factors or contributory factors which led to Molly’s very sad death.” Source location Response from Essex County Council
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Molly was not made to choose between family members during discharge planning; independent supported living was the only feasible alternative.
Verbatim wording from the response “It is not our view that Molly was made to choose between family members as part of her discharge planning; the only other feasible alternative for Molly would have been independent supported living accommodation, and no professional working with Molly thought this would be an appropriate option.” Source location Response from Essex County Council
Open published response
13 Jul 2020 Luiz Claudio Ramos Dos Anjos · Prevention of Future Deaths report Essex
View report summary
Concerns raised 1 Relatively easy access over the footbridge parapet and sides View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Luiz Claudio Ramos Dos Anjos · 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
Luiz Claudio Ramos Dos Anjos died on 7 November 2019 at the railway track at St Dominic’s footbridge, Colchester, from multiple traumatic injuries following a train collision. The report raised concern that the footbridge parapet and sides provided relatively easy access to the railway track, and stated that this issue had not been remedied.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Relatively easy access over the footbridge parapet and sides
Wider context from the report “The BTP post incident site report reported the following:-
1. No crisis signs at the location
2. Relatively easy access over the footbridge parapet and sides.
It is my understanding that point 1. has been remedied but not point 2.
The family of the deceased has photographs of the location which can be sent on to you.
” Open source report
16 Sep 2015 Mr David John James Charles · Prevention of Future Deaths report Essex
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Concerns raised 1 Unavailability of street lighting on a road used by pedestrians View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Mr David John James Charles · 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
On 29 November 2014, Mr David John James Charles was walking in the carriageway of Cranes Farm Road, Basildon, while under the influence of alcohol when he was struck by two cars and died from multiple injuries. The street lighting was switched off, and the report states that illumination would have improved his chance of being seen and given him a better chance of living.
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. The report was sent to Essex County Council; that does not assign responsibility.
PFD Monitor interpretation Unavailability of street lighting on a road used by pedestrians
Wider context from the report “It was a dark and dry night. The section of Cranes Farm Road on which Mr Charles was walking when he was struck is provided with a system of street lighting. The lighting was switched off at the time of this incident. In the case of each driver, the evidence was that they could have done nothing to avoid the collision. This was due to the lack of ambient light and lack of expectation of seeing a pedestrian in the carriageway. If the street lights had been illuminated it would have improved Mr Charles’s chance of being seen although this did not necessarily mean that either collision could have been avoided. It would, however, have given him a better chance of living.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations