Recipient

Essex Partnership University NHS Foundation Trust

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First report 25 Jun 2014•Latest report 1 Jun 2026

Recipient record

Reports, concerns and published responses

Health and care · NHS trust. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
53

Naming this recipient

Published responses
66%

Found for named reports

Concerns addressed
217

Across all linked responses

Stated actions
421

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

66%published responses found
421stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Essex Partnership University NHS Foundation Trust linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Essex

    AI-generated summary

    Katharine Emma Corrigan · 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

    Katharine Emma Corrigan, a patient detained under the Mental Health Act, died by suicide after failing to return from unescorted leave on 22 July 2023. The report identifies concerns about failures in the management and recording of Section 17 leave, inadequate risk assessments and care planning, staffing and oversight, and failures concerning access to recognised treatment for a pre-existing hormonal imbalance.

    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to report and audit unauthorised Section 17 Leave incidents

    Wider context from the report

    “4. There was a lack of Datix reports for Ms Corrigan accessing Section 17 leave when the leave had been rescinded by the Responsible Clinician. Datix is the incident reporting system utilised within the Trust. There had been no auditing of the new system and senior managers had not been aware that Ms Corrigan had repeatedly accessed unauthorised section 17 leave on multiple occasions prior to her death when they gave evidence at the inquest. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to respond appropriately to family concerns and communicate the patient’s treatment wishes

    Wider context from the report

    “10. The Family had raised repeated concerns that Ms Corrigan was not receiving appropriate treatment on the ward and about the risks to herself, verbally and in writing. The Family correspondence contained communications evidencing their concerns emanating from Ms Corrigan herself in text messages to the responsible clinician and other staff. Ms Corrigan was encouraged to undergo intensive psychoanalytical psychotherapy even though she explained she did not feel ready and her family did not know or understand about how rare this form of therapy is and relied on her treating clinical team. They were encouraged to fund this and convey her to the therapy in the community without an understanding that Ms Corrigan did not wish for it. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to prevent and scrutinise access to unauthorised or rescinded Section 17 Leave

    Wider context from the report

    “5. Ms Corrigan was absent without leave on multiple occasions and this had been facilitated by staff. There was a lack of scrutiny as to how and why Ms Corrigan was able to access leave that had not been authorised under section 17 Mental Health Act and/or had been rescinded by the Responsible Clinician due to risks of self-harm. On one occasion the Family went and searched for Ms Corrigan and returned her to the ward with reported risks that she was found near to train tracks and where her mother was buried. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Use of Oxehealth for observation outside its intended purpose

    Wider context from the report

    “11. A digital system ‘Oxehealth’ was used to observe Ms Corrigan using tweezers as a risk item. This is not the purpose of this system. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Promotion of inappropriate psychotherapy for immediate suicide risk despite the patient’s unwillingness

    Wider context from the report

    “9. Expert evidence was that Dialectic Behavioural Therapy can be useful for a patient like Ms Corrigan to attempt to find strategies for learned maladaptive behaviours with complex trauma. Ms Corrigan’s family were encouraged to privately fund intensive psychoanalytical psychotherapy as a mitigation for Ms Corrigan’s significant risk of killing herself. Expert evidence was that this was not a therapy modality which was understood to be appropriate for Ms Corrigan: a. specifically, to mitigate a significant and immediate risk of her ending her life b. for a detained patient with her presenting mental state and risks and, c. when Ms Corrigan had indicated that she did not wish to participate in it. d. When Ms Corrigan had not completed DBT. e. who was reporting nightmares and flashbacks of complex trauma. f. When it was understood by the professionals that this therapy would last for years and would involve delving into the unconscious. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure staff understand Section 17 Leave requirements and conduct required risk assessments

    Wider context from the report

    “2. Policies and protocols on section 17 Leave granted under the Mental Health Act (Section 17 Leave) were not properly understood by all staff and the required risk assessments were not conducted by appropriately qualified and trained 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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain collaborative, complete and accurate risk assessments and care plans

    Wider context from the report

    “6. Ms Corrigan’s risk assessment and care plans had not been appropriately updated in her medical records such that: a. They had not been developed in collaboration with her and did not contain: i. Early warning signs and triggers ii. Which mitigations were appropriate iii. Rationale as to why section 17 leaves were granted and/or rescinded b. With accurate risk information of her presentation and deterioration on the ward and with concerns raised by Family which were put in writing to the responsible clinician c. They contained inaccurate information on fire safety that had never been a part of her presentation . It was not understood where this had emanated from. d. That Ms Corrigan had tried to get rid of all her clothes and this was behaviour Ms Corrigan had previously displayed before attempting to end her life. e. That her mental health deteriorated in the days prior to her death and staff were concerned about the risks to herself due to her low mood. Nursing staff instigated the risk protocol such that Ms Corrigan should not have been able to access section 17 leave until reviewed by the multidisciplinary team and there was confusion about the Level of observations that had been put in place for Ms Corrigan on 21 July. Medical records and section 17 leave forms were not amended to ensure that staff could understand that due to her low mood with consequent risks, leave must not take place until a medical review. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide or record available non-contraindicated treatment for a pre-existing hormonal imbalance

    Wider context from the report

    “1. Ms Corrigan was undergoing recognised therapy consistent with the national guidelines for a pre-existing hormonal imbalance prior to her detention under the Mental Health Act and was prevented from continuing with it. Ms Corrigan’s Consultant Gynaecologist telephoned the ward and wrote twice to the Responsible Clinician setting out the history and his willingness to continue to treat Ms Corrigan with permission from her treating mental health team and on the second occasion with an alternative plan for treatment under a local NHS gynaecology team. There was no response, and Ms Corrigan was prevented from accessing this therapy. Expert evidence was that this therapy was not contraindicated. None of this was recorded appropriately in the medical records and no rationale given for Ms Corrigan not having the available treatment. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure qualified and clearly designated nurse-in-charge cover

    Wider context from the report

    “8. Preceptorship nurses were left in charge on the mental health ward on the morning of 22 July 2023 and a qualified nurse attended several hours after the commencement of the shift. This was known about and management staff did not check that the arrangements to mitigate this had been facilitated. There was no clear understanding of how and by whom the nurse in charge role was being undertaken. This contributed to Ms Corrigan accessing the community when leave had been removed temporarily by the ward manager the previous evening in accordance with protocol. The medical records were not clearly updated to reflect this, and the Section 17 Leave form had not been updated. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Electronic Section 17 Leave recording failing to preserve leave timings, conditions and return visibility

    Wider context from the report

    “3. Section 17 Leave forms and the process of recording of the required components for timings and conditions of such leave had been changed by the Trust in May 2023 from a paper system to electronic recording. The new system: a. omitted previously detailed information on the timings and conditions of the leave that included required scrutiny by a qualified mental health nurse. b. Staff then recorded some information on the Bed State document and evidence was this was not the purpose of this document and led to lack of visibility of any patient who had not returned at the specified time. This was not questioned or queried by senior staff. c. Senior management staff gave evidence that they were unaware of the lack of visibility of the conditions for Section 17 leave under the new electronic system of recording and had not been consulted when the changes were being made. This was still the system in place. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Overreliance on unsupervised preceptorship nurses for mental health ward roles

    Wider context from the report

    “7. There were known and ongoing issues with staffing and shift planning. There was an overreliance on preceptorship nurses who the Trust knew according to national and local policy and guidance, could not undertake all the roles required on the mental health ward unsupervised. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to update records and Section 17 Leave forms when risk requires medical review before leave

    Wider context from the report

    “6. Ms Corrigan’s risk assessment and care plans had not been appropriately updated in her medical records such that: a. They had not been developed in collaboration with her and did not contain: i. Early warning signs and triggers ii. Which mitigations were appropriate iii. Rationale as to why section 17 leaves were granted and/or rescinded b. With accurate risk information of her presentation and deterioration on the ward and with concerns raised by Family which were put in writing to the responsible clinician c. They contained inaccurate information on fire safety that had never been a part of her presentation . It was not understood where this had emanated from. d. That Ms Corrigan had tried to get rid of all her clothes and this was behaviour Ms Corrigan had previously displayed before attempting to end her life. e. That her mental health deteriorated in the days prior to her death and staff were concerned about the risks to herself due to her low mood. Nursing staff instigated the risk protocol such that Ms Corrigan should not have been able to access section 17 leave until reviewed by the multidisciplinary team and there was confusion about the Level of observations that had been put in place for Ms Corrigan on 21 July. Medical records and section 17 leave forms were not amended to ensure that staff could understand that due to her low mood with consequent risks, leave must not take place until a medical review. ”
    Open source report

  2. Essex

    AI-generated summary

    Abbigail Louise SMITH · 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

    Abbigail Louise Smith was found at Braintree Recreation Ground on 15 February 2022 and was pronounced deceased shortly after midnight on 16 February 2022 from compression of the neck by ligature. The report describes concerns about failures in mental-health care, communication, staff training, risk assessment and discharge planning, including her discharge to supported living without an adequate plan to mitigate a known risk of self-harm.

    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to record, review and query diagnostic changes

    Wider context from the report

    “2. The diagnosis of personality disorder was later reapplied to Abbi by a junior in the community with no rationale recorded and this was not noted or queried by the local community team or Consultant Psychiatrist. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Continuation and increase of Diazepam during crisis deterioration

    Wider context from the report

    “9. Abbi’s diazepam was continued and increased during her crisis and deterioration. Abbi was prescribed a treatment medication regime that had been unsuccessful in the past and had not mitigated attempts to end her life by ligature whilst she was detained in her last admission 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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain significant clinical information and escalate deterioration to the Consultant Psychiatrist

    Wider context from the report

    “3. In October 2021 Abbi suffered a deterioration in her mental health with reported non-compliance of Clozapine medication. The Consultant Psychiatrist emergency plan was not followed: a. Short-term prescription of Diazepam to assist with an exacerbation of distressing symptoms to permit Abbi’s Clozapine to be re-titrated was incorrectly continued as a permanent prescription in the absence of a medical review and this was not compliant with the NICE Guidelines. b. urgent follow-up required for a predicted and inevitable deterioration in the event of continued non-compliance did not take place. c. Abbi’s medical records were not updated as required; there were omissions in the significant information about Abbi’s clinical condition and Abbi was not escalated back to the Consultant Psychiatrist. These matters were then not understood by the mental health professionals as Abbi continued to deteriorate and increase in Abbi Diazepam was prescribed. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of up-to-date care plans and risk assessments for significant self-harm risk

    Wider context from the report

    “10. There were no up-to-date care plans and risk assessments in place for Abbi during her detention and when she was discharged to the community on 14 February 2022 to mitigate a known significant risk. Abbi had tied multiple tight ligatures during her 11-day admission under detention of the Mental Health Act and her usual clothing removed on 4 February due to her risks, the precise date her clothing was returned, and the rationale was not recorded. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Inclusion of inaccurate patient information in AMHP assessment documentation

    Wider context from the report

    “5. Abbi deteriorated significantly at the end of January 2022 and February 2022 requiring police to take Abbi to a place of safety due to her presentation and level of self-harm and suicidality that required a Mental Health Act assessment. Professional concerns were raised about inaccurate clinical information contained in the documentation from the Approved Mental Health Act Professional (AMHP) that were about another patient. Abbi made a video about the contents of this letter that reinforced her view that professionals did not care about her. Abbi received an apology about the inaccuracies in this AMHP assessment shortly before her death. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to mitigate use of a treatment regime known to be unsuccessful

    Wider context from the report

    “4. Abbi remained on a treatment regime during her last admission and discharge at the mental health Trust that was known and recorded as had not been previously successful. Abbi had positively responded to Clozapine in the past such that Abbi was discharged to supported living from the Tier 4 specialist unit. Abbi’s deterioration with continued non-compliance with Clozapine was recorded by the local community Consultant Psychiatrist as predicted and inevitable. No plans were put in place to mitigate this. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to review short-term Diazepam prescriptions before continuation

    Wider context from the report

    “3. In October 2021 Abbi suffered a deterioration in her mental health with reported non-compliance of Clozapine medication. The Consultant Psychiatrist emergency plan was not followed: a. Short-term prescription of Diazepam to assist with an exacerbation of distressing symptoms to permit Abbi’s Clozapine to be re-titrated was incorrectly continued as a permanent prescription in the absence of a medical review and this was not compliant with the NICE Guidelines. b. urgent follow-up required for a predicted and inevitable deterioration in the event of continued non-compliance did not take place. c. Abbi’s medical records were not updated as required; there were omissions in the significant information about Abbi’s clinical condition and Abbi was not escalated back to the Consultant Psychiatrist. These matters were then not understood by the mental health professionals as Abbi continued to deteriorate and increase in Abbi Diazepam was prescribed. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of multidisciplinary crisis planning meetings

    Wider context from the report

    “8. There were no professionals’ meetings to consider how best to respond to Abbi when in crisis and how crisis could be mitigated to avoid hospital admission. Abbi was a complex young woman who suffered an obvious and predicted deterioration. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to resolve unmet discharge conditions and escalated self-harm concerns before discharge

    Wider context from the report

    “11. On 9 February 2022 community mental health staff required 3 conditions to be met before they would support Abbi’s discharge, none of which were met on 14 February 2022. Abbi’s was a very complex patient and her care co-ordinator wanted to attend Abbi’s ward review on 14 February and emailed the consultant psychiatrist that she had not received a link. The ward review went ahead in absence of the care co-ordinator and concerns that the care co-ordinator had about Abbi’s risks of her harming herself and ending her life on the discharge were escalated. The plan did not change. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of understanding of Care, Education and Treatment Reviews

    Wider context from the report

    “14. There was a lack of understanding within the EPUT mental health teams of Care, Education and Treatment Reviews and that has continued. This could have prompted a professionals meeting for Abbi. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to verify service acceptance and agree an appropriate discharge care plan

    Wider context from the report

    “12. Abbi had anti-ligature bedding, and her room stripped of her possessions, and this remained in place at the time of her discharge. The responsible clinician was informed by a preceptorship nurse that the Home Treatment Team had refused to accept Abbi as she had a care co-ordinator. This information was known by the treating team to be incorrect, the Home Treatment team had agreed to see Abbi on 25 January 2022, and other patients had been assessed and discharged from the Ward with these arrangements previously. This was not checked or challenged, and Abbi was discharged without further discussion with professionals about an appropriate care plan. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to adapt communication and information presentation to neurodivergent patients

    Wider context from the report

    “7. Staff at were not trained in Autism or how to communicate with Abbi as a neurodivergent person with a learning disability. Expert evidence was that there was insufficient exploration of how this impacted specifically on Abbi and how to communicate with her and how information should have been presented to her about her diagnosis, care and treatment. The evidence of some later training was not considered sufficient. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of staff training in autism and communication with neurodivergent people with learning disabilities

    Wider context from the report

    “7. Staff at were not trained in Autism or how to communicate with Abbi as a neurodivergent person with a learning disability. Expert evidence was that there was insufficient exploration of how this impacted specifically on Abbi and how to communicate with her and how information should have been presented to her about her diagnosis, care and treatment. The evidence of some later training was not considered sufficient. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to record the timing and rationale for returning usual clothing after ligature risk

    Wider context from the report

    “10. There were no up-to-date care plans and risk assessments in place for Abbi during her detention and when she was discharged to the community on 14 February 2022 to mitigate a known significant risk. Abbi had tied multiple tight ligatures during her 11-day admission under detention of the Mental Health Act and her usual clothing removed on 4 February due to her risks, the precise date her clothing was returned, and the rationale was not recorded. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Use of insufficiently senior clinical assessment for complex mental health patients

    Wider context from the report

    “1. Abbi spent most of her adult life in detention and was Abbi was transferred to a specialist Tier 4 mental health hospital by EPUT for investigation and assessment of her diagnosis who confirmed she did not have personality disorder. Abbi was seen by very junior clinicians even though she was an extremely complex patient. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide urgent follow-up after predicted medication non-compliance deterioration

    Wider context from the report

    “3. In October 2021 Abbi suffered a deterioration in her mental health with reported non-compliance of Clozapine medication. The Consultant Psychiatrist emergency plan was not followed: a. Short-term prescription of Diazepam to assist with an exacerbation of distressing symptoms to permit Abbi’s Clozapine to be re-titrated was incorrectly continued as a permanent prescription in the absence of a medical review and this was not compliant with the NICE Guidelines. b. urgent follow-up required for a predicted and inevitable deterioration in the event of continued non-compliance did not take place. c. Abbi’s medical records were not updated as required; there were omissions in the significant information about Abbi’s clinical condition and Abbi was not escalated back to the Consultant Psychiatrist. These matters were then not understood by the mental health professionals as Abbi continued to deteriorate and increase in Abbi Diazepam was prescribed. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to review patient history and query inconsistencies in medical records

    Wider context from the report

    “6. There were issues in communication and sharing of information. Evidence was that some EPUT staff did not appreciate Abbi’s history and did not read the medical records or query inconsistencies. Not all clinical contacts were appropriately recorded. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to seek Home Treatment Team advice and implement the appropriate crisis pathway

    Wider context from the report

    “13. Although Abbi had some dialogue about the future on 15 February, she informed the community mental health team that she did not want to go on anymore, had lived her life, could not give any assurances for her safety and was declining help. Advice from the Home Treatment Team was not sought and the community team wanted to step up care, but this had not been put in place and was not the process to be followed for a crisis. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to appropriately record all clinical contacts

    Wider context from the report

    “6. There were issues in communication and sharing of information. Evidence was that some EPUT staff did not appreciate Abbi’s history and did not read the medical records or query inconsistencies. Not all clinical contacts were appropriately recorded. ”
    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

    Review and document MDT decisions on anti-ligature clothing and bedding through regular MDT and ward-review processes.

    Verbatim wording from the response

    “In the interests of safety and based on risk assessment, it is noted that Abbi was issued with anti-ligature clothing during her admission (with her clothes being returned after discharge); during this time her attempts at ligatures were reduced.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 9 · response
    Published 13 August 2026

    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

    Hold weekly ward discharge-planning meetings with key care workers and community leads, documenting complex-discharge actions.

    Verbatim wording from the response

    “Discharge Planning meetings occur throughout the patient’s admission, this ensures constant focus on how to support someone through to discharge and provides enhanced opportunities for MDT in-put.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 9 · response
    Published 13 August 2026

    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

    Provide sensory rooms and individual sensory boxes across Linden and Crystal Centres for patients requiring neurodiversity-related adjustments.

    Verbatim wording from the response

    “A range of different initiates are available on different wards, within the Linden Centre there are now Sensory Rooms within three of the wards (including Galleywood). The sensory rooms have dimmed lights, sensory equipment such as sensory chairs, rocking chairs, black out blinds, projectors, a water bed, and weighted blankets. These rooms have been developed with the help of Occupational Therapists, Psychology and the patients themselves and are available to use 24/7.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 6 · response
    Published 13 August 2026

    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

    Save care-related emails to patient records and deliver Trust-wide training on timely records storage.

    Verbatim wording from the response

    “• The Care Coordinator who was involved in Abbi’s care now ensures that all email documentation is saved on the patient’s records. In addition, Trust wide training has been delivered on the importance of ensuring full records are stored / saved in a timely manner into patient records.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 3 · response
    Published 13 August 2026

    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

    Maintain inpatient operating-model guidance on reasonable adjustments and support for adults with learning disabilities and autistic adults.

    Verbatim wording from the response

    “A number of steps have been taken to address Neurodiversity support within the Inpatient setting. There is a section on page 41/42 in the EPUT Therapeutic Acute Inpatient Operating Model for Adults and Older Adults’ (2024) with the heading ‘Adults with a learning disability and autistic adults’ which includes ‘reasonable adjustments’ and NHSE Guidance references, which includes key actions which need to take place for adults with a learning disability and autistic adults.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 6 · response
    Published 13 August 2026

    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

    Provide senior clinical supervision and consultant support to clinicians managing complex patients.

    Verbatim wording from the response

    “• Senior clinical supervision and consultant support is now available to all clinicians managing complex patients.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 2 · response
    Published 13 August 2026

    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

    Provide greater pharmacy input to inpatient MDTs and medication-history reviews through pharmacist participation.

    Verbatim wording from the response

    “There is now an Electronic Patient Medication System in place where clinicians are able to see the patient’s previous medical history in respect of previous hospital attendances and past medication reviews. There is now greater pharmacy input in place for Inpatient Services, with pharmacists now sitting in on MDT’s and supporting medication history reviews.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 8 · response
    Published 13 August 2026

    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 inpatient autism training developed from the National Autism Training Programme framework.

    Verbatim wording from the response

    “From a psychology perspective, a number of staff within the Trust have undertaken the National Autism Training Programme which has a specific focus on inpatient settings. The in-patient Psychology team have used this framework to develop a one day training around working with Autistic individuals for inpatient staff. This has been in operation for approximately 2 years at the Trust.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 7 · response
    Published 13 August 2026

    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

    Use Dynamic Support Register and Care and Treatment Review referral processes to coordinate enhanced community support and alternatives to hospital admission.

    Verbatim wording from the response

    “As stated above, the Trust has also implemented the MaST tool to identify patients at increased risk of crisis in order to facilitate earlier review. The Trust rolled out this tool from April 2024, which is now in place across all community teams. In addition, patients with autism and/or learning disabilities can now be referred through the Dynamic Support Register and Community Care and Treatment Review processes to bring agencies together to consider enhanced community support and alternatives to hospital admission.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 7 · response
    Published 13 August 2026

    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

    Conduct a Trust-wide community benzodiazepine-prescribing audit against NICE and BNF requirements and use findings for quality improvement.

    Verbatim wording from the response

    “• A Trust wide audit of benzodiazepine prescribing in the community has been commissioned to provide assurance that all prescribing adheres to NICE Guidelines and BNF guidance regarding indication, dosage, duration, and review, with findings informing quality improvement actions where required.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 3 · response
    Published 13 August 2026

    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

    Require all staff to complete national mandatory Oliver McGowan training.

    Verbatim wording from the response

    “All staff are now required to take part in the national mandatory Oliver McGowan training which was legislated on 1st July 2022, and rolled out at EPUT in 2023.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 5 · response
    Published 13 August 2026

    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

    Use ward-specific electronic dashboards and daily printed information to identify and address gaps in records, risk assessments, and care plans.

    Verbatim wording from the response

    “Management Teams and staff also have access to an electronic Trust dashboard which is specific to each ward and provides a full oversight of relevant ward information about their current patients (including records, risk assessments and care plans), this supported the identification of any record gaps that can then be promptly addressed. These are printed on a daily basis for staff.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 9 · response
    Published 13 August 2026

    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

    Provide increased psychology support for Positive Behaviour Support plans, Care and Treatment Reviews, and reasonable adjustments for autistic people.

    Verbatim wording from the response

    “In-patient Psychologists support around PBS (Positive Behaviour Support Plans) and CTRs (Care and Treatment Reviews). In terms of community teams, we have psychologists based in community teams who work to support colleagues around reasonable adjustments for working with Autistic individuals.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 7 · response
    Published 13 August 2026

    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

    Require short-term benzodiazepine prescribing, documented rationale, explicit review dates, and supervision-based monitoring of adherence.

    Verbatim wording from the response

    “• Consultant Psychiatrists are required to adhere to Trust policy and NICE guidance on benzodiazepine prescribing, with particular emphasis on short term use, clear documentation of clinical rationale, and explicit review dates. Adherence continues to be monitored via direct supervision reviews.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 3 · response
    Published 13 August 2026

    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

    Escalate medication non-adherence to the responsible Consultant Psychiatrist, discuss it in MDT and zoning meetings, assess risk, and document an agreed action plan.

    Verbatim wording from the response

    “• Upon staff becoming aware that a patient is not taking their medication as prescribed, immediate escalation is made to the responsible Consultant Psychiatrist, the case is discussed at the multidisciplinary team (MDT) meeting, risk is formally assessed and RAG-rated within the zoning meeting, and an agreed action plan is documented; a copy of the MDT minutes is uploaded to the patient’s electronic record (PARIS) and circulated to all relevant professionals.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 4 · response
    Published 13 August 2026

    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

    Use the MaST tool across community teams to monitor caseloads and identify patients needing additional support or follow-up.

    Verbatim wording from the response

    “Trust services also use the MaST tool to monitor and audit caseloads. MaST employs an algorithm which takes into account a number of different factors that might influence a patient's needs – like housing, medications, disabilities and other health conditions – and highlights where a patient may need additional support. The dashboard highlights patients who may be at increased risk of crisis. It also flags when patients have not been contacted recently, or need a follow-up appointment. While MaST is not designed to replace clinical expertise and judgement in managing their caseloads, it brings a range of relevant information into one place, enabling informed, evidence-based decisions.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 5 · response
    Published 13 August 2026

    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

    Recruit a Community and Inpatient Liaison Practitioner CPN to coordinate inpatient communication and safer discharge planning.

    Verbatim wording from the response

    “The GabIes Specialist Mental Health Team (SMHT) have recruited a new post, a Community and Inpatient Liaison Practitioner Community Psychiatric Nurse (CPN). This role is intended to work directly with inpatient services.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 7 · response
    Published 13 August 2026

    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

    Ensure Home First Home Team staff attend inpatient MDT meetings and ward reviews to coordinate discharge interventions.

    Verbatim wording from the response

    “A weekly discharge planning meeting is held on each ward with all key care workers and community leads present to highlight any complex discharges. This is documented within the action plan. Meetings may still proceed without a member of the community team being present. All members of the team have access to the records / MDT notes relating to planned discharges. All MDT’s and ward reviews have a member of staff from the Home First Home Team in attendance.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 9 · response
    Published 13 August 2026

    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

    Trigger urgent treatment-plan review jointly by the Care Coordinator and prescriber when patients miss appointments while prescribed time-limited medication.

    Verbatim wording from the response

    “• Non-attendance by a patient prescribed time-limited medication (such as benzodiazepines) will trigger an urgent review of treatment plan, raised jointly by the Care Coordinator and the prescribing medic, to ensure the ongoing appropriateness of the prescription is actively assessed.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 3 · response
    Published 13 August 2026

    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

    Provide neurodiversity-specific care plans with MDT involvement and access to Psychology and the Trust autism specialist.

    Verbatim wording from the response

    “Patients with an identified Neurodiversity need / diagnosis will have a specified care plan suited to their needs working alongside the MDT. Staff are also clear to seek the support of Psychology when a need is identified as well as the Trust- Autism Specialist, Dr Dakin.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 6 · response
    Published 13 August 2026

    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

    Strengthen documented clinical rationale and consultant oversight for amended or reapplied diagnoses in complex patients.

    Verbatim wording from the response

    “The Trust has strengthened requirements for documented clinical rationale when any diagnosis is amended or reapplied. Consultant oversight of diagnostic decisions for complex patients is an expectation within the community teams. The Community First team will further embed these expected standards structurally, by reducing Consultant caseloads and ensuring that oversight is achievable in practice.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 2 · response
    Published 13 August 2026

    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

    Conduct every-shift record-keeping audits at the Linden Centre and cascade identified corrective actions.

    Verbatim wording from the response

    “To ensure that risk assessments are up to standard, a record keeping audit is undertaken at every shift at the Linden Centre to monitor details, accuracy and that information is up to date particularly with recent incidents. This is undertaken by the allocated qualified staff member and any identified actions are cascaded at the end of every shift. Should any staff have an identified training need this will be addressed in supervision to ensure performance management.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 9 · response
    Published 13 August 2026

    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

    Reduce Community First consultant caseloads to make clinical oversight achievable in practice.

    Verbatim wording from the response

    “The Trust has strengthened requirements for documented clinical rationale when any diagnosis is amended or reapplied. Consultant oversight of diagnostic decisions for complex patients is an expectation within the community teams. The Community First team will further embed these expected standards structurally, by reducing Consultant caseloads and ensuring that oversight is achievable in practice.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 2 · response
    Published 13 August 2026

    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

    Revise Gables community-team allocation through senior nursing triage and consultant oversight based on patient complexity and clinician expertise.

    Verbatim wording from the response

    “In response, the Trust has taken the following actions:”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 1 · response
    Published 13 August 2026

    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

    Reinforce review of patient history and information gathering from consenting families through supervision and governance meetings.

    Verbatim wording from the response

    “A task and finish group was established as part of the Trust PSII Review Action Plan in respect of the vital importance of records review. In response to this concern, staff have been reminded again to review relevant patient history and gather information from family (where there is consent to do so). As per the evidence presented in court such reminders form part of structured supervision meetings as well as service governance meetings.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 5 · response
    Published 13 August 2026

    Open published response

    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 community crisis pathway requires additional community measures to be attempted before referral to the Home Treatment Team.

    Verbatim wording from the response

    “The Gables duly updated the team at the Pavilion where Abbi resided. It is important to note that Abbi would need to agree to the referral to the Home Treatment Team (HTT) before this could be arranged for her.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 11 · response
    Published 13 August 2026

    Open published response

    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

    A Home Treatment Team referral could not be arranged without the patient’s agreement.

    Verbatim wording from the response

    “It is important to note that the Home Treatment Team have 24hrs to complete their gatekeeping assessment, whereas the Gables SMHT saw her in less than 24hrs. In addition, the Gables attended to Abbi via a face to face review and made a call to Abbi on the morning of the 15ᵗʰ February 2022 to inform her of the discussion and plan to further support her via an MDT discussion.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 11 · response
    Published 13 August 2026

    Open published response

    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

    Diazepam or another benzodiazepine may be continued or increased during crisis when clinically indicated, because medications may not take effect immediately.

    Verbatim wording from the response

    “The Trust accepts that continued prescribing of Diazepam should have been supported by clearer review arrangements and consultant oversight. Please see responses to concerns 3 and 4.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 8 · response
    Published 13 August 2026

    Open published response

    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

    Discharge to community mental health services was considered appropriate and proportionate based on multidisciplinary risk assessment and the patient’s clinical presentation.

    Verbatim wording from the response

    “Abbi was reviewed by the Care Coordinator on the day following discharge. The contemporaneous clinical records indicate that the Care Coordinator assessed Abbi’s presentation and concluded that ongoing follow-up by the Community Mental Health Team was appropriate and that the Home Treatment Team involvement was not warranted at that stage. The risks identified at the time were recognised by both inpatient and community teams as longstanding and chronic in nature.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 9 · response
    Published 13 August 2026

    Open published response

    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 AMHP service falls outside the Trust’s remit because it is provided by Essex County Council.

    Verbatim wording from the response

    “Please note that the AMHP service is not provided by EPUT, this is provided by Essex County Council (ECC) who would be best placed to respond to this concern.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 5 · response
    Published 13 August 2026

    Open published response

    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

    Essex County Council, which provides the AMHP service, is best placed to respond to concerns about that service.

    Verbatim wording from the response

    “Please note that the AMHP service is not provided by EPUT, this is provided by Essex County Council (ECC) who would be best placed to respond to this concern.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 5 · response
    Published 13 August 2026

    Open published response

    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

    Stepped-up care from the community team was used instead of Home Treatment Team referral because it provided prompt, familiar and consistent support.

    Verbatim wording from the response

    “In line with the evidence provided at the Inquest, Abbi was keen to only work with those she was familiar with and had built a good rapport with which included her Care Co-ordinator who visited Abbi at home. The community team worked hard to build this rapport with Abbi and with the community team as a whole and arrange visits to support Abbi in an attempt to build rapport.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 10 · response
    Published 13 August 2026

    Open published response

    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

    Discharge planning meetings may proceed without a community team member because records and multidisciplinary notes remain accessible to all relevant staff.

    Verbatim wording from the response

    “Discharge Planning meetings occur throughout the patient’s admission, this ensures constant focus on how to support someone through to discharge and provides enhanced opportunities for MDT in-put.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 9 · response
    Published 13 August 2026

    Open published response

  3. Essex

    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. The report was sent to Essex Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of pharmacist scrutiny of medication changes

    Wider context from the report

    “2. Elise’s medication changes whilst in mental health hospital were not correctly entered onto the medication chart: a. Elise asked for changes to her medication and then reported that these changes were not therapeutic. It was agreed with her consultant that her previous regime would be implemented. The medication was crossed out and removed from the prescription chart. Sertraline 200mg was re-prescribed by the consultant but not entered onto the medication chart and not administered. b. Nursing staff did not query the sudden cessation of medication for treating mental health with no replacement or explanation given. Elise suffered a significant deterioration in her mental health during this time, the frequency and severity of ligatures increased, and Elise had to be placed under section 3 Mental Health Act. c. There was no pharmacist scrutiny just prior to the Bank Holiday and the medication error was only noted when questioned by Elise’s family when she went on home leave. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Incomplete, inaccurate and inconsistent care records

    Wider context from the report

    “9. Elise’s key nurse was working nights and was not having the required 1:1 with Elise and key documents were not completed for Elise’s care. Inaccuracies and inconsistencies in record-keeping remains a concern. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate supervision of patients moving between areas at mealtimes

    Wider context from the report

    “6. Detained patients including Elise were not kept under observations by trained staff and mealtimes were chaotic with patients moving between areas without the required supervision. On 17 April the activity co-ordinator left a box of mobile phone chargers and headphones that posed a ligature risk, with a member of ward staff in a communal area, asking that she look after this whilst he collected some takeaway food that had been ordered by patients from the ward entrance. On his return, the box was unattended in the presence of patients with a high risk of ligature and suicide, with no member of ward staff present to keep patients who required level 2 and level 3 observations. This was not reported to the nurse in charge, and no incident report was completed. Evidence was that there were many new staff and that breaches of procedure were a regular occurrence. This left patients at risk. Evidence was heard that patients are still being left without the required observations since this death. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Unsecured ligature-risk items in the presence of high-risk patients

    Wider context from the report

    “6. Detained patients including Elise were not kept under observations by trained staff and mealtimes were chaotic with patients moving between areas without the required supervision. On 17 April the activity co-ordinator left a box of mobile phone chargers and headphones that posed a ligature risk, with a member of ward staff in a communal area, asking that she look after this whilst he collected some takeaway food that had been ordered by patients from the ward entrance. On his return, the box was unattended in the presence of patients with a high risk of ligature and suicide, with no member of ward staff present to keep patients who required level 2 and level 3 observations. This was not reported to the nurse in charge, and no incident report was completed. Evidence was that there were many new staff and that breaches of procedure were a regular occurrence. This left patients at risk. Evidence was heard that patients are still being left without the required observations since this death. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to identify falsified observation records in post-death investigation

    Wider context from the report

    “4. Mental Health Trust staff falsified Elise’s observation records and this was not identified by the Trust post-death investigation despite the availability of timings from Oxevision imaging. This matter arose in an inquest that significantly post-dated Elise’s death and there is concern that lessons had not been learned. The Trust internal investigation does not refer to this and these matters are arising with scrutiny within the inquest hearing. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Incomplete risk assessments failing to include all ligatures

    Wider context from the report

    “5. The observation level for each young person is decided by the medical staff at the Trust and can be altered dependent on the patient’s risk level. The Trust Policy had a protocol on how observations should be conducted. All observations should be recorded by the staff on formal observation sheets. There were sheets for Level 1 and another sheet for the levels 2,3 & 4. Risk assessments were incomplete and not all ligatures were included. The entries in the records were not all consistent, some contradicted others and this included the levels of observations required to keep Elise safe on the observation charts that were required to be completed. This was confusing and remains a concern as these are entries made by qualified Trust staff who have received training in observations. During the Trust internal investigation after Elise’s death, the investigator visited the ward and found observations were not being conducted in accordance with the Trust Policy. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Delay in bringing the emergency grab bag

    Wider context from the report

    “10. Whilst this did not directly cause Elise’s death, there were plenty of staff who responded quickly to the emergency when Elise was found unresponsive but there was a delay: a. bringing the grab bag to this emergency b. obtaining and attaching the defibrillator. c. In notifying the duty doctor who was not contacted for over 40 minutes. d. The expert witness was of the opinion once the defibrillator was attached, it was being switched on and off in the first few minutes. When looking at the machine analysis there appeared to be 3 analysis checks on the machine within the first few minutes when the machine is set to conduct analysis at set intervals which is inconsistent with this. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Falsification of patient observation records

    Wider context from the report

    “4. Mental Health Trust staff falsified Elise’s observation records and this was not identified by the Trust post-death investigation despite the availability of timings from Oxevision imaging. This matter arose in an inquest that significantly post-dated Elise’s death and there is concern that lessons had not been learned. The Trust internal investigation does not refer to this and these matters are arising with scrutiny within the inquest hearing. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    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. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Delay in notifying the duty doctor during an emergency

    Wider context from the report

    “10. Whilst this did not directly cause Elise’s death, there were plenty of staff who responded quickly to the emergency when Elise was found unresponsive but there was a delay: a. bringing the grab bag to this emergency b. obtaining and attaching the defibrillator. c. In notifying the duty doctor who was not contacted for over 40 minutes. d. The expert witness was of the opinion once the defibrillator was attached, it was being switched on and off in the first few minutes. When looking at the machine analysis there appeared to be 3 analysis checks on the machine within the first few minutes when the machine is set to conduct analysis at set intervals which is inconsistent with this. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Inexperienced ward staffing for detained children

    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. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of nursing staff to query unexplained cessation of mental-health medication

    Wider context from the report

    “2. Elise’s medication changes whilst in mental health hospital were not correctly entered onto the medication chart: a. Elise asked for changes to her medication and then reported that these changes were not therapeutic. It was agreed with her consultant that her previous regime would be implemented. The medication was crossed out and removed from the prescription chart. Sertraline 200mg was re-prescribed by the consultant but not entered onto the medication chart and not administered. b. Nursing staff did not query the sudden cessation of medication for treating mental health with no replacement or explanation given. Elise suffered a significant deterioration in her mental health during this time, the frequency and severity of ligatures increased, and Elise had to be placed under section 3 Mental Health Act. c. There was no pharmacist scrutiny just prior to the Bank Holiday and the medication error was only noted when questioned by Elise’s family when she went on home leave. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    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. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of staff training in autism

    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. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to hand over vital self-harm and ligature information at shift change

    Wider context from the report

    “3. There was poor communication between ward staff and vital information about self-harm and ligaturing was not handed over on shift change. It was undisputed that Elise tied 12 Ligatures between 7ᵗʰ and 14ᵗʰ April and ████████ on 15 April. The Datix incident recording gave minimal details and only the ligatures from the 13ᵗʰ and 14ᵗʰ were recorded on the whiteboard in the nurse’s office. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Falsification of observation logs

    Wider context from the report

    “7. Oxevision imaging showed Elise entering her bedroom alone at approximately 18:10 hours and she remained in her room until she was found unresponsive at approximately 18:29. Elise’s observation logs for 17:30-18:30 on 17 April were falsified recording that Elise was in the communal area with checks completed at 17:30 17:40 17:50 18:00 18:10 and 18:20 recorded that Elise was present in the communal area. Elise was required to be on constant eyesight observations whilst in her bedroom. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Incorrect operation of the defibrillator during initial analysis

    Wider context from the report

    “10. Whilst this did not directly cause Elise’s death, there were plenty of staff who responded quickly to the emergency when Elise was found unresponsive but there was a delay: a. bringing the grab bag to this emergency b. obtaining and attaching the defibrillator. c. In notifying the duty doctor who was not contacted for over 40 minutes. d. The expert witness was of the opinion once the defibrillator was attached, it was being switched on and off in the first few minutes. When looking at the machine analysis there appeared to be 3 analysis checks on the machine within the first few minutes when the machine is set to conduct analysis at set intervals which is inconsistent with this. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Delay in obtaining and attaching the defibrillator

    Wider context from the report

    “10. Whilst this did not directly cause Elise’s death, there were plenty of staff who responded quickly to the emergency when Elise was found unresponsive but there was a delay: a. bringing the grab bag to this emergency b. obtaining and attaching the defibrillator. c. In notifying the duty doctor who was not contacted for over 40 minutes. d. The expert witness was of the opinion once the defibrillator was attached, it was being switched on and off in the first few minutes. When looking at the machine analysis there appeared to be 3 analysis checks on the machine within the first few minutes when the machine is set to conduct analysis at set intervals which is inconsistent with this. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Inconsistent and contradictory observation records

    Wider context from the report

    “5. The observation level for each young person is decided by the medical staff at the Trust and can be altered dependent on the patient’s risk level. The Trust Policy had a protocol on how observations should be conducted. All observations should be recorded by the staff on formal observation sheets. There were sheets for Level 1 and another sheet for the levels 2,3 & 4. Risk assessments were incomplete and not all ligatures were included. The entries in the records were not all consistent, some contradicted others and this included the levels of observations required to keep Elise safe on the observation charts that were required to be completed. This was confusing and remains a concern as these are entries made by qualified Trust staff who have received training in observations. During the Trust internal investigation after Elise’s death, the investigator visited the ward and found observations were not being conducted in accordance with the Trust Policy. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to report supervision and ligature-risk breaches

    Wider context from the report

    “6. Detained patients including Elise were not kept under observations by trained staff and mealtimes were chaotic with patients moving between areas without the required supervision. On 17 April the activity co-ordinator left a box of mobile phone chargers and headphones that posed a ligature risk, with a member of ward staff in a communal area, asking that she look after this whilst he collected some takeaway food that had been ordered by patients from the ward entrance. On his return, the box was unattended in the presence of patients with a high risk of ligature and suicide, with no member of ward staff present to keep patients who required level 2 and level 3 observations. This was not reported to the nurse in charge, and no incident report was completed. Evidence was that there were many new staff and that breaches of procedure were a regular occurrence. This left patients at risk. Evidence was heard that patients are still being left without the required observations since this death. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to conduct observations in accordance with Trust policy

    Wider context from the report

    “5. The observation level for each young person is decided by the medical staff at the Trust and can be altered dependent on the patient’s risk level. The Trust Policy had a protocol on how observations should be conducted. All observations should be recorded by the staff on formal observation sheets. There were sheets for Level 1 and another sheet for the levels 2,3 & 4. Risk assessments were incomplete and not all ligatures were included. The entries in the records were not all consistent, some contradicted others and this included the levels of observations required to keep Elise safe on the observation charts that were required to be completed. This was confusing and remains a concern as these are entries made by qualified Trust staff who have received training in observations. During the Trust internal investigation after Elise’s death, the investigator visited the ward and found observations were not being conducted in accordance with the Trust Policy. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide required key-nurse one-to-one sessions

    Wider context from the report

    “9. Elise’s key nurse was working nights and was not having the required 1:1 with Elise and key documents were not completed for Elise’s care. Inaccuracies and inconsistencies in record-keeping remains a concern. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide constant eyesight observations in a patient’s bedroom

    Wider context from the report

    “7. Oxevision imaging showed Elise entering her bedroom alone at approximately 18:10 hours and she remained in her room until she was found unresponsive at approximately 18:29. Elise’s observation logs for 17:30-18:30 on 17 April were falsified recording that Elise was in the communal area with checks completed at 17:30 17:40 17:50 18:00 18:10 and 18:20 recorded that Elise was present in the communal area. Elise was required to be on constant eyesight observations whilst in her bedroom. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    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. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to raise Datix incident reports

    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. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate recording of ligature incidents and risks

    Wider context from the report

    “3. There was poor communication between ward staff and vital information about self-harm and ligaturing was not handed over on shift change. It was undisputed that Elise tied 12 Ligatures between 7ᵗʰ and 14ᵗʰ April and ████████ on 15 April. The Datix incident recording gave minimal details and only the ligatures from the 13ᵗʰ and 14ᵗʰ were recorded on the whiteboard in the nurse’s office. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient staffing for required patient observations

    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. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to further investigate or monitor falsified observation records

    Wider context from the report

    “8. The mental health Trust were on notice that staff must have falsified the observations logs for Elise in 2021. Another inquest for a St. Aubyn’s patient who died on 12 July 2022, also found that observation logs were falsified and contained errors. Trust staff falsification of records were not further investigated or monitored after Elise’s death at St. Aubyn’s Centre. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to enter and administer re-prescribed medication

    Wider context from the report

    “2. Elise’s medication changes whilst in mental health hospital were not correctly entered onto the medication chart: a. Elise asked for changes to her medication and then reported that these changes were not therapeutic. It was agreed with her consultant that her previous regime would be implemented. The medication was crossed out and removed from the prescription chart. Sertraline 200mg was re-prescribed by the consultant but not entered onto the medication chart and not administered. b. Nursing staff did not query the sudden cessation of medication for treating mental health with no replacement or explanation given. Elise suffered a significant deterioration in her mental health during this time, the frequency and severity of ligatures increased, and Elise had to be placed under section 3 Mental Health Act. c. There was no pharmacist scrutiny just prior to the Bank Holiday and the medication error was only noted when questioned by Elise’s family when she went on home leave. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide required observations by trained staff

    Wider context from the report

    “6. Detained patients including Elise were not kept under observations by trained staff and mealtimes were chaotic with patients moving between areas without the required supervision. On 17 April the activity co-ordinator left a box of mobile phone chargers and headphones that posed a ligature risk, with a member of ward staff in a communal area, asking that she look after this whilst he collected some takeaway food that had been ordered by patients from the ward entrance. On his return, the box was unattended in the presence of patients with a high risk of ligature and suicide, with no member of ward staff present to keep patients who required level 2 and level 3 observations. This was not reported to the nurse in charge, and no incident report was completed. Evidence was that there were many new staff and that breaches of procedure were a regular occurrence. This left patients at risk. Evidence was heard that patients are still being left without the required observations since this death. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of project-board oversight of Oxevision rollout and interim safety arrangements

    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. ”
    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

    Implement patient-specific engagement and observation plans and maintain a maximum allocation of three level-two patients to one staff member in CAMHS.

    Verbatim wording from the response

    “▪ In June 2021 the Trust completed the new Engagement and Observation plan for each current inpatient, these were submitted to the CQC”

    Source location

    2026-0078 - Response from Essex University Partnership Trust
    Page 3 · response
    Published 13 February 2026

    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

    Further develop PSIIR support and quality-check tools, including detailed investigation checklists, care-team confirmation and organisational sign-off checks.

    Verbatim wording from the response

    “Proposed Improvement in PSIIs”

    Source location

    2026-0078 - Response from Essex University Partnership Trust
    Page 9 · response
    Published 13 February 2026

    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
    Page 5 · response
    Published 13 February 2026

    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

    Provide bespoke autism-awareness training within the CAMHS substantive-staff induction programme.

    Verbatim wording from the response

    “In addition to the above training, the Children and Young People’s mental health services (CAMHS) have a bespoke CAMHS Autism training which is part of a 4 day specific training module for substantive staff on appointment. Within this training, 2 days are focused on Autism awareness training. This training compliments the Oliver McGowan training (details of this training package were shared during the Inquest).”

    Source location

    2026-0078 - Response from Essex University Partnership Trust
    Page 2 · response
    Published 13 February 2026

    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

    Implement deteriorating-patient, non-touch-observation and emergency-call guidance tools and disseminate their learning to staff.

    Verbatim wording from the response

    “The ‘Assessing a Critically Unwell Patient’ Aide memoir document has been implemented within EPUT. The aim of the document is to help identify the deteriorating patient, treat and stabilise in order to prevent cardiac arrest and the resus bag will be taken to every unwell patient if an alarm is raised. The tool acts as an aide memoir to support the team carrying out the physical health assessment of the unwell patient. The aide-memoire must be located within the resus bags on the wards, so staff have easy access to the guidance during a medical emergency.”

    Source location

    2026-0078 - Response from Essex University Partnership Trust
    Page 12 · response
    Published 13 February 2026

    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

    Undertake medical-emergency simulations every three months in inpatient settings and record them using the approved report.

    Verbatim wording from the response

    “The Essex Partnership NHS Foundation Trust’s CPR procedure document (CLPG14A) states the Ward Manager, Matron or Service Manager/Clinical lead for each inpatient setting, will be responsible for ensuring that medical emergency simulations are undertaken every three months in the clinical environment. Each inpatient setting must record when a medical emergency simulation is facilitated, using the approved ‘Medical Emergency Simulation Practice Report’”

    Source location

    2026-0078 - Response from Essex University Partnership Trust
    Page 12 · response
    Published 13 February 2026

    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

    Implement staffing controls requiring appropriately skilled and inducted bank and agency staff, supported by rota review and competency oversight.

    Verbatim wording from the response

    “• A review of Rotas undertaken to ensure staffing requirements met including right staff with right training and competency skills.”

    Source location

    2026-0078 - Response from Essex University Partnership Trust
    Page 2 · response
    Published 13 February 2026

    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

    Implement enhanced escalation and local induction processes when CAMHS roster requirements or staff competencies are insufficient.

    Verbatim wording from the response

    “• The formulation of an enhanced escalation process when roster requirements are not met. This has been shared across all inpatient services.”

    Source location

    2026-0078 - Response from Essex University Partnership Trust
    Page 2 · response
    Published 13 February 2026

    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

    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
    Page 4 · response
    Published 13 February 2026

    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

    Implement electronic SBAR handovers to improve communication of patient safety information between shifts.

    Verbatim wording from the response

    “The Trust has also implemented changes to handover process using SBAR – an electronic handover system.”

    Source location

    2026-0078 - Response from Essex University Partnership Trust
    Page 8 · response
    Published 13 February 2026

    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

    Continue developing and refreshing personalised, descriptive risk assessments and safety plans, with daily prioritisation of significant risks.

    Verbatim wording from the response

    “In summary, risk assessment at the Trust have moved away from RAG rating and become more descriptive. This is part of the Trust move towards personalised risk assessment and safety planning in line with NICE guidance.”

    Source location

    2026-0078 - Response from Essex University Partnership Trust
    Page 13 · response
    Published 13 February 2026

    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

    Continue the Record Keeping Safety Improvement Programme to improve documentation through education and guidance.

    Verbatim wording from the response

    “The Trust has continued with a Record Keeping Safety Improvement Programme (SIP). This SIP program is focusing on improving patient safety in respect of documentation specifically through education and development of appropriate guidance.”

    Source location

    2026-0078 - Response from Essex University Partnership Trust
    Page 11 · response
    Published 13 February 2026

    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
    Page 6 · response
    Published 13 February 2026

    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

    Implement Oliver McGowan mandatory learning-disability and autism training across the Trust.

    Verbatim wording from the response

    “Response: During the evidence provided at this Inquest, it was acknowledged that the Trust did not have autism training provisions in place at the time of the incident. As part of the learning that has been taken from this case, the ‘Oliver McGowan’ training module has been implemented at the Trust.”

    Source location

    2026-0078 - Response from Essex University Partnership Trust
    Page 1 · response
    Published 13 February 2026

    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 CAMHS incident learning through ABC-format Datix records, staff training, action recording and ligature-risk categorisation.

    Verbatim wording from the response

    “▪ Training with preceptor nurses as part of induction”

    Source location

    2026-0078 - Response from Essex University Partnership Trust
    Page 8 · response
    Published 13 February 2026

    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

    Introduce Resus Link Practitioners across inpatient wards to support simulations, equipment readiness, life-support training, audit and dissemination of updates.

    Verbatim wording from the response

    “The Trust has also introduced the role of Resus Link Practitioners (RLP) to all inpatient ward settings. These volunteers will play a key role in strengthening the response to medical emergency situations within the wards. The role is open to all nurses and HCAs/support workers and the RLP will act as a link between the Resuscitation and Deteriorating Patient Group and their ward, promoting best practice and raising awareness. The RLP will:”

    Source location

    2026-0078 - Response from Essex University Partnership Trust
    Page 13 · response
    Published 13 February 2026

    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

    Discuss medication changes at multidisciplinary reviews and re-check prescriptions during those reviews.

    Verbatim wording from the response

    “To strengthen medicines management, medication changes are discussed at the MDT and prescriptions are re-checked during this review.”

    Source location

    2026-0078 - Response from Essex University Partnership Trust
    Page 7 · response
    Published 13 February 2026

    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

    Implement electronic prescribing and medicines administration safeguards against omitted medicines during prescription-chart changes.

    Verbatim wording from the response

    “The Trust has since intruded an electronic prescribing and medicines administration (ePMA) system. This new system provides safeguards around prescribing. ePMA will help prevent inadvertent omission of medicines which could occur when a paper drug chart reached completion and has to be rewritten.”

    Source location

    2026-0078 - Response from Essex University Partnership Trust
    Page 6 · response
    Published 13 February 2026

    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

    Facilitate life-support refresher sessions for CAMHS staff between mandatory training sessions.

    Verbatim wording from the response

    “The Head of Deteriorating Patient Pathways and Resuscitation Training Officer and The Head of Clinical Transformation have facilitated life support drop in refreshers sessions for EPUT staff working within a CAMHS setting. These sessions are an opportunity for staff to refresh their knowledge of BLS/ILS in small groups, in between their mandatory training sessions, including refreshers on topics such as chest compressions and airway management.”

    Source location

    2026-0078 - Response from Essex University Partnership Trust
    Page 12 · response
    Published 13 February 2026

    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

    Increase CAMHS staffing capacity and strengthen leadership through additional shift staff, retention premiums, new management and preceptor-support roles, and activity coordinators.

    Verbatim wording from the response

    “• The provision of a retention premium for band 5’s posts”

    Source location

    2026-0078 - Response from Essex University Partnership Trust
    Page 2 · response
    Published 13 February 2026

    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

    Remind staff through supervision to apply professional curiosity and challenge when medication changes require clarification.

    Verbatim wording from the response

    “Response Staff have been reminded via supervision sessions of the importance of applying professional curiosity and challenge as needed.”

    Source location

    2026-0078 - Response from Essex University Partnership Trust
    Page 7 · response
    Published 13 February 2026

    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

    Implement Trust-wide incident-reporting improvements covering form revisions, risk-assessment prompts, change communications, reporter feedback and completion of key fields.

    Verbatim wording from the response

    “The Trust undertook a project as part of a Trust-wide CQC action plan to improve incident reporting (both to ensure all incidents are recorded and to ensure all key information was captured in the incident). Actions taken have included:”

    Source location

    2026-0078 - Response from Essex University Partnership Trust
    Page 8 · response
    Published 13 February 2026

    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

    Continue developing CAMHS preceptorship and workforce planning, and use the Mental Health Optimal Staffing Tool across the Trust.

    Verbatim wording from the response

    “• Work has continued to develop staff and the CAMHS Preceptorship programme in place, guided practice development framework, led by band 6 practice development role.”

    Source location

    2026-0078 - Response from Essex University Partnership Trust
    Page 3 · response
    Published 13 February 2026

    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 annual face-to-face Immediate Life Support training to registered inpatient nurses and annual Basic Life Support training to non-registered CAMHS inpatient staff.

    Verbatim wording from the response

    “The Trust has made the decision to deliver the ‘gold standard’ Resuscitation Council UK Immediate Life Support (RCUK ILS) training to all registered nursing staff working within an inpatient setting. RCUK ILS training was rolled out from September 2022. The one day face to face training is accompanied by a RCUK ILS ‘hard copy’ training manual and is delivered on an annual basis.”

    Source location

    2026-0078 - Response from Essex University Partnership Trust
    Page 12 · response
    Published 13 February 2026

    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

    Implement daily handover checks and weekly audits to verify completion and appropriateness of patient observations.

    Verbatim wording from the response

    “▪ The Trust developed a daily handover checking audit to ensure observations were fully completed during shifts”

    Source location

    2026-0078 - Response from Essex University Partnership Trust
    Page 3 · response
    Published 13 February 2026

    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

    Strengthen observation monitoring through nurse-in-charge checks, handover checks, compliance audits, escalation, and staff accountability processes.

    Verbatim wording from the response

    “▪ The Nurse in Charge checks Observations intermittently during the day to ensure completed and takes immediate action with staff where any gaps are found in relation to administrative / recording errors.”

    Source location

    2026-0078 - Response from Essex University Partnership Trust
    Page 4 · response
    Published 13 February 2026

    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

    Implement electronic observations, staff training videos, engagement plans, and revised observation policies and procedures.

    Verbatim wording from the response

    “A Trust Observation and Engagement project group was established in 2021 who took forward a number of actions Trust wide. The CAMHS staff were part of this project. Actions included:”

    Source location

    2026-0078 - Response from Essex University Partnership Trust
    Page 4 · response
    Published 13 February 2026

    Open published response

    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 concern is factually incorrect because the 2022 inquest concerned a Derwent Centre patient, not a St Aubyn’s Centre patient.

    Verbatim wording from the response

    “Concern 8) The mental health Trust were on notice that staff must falsify the observations logs for Elise in 2021. Another inquest for a St. Aubyn’s patient who died on 12 July 2022, also found that observation logs were falsified and contained errors. Trust staff falsification of records were not further investigated or monitored after Elise’s death at St. Aubyn’s Centre.”

    Source location

    2026-0078 - Response from Essex University Partnership Trust
    Page 11 · response
    Published 13 February 2026

    Open published response

    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

    A pharmacist’s physical ward presence may not always be possible, although remote prescription screening provides an alternative safeguard.

    Verbatim wording from the response

    “Response In April 2021 three pharmacist posts were based at Colchester, one of which was vacant, one working from home due to COVID shielding, leaving only one (the most junior) on site. So whilst the clinical pharmacy rota included a weekly visit, that may not have been possible every week.”

    Source location

    2026-0078 - Response from Essex University Partnership Trust
    Page 7 · response
    Published 13 February 2026

    Open published response

    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

    Existing systems are considered robust enough to identify missed observations and ensure appropriate follow-up action with staff.

    Verbatim wording from the response

    “Response The Trust acknowledges that there are times when observations are not carried out in line with observation prescriptions. This is often down to human error. As outlined above there are robust systems in place to identify missed observations and the onward action that is addressed with staff.”

    Source location

    2026-0078 - Response from Essex University Partnership Trust
    Page 10 · response
    Published 13 February 2026

    Open published response

    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

    Existing monitoring by charge nurses, record review and reallocation processes is considered sufficient to address gaps in patients’ weekly key-nurse one-to-ones.

    Verbatim wording from the response

    “Response By way of assurance on this, the Court is advised that all staff are part of internal rotation, which includes nursing staff being rostered to work night and day duties. The night shifts start at 7pm; this enables staff to have 1:1 with patients during the course of the evening. This is often preferable for the young person depending on activities during the day. During the day, the unit provides a full education programme and therapeutic programme outside of education hours. Therefore, spending time with key nurse outside of these hours often means this is quality, uninterrupted time with patients.”

    Source location

    2026-0078 - Response from Essex University Partnership Trust
    Page 11 · response
    Published 13 February 2026

    Open published response

    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

    Environmental risks cannot be eliminated entirely, so safety work is limited to minimising risks without introducing restrictive practice.

    Verbatim wording from the response

    “There are a range of potential environmental risks on all wards. The Trust has a set of Environmental Standards to minimise risks and utilise reduced ligature products but it is not possible to eliminate all risks. Part of environmental risk mitigation is the observation level assigned to each person, based on that individual persons risks. Observation is about having a presence and engaging with patients and to empower staff to be curious and knowledgeable of the risks and mindful of the complexities of each individual patient.”

    Source location

    2026-0078 - Response from Essex University Partnership Trust
    Page 10 · response
    Published 13 February 2026

    Open published response

  4. Essex

    AI-generated summary

    Martin Douglas Bryant · 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

    Martin Douglas Bryant died by suicide on 19 January 2025 after presenting to the Mental Health Urgent Care Department following a suicide attempt. While awaiting informal admission and a bed, he was asked to wait in an open reception area from which he was free to come and go, and he subsequently left and did not return. The substantive concerns related to reliance on this waiting arrangement, the suitability of the waiting area, and shortages of mental health admission beds resulting in prolonged waits.

    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate capacity for suitable waiting accommodation within the MHUCD

    Wider context from the report

    “2. EPUT’s ability to accommodate improvement to where people wait within the MHUCD, particularly in light of the evidence given by nursing staff and the indication that rooms will always need to be kept vacant for patients requiring triage or assessment. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Reliance on an open reception area for people in mental health crisis while medical authority or beds are secured

    Wider context from the report

    “1. The reliance by EPUT that those suffering a mental health crisis will wait in the MHUCD’s open reception area, from which they are free to come and go as desired, whilst medical authority and/or beds are secured for them. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of locally and nationally available beds for mental health admissions

    Wider context from the report

    “3. The lack of beds, locally and nationally, for mental health admissions and the suggestion given in evidence that patients can be waiting in the open reception area for days or sometimes weeks for a bed. ”
    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

    Advise staff not to over-rely on partner support and share this learning through governance and wider learning structures.

    Verbatim wording from the response

    “Staff have been advised on the need to ensure there is not an over reliance on partner support; this learning is being shared via the care unit quality and safety governance structure and the wider learning functions through the ‘Learning Oversight Scrutiny Committee (LOSC)’. As the Court will be aware, the Trust may not detain a patient without legal authority to do so. Where appropriate, and if this is deemed in the patient’s best interests, common law is applied to restrain if a patient is deemed at risk. These safeguards remain available to the Trust in order to keep patients safe in a proportionate and lawful manner.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 26 January 2026

    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 ICBs, NHS England and system partners to address admission and discharge bed pressures, including delayed community discharges.

    Verbatim wording from the response

    “We are also working closely with our integrated care boards (ICBs), NHSE and wider system partners re bed pressures for admission and discharge to and from EPUT beds. This has included a recent workshop with Essex county council to review delayed discharges from EPUT beds into the community where accommodation needs are delaying discharges.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 3 · response
    Published 26 January 2026

    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

    Apply criteria and escalation processes for temporarily closing the MHUCD when safe staffing, capacity, acuity, complexity or triage thresholds are exceeded.

    Verbatim wording from the response

    “The MHUCD is no different in terms of waiting area as that of an A&E waiting area. However, the MHUCD has a clear criteria and escalation process in place for the temporary closure of the department, based on patient acuity and complexity exceeding safe staffing and resource levels, Triage times at risk of breaching the 30 minute standard, three of the five Assessment Rooms occupied by patients who cannot be safely managed in the waiting area and the department is at full capacity, including walk in patients. If capacity is reached and people can no longer be assessed or accommodated safely within the MHUCD, the department can temporarily be closed and patients will be diverted to local EDs during this time.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 26 January 2026

    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 MHUCD capacity daily and escalate capacity issues through scheduled locality and senior bed escalation meetings.

    Verbatim wording from the response

    “Capacity of the unit is reviewed and there is the opportunity for escalation at the morning and afternoon MSE Locality Sit rep calls seven days a week. Capacity issues can also be escalated at lunchtime Senior Bed Escalation Huddles, which are held Monday-Friday.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 26 January 2026

    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

    Keep vulnerable patients in swipe-access assessment rooms when risk assessment indicates reception waiting is unsafe.

    Verbatim wording from the response

    “This risk assessment is used to identify if someone is safe to wait in reception area and if not they will remain in an assessment room (this information was included in the action plan shared with Coroner and process had changed at point of inquest).”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 1 · response
    Published 26 January 2026

    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

    Require risk assessment for patients waiting for medical review or beds, with escalation when necessary.

    Verbatim wording from the response

    “In order to address the risks associated with waiting in an open reception area, management process has changed to ensure a risk assessment has been undertaken whilst patients await medical review and / or beds are secured for them. There are clear escalation processes in place when patients are waiting for beds.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 1 · response
    Published 26 January 2026

    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

    Implement the Therapeutic acute Inpatient Operating Model to reduce length of stay and support purposeful admissions, flow and safe discharge planning.

    Verbatim wording from the response

    “As per the evidence provided to the Court, the Trust has implemented the Therapeutic acute Inpatient Operating Model for adults and older adults. The objective of this model is to reduce length of stay when a patient requires hospital admission. This model aligns with national guidance around purposeful admissions including capacity and flow, therapeutic benefit, proactive, safe and effective discharge/transfer planning and trauma informed care.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 3 · response
    Published 26 January 2026

    Open published response

    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

    NHS England is responsible for responding to concerns about the local and national shortage of mental health admission beds.

    Verbatim wording from the response

    “Response: We respectfully advise that this concern is for NHS England to respond to. However, in an effort to provide assurance on this point, the Trust provided assurance re: the availability of beds as part of our evidence at this Inquest, namely that this continues to be a challenge for the Trust / the NHS as a whole. Every effort is made to assess and manage patients in a safe and timely manner, again flow and capacity challenges remain, leading to patients having to wait to be seen in the UCD.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 26 January 2026

    Open published response

    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

    Existing capacity criteria and escalation processes allow the MHUCD to close temporarily and divert patients when safe accommodation is unavailable.

    Verbatim wording from the response

    “The MHUCD is no different in terms of waiting area as that of an A&E waiting area. However, the MHUCD has a clear criteria and escalation process in place for the temporary closure of the department, based on patient acuity and complexity exceeding safe staffing and resource levels, Triage times at risk of breaching the 30 minute standard, three of the five Assessment Rooms occupied by patients who cannot be safely managed in the waiting area and the department is at full capacity, including walk in patients. If capacity is reached and people can no longer be assessed or accommodated safely within the MHUCD, the department can temporarily be closed and patients will be diverted to local EDs during this time.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 26 January 2026

    Open published response

    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 Trust cannot detain patients without legal authority, limiting its ability to keep patients safe through detention.

    Verbatim wording from the response

    “Staff have been advised on the need to ensure there is not an over reliance on partner support; this learning is being shared via the care unit quality and safety governance structure and the wider learning functions through the ‘Learning Oversight Scrutiny Committee (LOSC)’. As the Court will be aware, the Trust may not detain a patient without legal authority to do so. Where appropriate, and if this is deemed in the patient’s best interests, common law is applied to restrain if a patient is deemed at risk. These safeguards remain available to the Trust in order to keep patients safe in a proportionate and lawful manner.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 26 January 2026

    Open published response

    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

    Temporary bank staff may not have known about changes made to the MHUCD’s waiting arrangements.

    Verbatim wording from the response

    “Response: It is noted that witnesses in this Inquest were temporary bank staff and may not have been aware of changes that had been undertaken in respect of this concern (please also see our reply to under concern 1 above).”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 26 January 2026

    Open published response

  5. Essex

    AI-generated summary

    STUART CHRISTOPHER JAMES BERRY · 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

    STUART CHRISTOPHER JAMES BERRY, who had a history of mental health issues and significant cocaine misuse, was remanded to HMP Chelmsford on 27 January 2024 after expressing an intention to end his life. He was found suspended in his cell about seven hours after arrival and died at Broomfield Hospital on 1 February 2024; the medical cause of death was hanging and the jury concluded suicide. The principal concerns included failures in mental-health care, communication and risk documentation, failure to share information about his extreme suicide risk, inadequate assessment and supervision in prison, and the accessibility of cell-window ligature points.

    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to share critical suicide-risk information with prison staff

    Wider context from the report

    “In addition to failing to share crucial and obviously relevant information regarding Mr Berry’s extreme risk of suicide provided by the CPN at Court with prison staff, the jury found that the reception nurse, in the context of the clear information known to her, failed to: (a) document his risk of self-harm and suicide in the Systm One records and (b) failed to refer Mr Berry, that day, for an urgent review by the Mental Health team. CONCERN: Such comprehensive shortcomings in performance in respect of information sharing, conduct of assessments, basic documentation and escalation/referral on to relevant colleagues indicates (a) a failure in training of a very concerning kind, alongside (b) a failure in HCRG monitoring of standards, supervision and quality assurance processes to identify and address such extensive failures in performance. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of liaison with external specialist substance misuse services

    Wider context from the report

    “CONCERN: During Mr Berry’s inquest, once again, many of the continuing failings under precisely the themes identified in the 2024 ‘Thematic Review’ and in PFDR responses prior to that review as well as in the period since that Review, have been identified as having informed the causative features contributing to the death of a patient under EPUT’s care. In my opinion, the actions taken by EPUT to date to address the acknowledged failings reflected under the themes and issues referred to above have been, and remain, inadequate and incomplete, specifically: (a) Failures in the performance of the CMHT and the allocated Care Coordinator as required under the Care Programme Approach (CPA) and as mandated by EPUT policy. These failures indicated significant human error not detected by an insufficiently robust system and not therefore corrected prior to the death: (b) Failures in Care Planning: specifically, a failure to appropriately up-date and document matters relating to Mr Berry’s Care Plan consistent with Trust policy. (c) Failures in Risk Assessments: specifically, failures to appropriately up-date and document matters relating to Mr Berry’s risk assessment consistent with Trust policy. (d) Failures in Documentation: in a number of acknowledged respects the electronic records were inadequate - and inconsistent with EPUT policy. (e) Failure of joint working internally: the CC did not attempt to escalate or consult with EPUT colleagues via the regular weekly MTD meeting or any other type of Professionals’ Meeting. (f) Failure of joint working externally: the CC did not liaise at all with the external specialist substance misuse team, even though the cocaine misuse was a central aspect of his presentation and mental health deterioration. (g) Failures in Communication within and between teams as above but also, crucially, including a failure to appropriately liaise with the deceased’s Family to gather collateral information and to provide a carer’s assessment and/or support to Mr Berry’s family. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of internal multidisciplinary joint working

    Wider context from the report

    “CONCERN: During Mr Berry’s inquest, once again, many of the continuing failings under precisely the themes identified in the 2024 ‘Thematic Review’ and in PFDR responses prior to that review as well as in the period since that Review, have been identified as having informed the causative features contributing to the death of a patient under EPUT’s care. In my opinion, the actions taken by EPUT to date to address the acknowledged failings reflected under the themes and issues referred to above have been, and remain, inadequate and incomplete, specifically: (a) Failures in the performance of the CMHT and the allocated Care Coordinator as required under the Care Programme Approach (CPA) and as mandated by EPUT policy. These failures indicated significant human error not detected by an insufficiently robust system and not therefore corrected prior to the death: (b) Failures in Care Planning: specifically, a failure to appropriately up-date and document matters relating to Mr Berry’s Care Plan consistent with Trust policy. (c) Failures in Risk Assessments: specifically, failures to appropriately up-date and document matters relating to Mr Berry’s risk assessment consistent with Trust policy. (d) Failures in Documentation: in a number of acknowledged respects the electronic records were inadequate - and inconsistent with EPUT policy. (e) Failure of joint working internally: the CC did not attempt to escalate or consult with EPUT colleagues via the regular weekly MTD meeting or any other type of Professionals’ Meeting. (f) Failure of joint working externally: the CC did not liaise at all with the external specialist substance misuse team, even though the cocaine misuse was a central aspect of his presentation and mental health deterioration. (g) Failures in Communication within and between teams as above but also, crucially, including a failure to appropriately liaise with the deceased’s Family to gather collateral information and to provide a carer’s assessment and/or support to Mr Berry’s family. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to update and document risk assessments

    Wider context from the report

    “CONCERN: During Mr Berry’s inquest, once again, many of the continuing failings under precisely the themes identified in the 2024 ‘Thematic Review’ and in PFDR responses prior to that review as well as in the period since that Review, have been identified as having informed the causative features contributing to the death of a patient under EPUT’s care. In my opinion, the actions taken by EPUT to date to address the acknowledged failings reflected under the themes and issues referred to above have been, and remain, inadequate and incomplete, specifically: (a) Failures in the performance of the CMHT and the allocated Care Coordinator as required under the Care Programme Approach (CPA) and as mandated by EPUT policy. These failures indicated significant human error not detected by an insufficiently robust system and not therefore corrected prior to the death: (b) Failures in Care Planning: specifically, a failure to appropriately up-date and document matters relating to Mr Berry’s Care Plan consistent with Trust policy. (c) Failures in Risk Assessments: specifically, failures to appropriately up-date and document matters relating to Mr Berry’s risk assessment consistent with Trust policy. (d) Failures in Documentation: in a number of acknowledged respects the electronic records were inadequate - and inconsistent with EPUT policy. (e) Failure of joint working internally: the CC did not attempt to escalate or consult with EPUT colleagues via the regular weekly MTD meeting or any other type of Professionals’ Meeting. (f) Failure of joint working externally: the CC did not liaise at all with the external specialist substance misuse team, even though the cocaine misuse was a central aspect of his presentation and mental health deterioration. (g) Failures in Communication within and between teams as above but also, crucially, including a failure to appropriately liaise with the deceased’s Family to gather collateral information and to provide a carer’s assessment and/or support to Mr Berry’s family. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to document self-harm and suicide risk in clinical records

    Wider context from the report

    “In addition to failing to share crucial and obviously relevant information regarding Mr Berry’s extreme risk of suicide provided by the CPN at Court with prison staff, the jury found that the reception nurse, in the context of the clear information known to her, failed to: (a) document his risk of self-harm and suicide in the Systm One records and (b) failed to refer Mr Berry, that day, for an urgent review by the Mental Health team. CONCERN: Such comprehensive shortcomings in performance in respect of information sharing, conduct of assessments, basic documentation and escalation/referral on to relevant colleagues indicates (a) a failure in training of a very concerning kind, alongside (b) a failure in HCRG monitoring of standards, supervision and quality assurance processes to identify and address such extensive failures in performance. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure in HCRG staff training

    Wider context from the report

    “In addition to failing to share crucial and obviously relevant information regarding Mr Berry’s extreme risk of suicide provided by the CPN at Court with prison staff, the jury found that the reception nurse, in the context of the clear information known to her, failed to: (a) document his risk of self-harm and suicide in the Systm One records and (b) failed to refer Mr Berry, that day, for an urgent review by the Mental Health team. CONCERN: Such comprehensive shortcomings in performance in respect of information sharing, conduct of assessments, basic documentation and escalation/referral on to relevant colleagues indicates (a) a failure in training of a very concerning kind, alongside (b) a failure in HCRG monitoring of standards, supervision and quality assurance processes to identify and address such extensive failures in performance. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to update and document care plans

    Wider context from the report

    “CONCERN: During Mr Berry’s inquest, once again, many of the continuing failings under precisely the themes identified in the 2024 ‘Thematic Review’ and in PFDR responses prior to that review as well as in the period since that Review, have been identified as having informed the causative features contributing to the death of a patient under EPUT’s care. In my opinion, the actions taken by EPUT to date to address the acknowledged failings reflected under the themes and issues referred to above have been, and remain, inadequate and incomplete, specifically: (a) Failures in the performance of the CMHT and the allocated Care Coordinator as required under the Care Programme Approach (CPA) and as mandated by EPUT policy. These failures indicated significant human error not detected by an insufficiently robust system and not therefore corrected prior to the death: (b) Failures in Care Planning: specifically, a failure to appropriately up-date and document matters relating to Mr Berry’s Care Plan consistent with Trust policy. (c) Failures in Risk Assessments: specifically, failures to appropriately up-date and document matters relating to Mr Berry’s risk assessment consistent with Trust policy. (d) Failures in Documentation: in a number of acknowledged respects the electronic records were inadequate - and inconsistent with EPUT policy. (e) Failure of joint working internally: the CC did not attempt to escalate or consult with EPUT colleagues via the regular weekly MTD meeting or any other type of Professionals’ Meeting. (f) Failure of joint working externally: the CC did not liaise at all with the external specialist substance misuse team, even though the cocaine misuse was a central aspect of his presentation and mental health deterioration. (g) Failures in Communication within and between teams as above but also, crucially, including a failure to appropriately liaise with the deceased’s Family to gather collateral information and to provide a carer’s assessment and/or support to Mr Berry’s family. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to make urgent mental health referrals

    Wider context from the report

    “In addition to failing to share crucial and obviously relevant information regarding Mr Berry’s extreme risk of suicide provided by the CPN at Court with prison staff, the jury found that the reception nurse, in the context of the clear information known to her, failed to: (a) document his risk of self-harm and suicide in the Systm One records and (b) failed to refer Mr Berry, that day, for an urgent review by the Mental Health team. CONCERN: Such comprehensive shortcomings in performance in respect of information sharing, conduct of assessments, basic documentation and escalation/referral on to relevant colleagues indicates (a) a failure in training of a very concerning kind, alongside (b) a failure in HCRG monitoring of standards, supervision and quality assurance processes to identify and address such extensive failures in performance. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of HCRG monitoring, supervision and quality assurance

    Wider context from the report

    “In addition to failing to share crucial and obviously relevant information regarding Mr Berry’s extreme risk of suicide provided by the CPN at Court with prison staff, the jury found that the reception nurse, in the context of the clear information known to her, failed to: (a) document his risk of self-harm and suicide in the Systm One records and (b) failed to refer Mr Berry, that day, for an urgent review by the Mental Health team. CONCERN: Such comprehensive shortcomings in performance in respect of information sharing, conduct of assessments, basic documentation and escalation/referral on to relevant colleagues indicates (a) a failure in training of a very concerning kind, alongside (b) a failure in HCRG monitoring of standards, supervision and quality assurance processes to identify and address such extensive failures in performance. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of CMHT and Care Coordinator performance under the Care Programme Approach

    Wider context from the report

    “CONCERN: During Mr Berry’s inquest, once again, many of the continuing failings under precisely the themes identified in the 2024 ‘Thematic Review’ and in PFDR responses prior to that review as well as in the period since that Review, have been identified as having informed the causative features contributing to the death of a patient under EPUT’s care. In my opinion, the actions taken by EPUT to date to address the acknowledged failings reflected under the themes and issues referred to above have been, and remain, inadequate and incomplete, specifically: (a) Failures in the performance of the CMHT and the allocated Care Coordinator as required under the Care Programme Approach (CPA) and as mandated by EPUT policy. These failures indicated significant human error not detected by an insufficiently robust system and not therefore corrected prior to the death: (b) Failures in Care Planning: specifically, a failure to appropriately up-date and document matters relating to Mr Berry’s Care Plan consistent with Trust policy. (c) Failures in Risk Assessments: specifically, failures to appropriately up-date and document matters relating to Mr Berry’s risk assessment consistent with Trust policy. (d) Failures in Documentation: in a number of acknowledged respects the electronic records were inadequate - and inconsistent with EPUT policy. (e) Failure of joint working internally: the CC did not attempt to escalate or consult with EPUT colleagues via the regular weekly MTD meeting or any other type of Professionals’ Meeting. (f) Failure of joint working externally: the CC did not liaise at all with the external specialist substance misuse team, even though the cocaine misuse was a central aspect of his presentation and mental health deterioration. (g) Failures in Communication within and between teams as above but also, crucially, including a failure to appropriately liaise with the deceased’s Family to gather collateral information and to provide a carer’s assessment and/or support to Mr Berry’s family. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to communicate with families and gather collateral information

    Wider context from the report

    “CONCERN: During Mr Berry’s inquest, once again, many of the continuing failings under precisely the themes identified in the 2024 ‘Thematic Review’ and in PFDR responses prior to that review as well as in the period since that Review, have been identified as having informed the causative features contributing to the death of a patient under EPUT’s care. In my opinion, the actions taken by EPUT to date to address the acknowledged failings reflected under the themes and issues referred to above have been, and remain, inadequate and incomplete, specifically: (a) Failures in the performance of the CMHT and the allocated Care Coordinator as required under the Care Programme Approach (CPA) and as mandated by EPUT policy. These failures indicated significant human error not detected by an insufficiently robust system and not therefore corrected prior to the death: (b) Failures in Care Planning: specifically, a failure to appropriately up-date and document matters relating to Mr Berry’s Care Plan consistent with Trust policy. (c) Failures in Risk Assessments: specifically, failures to appropriately up-date and document matters relating to Mr Berry’s risk assessment consistent with Trust policy. (d) Failures in Documentation: in a number of acknowledged respects the electronic records were inadequate - and inconsistent with EPUT policy. (e) Failure of joint working internally: the CC did not attempt to escalate or consult with EPUT colleagues via the regular weekly MTD meeting or any other type of Professionals’ Meeting. (f) Failure of joint working externally: the CC did not liaise at all with the external specialist substance misuse team, even though the cocaine misuse was a central aspect of his presentation and mental health deterioration. (g) Failures in Communication within and between teams as above but also, crucially, including a failure to appropriately liaise with the deceased’s Family to gather collateral information and to provide a carer’s assessment and/or support to Mr Berry’s family. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate national prison officer training for suicide risk assessment

    Wider context from the report

    “CONCERN: In the context of the finding of the jury of a gross failure to ensure that Mr Berry was, in all the circumstances as known to the prison staff, subject to Constant Supervision, I am concerned that inadequate national training contributed to an over-reliance by prison staff on the subjective perception of an ‘improvement’ in a prisoner’s transient presentation and demeanour over obvious and grave documented risk factors when assessing risk and setting observation levels. The reassurance provided by Mr Berry, (according to the Supervising Officer) appears to have been dangerously misleading and uncritically accepted notwithstanding the clear, high risk of suicide Mr Berry presented. This, in turn, gives rise to my concern (in the light of the evidence provided by the POELT trainer) that the exceptionally short time allocated in national prison officer training to equip officers with the requisite skills to assess, identify and records triggers, risk factors and protective factors is wholly inadequate. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to cost structural mitigation of accessible window-bar ligature points

    Wider context from the report

    “CONCERN: A further concern raised by the evidence relates to the lack of any attempt to cost structural cell improvements to mitigate, at least in some cells on each wing, the most obvious of ligature points in the Victorian Prison estates’ cells, namely the readily accessible fixed bars at the windows. Whilst other less obvious ligature points are potentially available in cells, all the (multiple) self-inflicted ligature related deaths at HMP Chelmsford in recent years have exclusively involved the use of the window bars. The HMPPS Prison Group Director for Hertfordshire, Essex and Suffolk prisons undertook, following his evidence that such costings had not even been sought to date, to now ensure that such an exercise is undertaken. However, the concern remains that this is a national issue in relation to all Victorian or equivalent prisons and that absent even a costing exercise, steps to mitigate this serious, obvious and continuing risk will not be addressed. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate electronic record documentation

    Wider context from the report

    “CONCERN: During Mr Berry’s inquest, once again, many of the continuing failings under precisely the themes identified in the 2024 ‘Thematic Review’ and in PFDR responses prior to that review as well as in the period since that Review, have been identified as having informed the causative features contributing to the death of a patient under EPUT’s care. In my opinion, the actions taken by EPUT to date to address the acknowledged failings reflected under the themes and issues referred to above have been, and remain, inadequate and incomplete, specifically: (a) Failures in the performance of the CMHT and the allocated Care Coordinator as required under the Care Programme Approach (CPA) and as mandated by EPUT policy. These failures indicated significant human error not detected by an insufficiently robust system and not therefore corrected prior to the death: (b) Failures in Care Planning: specifically, a failure to appropriately up-date and document matters relating to Mr Berry’s Care Plan consistent with Trust policy. (c) Failures in Risk Assessments: specifically, failures to appropriately up-date and document matters relating to Mr Berry’s risk assessment consistent with Trust policy. (d) Failures in Documentation: in a number of acknowledged respects the electronic records were inadequate - and inconsistent with EPUT policy. (e) Failure of joint working internally: the CC did not attempt to escalate or consult with EPUT colleagues via the regular weekly MTD meeting or any other type of Professionals’ Meeting. (f) Failure of joint working externally: the CC did not liaise at all with the external specialist substance misuse team, even though the cocaine misuse was a central aspect of his presentation and mental health deterioration. (g) Failures in Communication within and between teams as above but also, crucially, including a failure to appropriately liaise with the deceased’s Family to gather collateral information and to provide a carer’s assessment and/or support to Mr Berry’s family. ”
    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

    Monitor clinical-documentation timeliness and quality through supervision, monthly performance reporting, and targeted follow-up.

    Verbatim wording from the response

    “As set out in our earlier response to the Prevention of Future Deaths report, we continue to monitor adherence to the 95% target for clinical documentation to be completed within 24–48 hours of patient contact. This is overseen through a combination of:”

    Source location

    2026-0015 - Response from Essex Partnership University Foundation Trust
    Page 7 · response
    Published 20 January 2026

    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 existing EPR capability for consolidated personalised-care and safety-planning records and update standard operating procedures.

    Verbatim wording from the response

    “Until NOVA is fully operational, EPUT continues to maintain robust interim monitoring arrangements to support safe and timely documentation. Alongside this, the Trust is currently reviewing the requirements for personalised care planning and safety planning documentation, with the aim of determining whether the existing EPR can accommodate a single, consolidated place for recording and update associated standard operating procedures. This work is intended to reduce the burden associated with navigating multiple tabs and scattered documentation fields, making it easier for clinicians to record care consistently and for teams to access essential information quickly.”

    Source location

    2026-0015 - Response from Essex Partnership University Foundation Trust
    Page 6 · response
    Published 20 January 2026

    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

    Require teams to record cases needing MDT discussion and require team leaders to review compliance weekly.

    Verbatim wording from the response

    “• MDT attendance and oversight: All teams are now required to document which cases need MDT discussion, with team leaders reviewing compliance weekly.”

    Source location

    2026-0015 - Response from Essex Partnership University Foundation Trust
    Page 8 · response
    Published 20 January 2026

    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

    Reissue mandatory escalation guidance and introduce MDT agendas and case-presentation templates for changing risk or uncertainty.

    Verbatim wording from the response

    “Since the incident, we have introduced measures to support staff in consistently meeting expectations around escalation and collaborative working. We recognise that embedding these behaviours is a gradual process and requires ongoing reinforcement, supervision and oversight, which we will continue to prioritise through:”

    Source location

    2026-0015 - Response from Essex Partnership University Foundation Trust
    Page 8 · response
    Published 20 January 2026

    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

    Complete and roll out the organisational Care Planning Framework.

    Verbatim wording from the response

    “This ensures that new colleagues not only receive structured learning but can also evidence their skills, knowledge, and decision-making in practice. In parallel with the interim Care Planning Training Package, the Trust has been contributing to the development of a new Care Planning Framework, which is currently in the final stages of review. The full organisational roll-out is scheduled to commence in Summer 2026. This framework is intentionally aligned with the national shift away from the traditional CPA model and towards a more personalised care agenda. As such, significant time and collaboration have been invested to ensure that the framework is authentic, meaningful, and genuinely reflective of modern person-centred practice, rather than creating a task-based or overly procedural approach to competencies.”

    Source location

    2026-0015 - Response from Essex Partnership University Foundation Trust
    Page 5 · response
    Published 20 January 2026

    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

    Expand STORM training from Crisis Teams into Community Mental Health Teams.

    Verbatim wording from the response

    “Failure of Joint Working Externally (concern f) In parallel, we are expanding the rollout of STORM training, which has been successfully embedded within Crisis Teams, into our Community Mental Health Teams. This training supports high-quality, evidence-based assessment, safety planning, and risk documentation—all of which are critical components of safe community mental health practice. These capabilities are also essential for effective internal and external joint working, ensuring that when multiple agencies are involved in a person’s care, information is clear, risk is articulated consistently, and actions are well-coordinated. High-quality documentation and shared understanding of risk are safer handovers with partners such as primary care, crisis services, social care, ambulance services, and police, and they support more timely and informed decision-making across agencies.”

    Source location

    2026-0015 - Response from Essex Partnership University Foundation Trust
    Page 9 · response
    Published 20 January 2026

    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

    Embed performance, quality, risk, and safety escalation within the organisational Accountability Framework.

    Verbatim wording from the response

    “EPUT maintains systematic performance monitoring and governance oversight, which is formally reviewed each month through established reporting structures.”

    Source location

    2026-0015 - Response from Essex Partnership University Foundation Trust
    Page 7 · response
    Published 20 January 2026

    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

    Introduce a care-coordination competency framework for new starters as part of probation.

    Verbatim wording from the response

    “The practitioner involved is currently subject to the Trust’s capability process. To complement formal training, EPUT is in the process of introducing a Care Coordination Competency Framework for all new starters. This framework will sit alongside the valued and essential on-the-job learning already provided within teams and will form a core component of each new staff member’s probationary period.”

    Source location

    2026-0015 - Response from Essex Partnership University Foundation Trust
    Page 5 · response
    Published 20 January 2026

    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 the need for an interim documentation and workflow support post before NOVA implementation.

    Verbatim wording from the response

    “To further support sustainable improvements in documentation quality and workflow, EPUT is reviewing the need for an interim post dedicated to assisting with documentation and workflow management ahead of the planned implementation of NOVA, the Trust’s new electronic patient record (EPR) system.”

    Source location

    2026-0015 - Response from Essex Partnership University Foundation Trust
    Page 6 · response
    Published 20 January 2026

    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

    Standardise sample-based community mental health caseload audits across localities.

    Verbatim wording from the response

    “(a) Performance of the CMHT and the allocated Care Coordinator (under CPA/EPUT policy) EPUT maintains a governance framework that includes regular clinical supervision, weekly MDT forums, escalation procedures, and case auditing to identify and address gaps. We recognise the expectation that staff practise in line with Trust policy. Trust-wide audit requirements were reviewed in January 2026. While the final Trust standard is being confirmed through the Community First Project, our interim approach combines:”

    Source location

    2026-0015 - Response from Essex Partnership University Foundation Trust
    Page 3 · response
    Published 20 January 2026

    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

    Mandate and deliver care-planning training for community and primary-care staff.

    Verbatim wording from the response

    “As part of strengthening practice, EPUT has developed a Care Planning Training Package, initially piloted in North East Essex and reviewed across the EPUT-wide safeguarding forums during 2024/25. The pilot was complex, partly due to delays in the release of updated national CPA guidance from NHS England. In response, EPUT adopted a pragmatic interim approach, embedding the updated care planning principles into a holding training package. This approach has been agreed collaboratively with regional colleagues through NHS England forums to ensure best practice while awaiting the final national framework.”

    Source location

    2026-0015 - Response from Essex Partnership University Foundation Trust
    Page 4 · response
    Published 20 January 2026

    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

    Embed dual-diagnosis capability within community teams through Care Coordinator training and team-based Dual Diagnosis Ambassadors.

    Verbatim wording from the response

    “Significant changes to the Dual Diagnosis pathway will support a reduction in ‘refer-on’ practices and minimise the passing of individuals between teams.”

    Source location

    2026-0015 - Response from Essex Partnership University Foundation Trust
    Page 8 · response
    Published 20 January 2026

    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

    Provide targeted complexity-and-escalation training, reflective supervision, and monthly CPD review for Care Coordinators.

    Verbatim wording from the response

    “Training and supervision improvements: Care Coordinators are receiving targeted training on recognising complexity and the thresholds for escalation, supported through reflective, restorative supervision. This was rolled out in 2024. Monthly CPD review sessions are in place for staff (these have been in place since beginning of 2025) which incorporate elements of restorative supervision, as appropriate. Staff 1:1 and staff mediation sessions also remain in place.”

    Source location

    2026-0015 - Response from Essex Partnership University Foundation Trust
    Page 8 · response
    Published 20 January 2026

    Open published response

    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

    Existing supervision, MDT escalation, governance, and proportionate sample-based audits are considered sufficient; exhaustive case-by-case auditing is not required.

    Verbatim wording from the response

    “(a) Performance of the CMHT and the allocated Care Coordinator (under CPA/EPUT policy) EPUT maintains a governance framework that includes regular clinical supervision, weekly MDT forums, escalation procedures, and case auditing to identify and address gaps. We recognise the expectation that staff practise in line with Trust policy. Trust-wide audit requirements were reviewed in January 2026. While the final Trust standard is being confirmed through the Community First Project, our interim approach combines:”

    Source location

    2026-0015 - Response from Essex Partnership University Foundation Trust
    Page 3 · response
    Published 20 January 2026

    Open published response

    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

    Clinicians, rather than monitoring systems, remain responsible for identifying clinical-risk changes and initiating out-of-cycle care-plan updates.

    Verbatim wording from the response

    “Mr Berry had been known to the Team for just over three months. During this period, the Management and Supervision Tool (MaST) showed that documentation was in date. However, MaST only identifies whether Care Plans or reviews meet the mandated six-monthly cycle. It does not analyse the content of those documents and therefore cannot detect when a review should be completed earlier due to a change in clinical risk. Identifying such changes and initiating an out-of-cycle update remains a core clinician responsibility.”

    Source location

    2026-0015 - Response from Essex Partnership University Foundation Trust
    Page 4 · response
    Published 20 January 2026

    Open published response

    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 concerns reflect professional practice failures rather than a systemic organisational failure of care-planning systems or governance.

    Verbatim wording from the response

    “b. Failures in Care Planning In reviewing Mr Berry’s case, there is no evidence to suggest a systemic organisational failure. The required systems, governance structures, and escalation processes were in place and functioning. The concerns identified relate to professional practice, rather than a failure of the systems themselves.”

    Source location

    2026-0015 - Response from Essex Partnership University Foundation Trust
    Page 4 · response
    Published 20 January 2026

    Open published response

    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

    Proactive detailed review of every case is operationally infeasible because community caseloads are large and existing resources are limited.

    Verbatim wording from the response

    “Given the size of the caseload—approximately 380 patients—it is neither operationally feasible nor supported by existing resources for senior staff to proactively review every case in detail. The system therefore relies on clinicians applying sound judgement, using supervision effectively, and escalating concerns appropriately through MDT structures. These processes were available, embedded, and repeatedly communicated. In Mr Berry’s case, they were not utilised as required, and the necessary out-of-cycle CPA update following a change in risk did not take place. This represents a professional practice failure, not a failure of organisational systems.”

    Source location

    2026-0015 - Response from Essex Partnership University Foundation Trust
    Page 5 · response
    Published 20 January 2026

    Open published response

  6. Essex

    AI-generated summary

    Stephen John Neville · 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

    Stephen John Neville, aged 68, was an informal inpatient at Beech Ward for planned ECT after a history of severe treatment-resistant depression, anxiety, agitation, and repeated suicide attempts. He died by hanging while in hospital. The report identified concerns including failures in risk communication and assessment, abrupt medication changes, inadequate therapeutic observations and engagement, insufficient auditing and quality assurance, and failure to mitigate risks associated with an unlocked shower room.

    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to record therapeutic engagement and interaction during observations

    Wider context from the report

    “1. There was a failure on the part of EPUT nursing and (particularly) support staff to appropriately undertake and record the required therapeutic engagement and interaction observations. Members of support staff demonstrably misunderstood (and appear to still misunderstand) the nature and purpose of Level 2 ‘intermittent’ (4 to 5 times) hourly observations, apparently routinely conducting such observations every 15 minutes on the hour, the quarter past and so on. Whilst the observations, when made, recorded the location of the patient and (very occasionally) noted what the patient may be doing, nothing was recorded in respect of an interaction or therapeutic engagement, as required by Trust policy. Such a lack of understanding of the basic role of the support worker and/or nursing staff in undertaking such critically important roles disclosed an (on-going) deficit in training. 2. Further, the clear evidence also disclosed an on-going failure in the quality assurance and auditing processes deployed by EPUT. A purported weekly quality assurance check being undertaken by the Ward Manager in December 2021, which claimed “an audit score of 100%”, was entirely at odds with the evidence at inquest which revealed repeated and significant inadequacies in the nature and quality of the observations undertaken and recorded. 3. Of even greater concern is that even after the move from paper to electronic observation records the same Beech Ward Manager (then and now) stated in evidence: “I have no audit tool …. I am not confident that the audits are accurate and complete now … there is no audit process in place to check the quality of observation and engagement documentation.” 4. The Deputy Director of Quality and Safety (Inpatient and Urgent Care) recognised in her written and oral evidence that the available free text box now included on the electronic version of the records relating to observation and engagement is “not a mandatory field” in the recording process and that: “it appears that at some point the Tendable audits were amended to omit the audits of the quality and nature of the observation records.” 5. It remains unclear how (or why) this came about, and I am very concerned that the apparent reliance on staff supervision (as per paragraph 7.1 of the Therapeutic Engagement and Supportive Observation Clinical Guideline (Inpatients)) and staff handovers to rigorously audit the nature and quality of the conduct and recording of therapeutic engagement and supportive observations remains a wholly inadequate mechanism for the purposes of achieving appropriate qualitative compliance monitoring. 6. The lacuna identified above gives rise to a real concern regarding the robustness of EPUT quality assurance and auditing processes generally, and particularly in the context of the on-going issues relating to the nature and quality of the conduct by EPUT staff of such critically important observations including the essential therapeutic engagements and interactions, with highly vulnerable inpatients at risk of suicide. This is a concern, I am told, also shared by the Deputy Director quoted above. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Omission of quality and nature audits from observation records auditing

    Wider context from the report

    “4. The Deputy Director of Quality and Safety (Inpatient and Urgent Care) recognised in her written and oral evidence that the available free text box now included on the electronic version of the records relating to observation and engagement is “not a mandatory field” in the recording process and that: “it appears that at some point the Tendable audits were amended to omit the audits of the quality and nature of the observation records.” ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to require completion of the electronic observation and engagement record field

    Wider context from the report

    “4. The Deputy Director of Quality and Safety (Inpatient and Urgent Care) recognised in her written and oral evidence that the available free text box now included on the electronic version of the records relating to observation and engagement is “not a mandatory field” in the recording process and that: “it appears that at some point the Tendable audits were amended to omit the audits of the quality and nature of the observation records.” ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Deficit in training for staff undertaking therapeutic engagement and supportive observations

    Wider context from the report

    “1. There was a failure on the part of EPUT nursing and (particularly) support staff to appropriately undertake and record the required therapeutic engagement and interaction observations. Members of support staff demonstrably misunderstood (and appear to still misunderstand) the nature and purpose of Level 2 ‘intermittent’ (4 to 5 times) hourly observations, apparently routinely conducting such observations every 15 minutes on the hour, the quarter past and so on. Whilst the observations, when made, recorded the location of the patient and (very occasionally) noted what the patient may be doing, nothing was recorded in respect of an interaction or therapeutic engagement, as required by Trust policy. Such a lack of understanding of the basic role of the support worker and/or nursing staff in undertaking such critically important roles disclosed an (on-going) deficit in training. 2. Further, the clear evidence also disclosed an on-going failure in the quality assurance and auditing processes deployed by EPUT. A purported weekly quality assurance check being undertaken by the Ward Manager in December 2021, which claimed “an audit score of 100%”, was entirely at odds with the evidence at inquest which revealed repeated and significant inadequacies in the nature and quality of the observations undertaken and recorded. 3. Of even greater concern is that even after the move from paper to electronic observation records the same Beech Ward Manager (then and now) stated in evidence: “I have no audit tool …. I am not confident that the audits are accurate and complete now … there is no audit process in place to check the quality of observation and engagement documentation.” 4. The Deputy Director of Quality and Safety (Inpatient and Urgent Care) recognised in her written and oral evidence that the available free text box now included on the electronic version of the records relating to observation and engagement is “not a mandatory field” in the recording process and that: “it appears that at some point the Tendable audits were amended to omit the audits of the quality and nature of the observation records.” 5. It remains unclear how (or why) this came about, and I am very concerned that the apparent reliance on staff supervision (as per paragraph 7.1 of the Therapeutic Engagement and Supportive Observation Clinical Guideline (Inpatients)) and staff handovers to rigorously audit the nature and quality of the conduct and recording of therapeutic engagement and supportive observations remains a wholly inadequate mechanism for the purposes of achieving appropriate qualitative compliance monitoring. 6. The lacuna identified above gives rise to a real concern regarding the robustness of EPUT quality assurance and auditing processes generally, and particularly in the context of the on-going issues relating to the nature and quality of the conduct by EPUT staff of such critically important observations including the essential therapeutic engagements and interactions, with highly vulnerable inpatients at risk of suicide. This is a concern, I am told, also shared by the Deputy Director quoted above. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to undertake Level 2 intermittent observations at the required frequency

    Wider context from the report

    “1. There was a failure on the part of EPUT nursing and (particularly) support staff to appropriately undertake and record the required therapeutic engagement and interaction observations. Members of support staff demonstrably misunderstood (and appear to still misunderstand) the nature and purpose of Level 2 ‘intermittent’ (4 to 5 times) hourly observations, apparently routinely conducting such observations every 15 minutes on the hour, the quarter past and so on. Whilst the observations, when made, recorded the location of the patient and (very occasionally) noted what the patient may be doing, nothing was recorded in respect of an interaction or therapeutic engagement, as required by Trust policy. Such a lack of understanding of the basic role of the support worker and/or nursing staff in undertaking such critically important roles disclosed an (on-going) deficit in training. 2. Further, the clear evidence also disclosed an on-going failure in the quality assurance and auditing processes deployed by EPUT. A purported weekly quality assurance check being undertaken by the Ward Manager in December 2021, which claimed “an audit score of 100%”, was entirely at odds with the evidence at inquest which revealed repeated and significant inadequacies in the nature and quality of the observations undertaken and recorded. 3. Of even greater concern is that even after the move from paper to electronic observation records the same Beech Ward Manager (then and now) stated in evidence: “I have no audit tool …. I am not confident that the audits are accurate and complete now … there is no audit process in place to check the quality of observation and engagement documentation.” 4. The Deputy Director of Quality and Safety (Inpatient and Urgent Care) recognised in her written and oral evidence that the available free text box now included on the electronic version of the records relating to observation and engagement is “not a mandatory field” in the recording process and that: “it appears that at some point the Tendable audits were amended to omit the audits of the quality and nature of the observation records.” 5. It remains unclear how (or why) this came about, and I am very concerned that the apparent reliance on staff supervision (as per paragraph 7.1 of the Therapeutic Engagement and Supportive Observation Clinical Guideline (Inpatients)) and staff handovers to rigorously audit the nature and quality of the conduct and recording of therapeutic engagement and supportive observations remains a wholly inadequate mechanism for the purposes of achieving appropriate qualitative compliance monitoring. 6. The lacuna identified above gives rise to a real concern regarding the robustness of EPUT quality assurance and auditing processes generally, and particularly in the context of the on-going issues relating to the nature and quality of the conduct by EPUT staff of such critically important observations including the essential therapeutic engagements and interactions, with highly vulnerable inpatients at risk of suicide. This is a concern, I am told, also shared by the Deputy Director quoted above. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of quality assurance and auditing processes to monitor the quality of observations and engagement documentation

    Wider context from the report

    “5. It remains unclear how (or why) this came about, and I am very concerned that the apparent reliance on staff supervision (as per paragraph 7.1 of the Therapeutic Engagement and Supportive Observation Clinical Guideline (Inpatients)) and staff handovers to rigorously audit the nature and quality of the conduct and recording of therapeutic engagement and supportive observations remains a wholly inadequate mechanism for the purposes of achieving appropriate qualitative compliance monitoring. 6. The lacuna identified above gives rise to a real concern regarding the robustness of EPUT quality assurance and auditing processes generally, and particularly in the context of the on-going issues relating to the nature and quality of the conduct by EPUT staff of such critically important observations including the essential therapeutic engagements and interactions, with highly vulnerable inpatients at risk of suicide. This is a concern, I am told, also shared by the Deputy Director quoted above. ”
    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

    Re-undertake Observation and Engagement competencies for the staff member requiring renewed training.

    Verbatim wording from the response

    “At this Inquest it was evident that one Health Care Assistant (HCA) did not understand the requirements of level 2 observation in relation to the random nature of level 2 observations. It is of that that they had been absent from work for a period of 9 months before the inquest. The Ward Manager is working with this staff member to re-undertake Observation and Engagement Competencies.”

    Source location

    Response from Essex Partnership NHS Foundation Trust
    Page 2 · response
    Published 5 November 2025

    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

    Continue reviewing and evolving training and staff-support programmes with relevant experts and learning.

    Verbatim wording from the response

    “The trust recognises it is important that it continually reviews and evolves all training and staff support programmes and this is undertaken by the Training Team with relevant experts, taking into account new guidance and learning.”

    Source location

    Response from Essex Partnership NHS Foundation Trust
    Page 2 · response
    Published 5 November 2025

    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

    Implement three Oxevision audits covering consent, staff training, and policy and governance, with findings reported and corrective actions monitored.

    Verbatim wording from the response

    “Building on this review, further enhancements were introduced following inquest-related reflections. In November 2025, three new Oxevision audits were implemented to strengthen oversight of observation and therapeutic engagement, incorporating both staff and patient feedback:”

    Source location

    Response from Essex Partnership NHS Foundation Trust
    Page 3 · response
    Published 5 November 2025

    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 Tendable audit templates within the wider Trust audit-assurance process.

    Verbatim wording from the response

    “We have also reviewed the audit templates within our tenable system to ensure the quality of this process is now reviewed as part of the trust wider audit assurance process, this alongside making the commentary box within observation recording a mandatory field has considerably strengthened our trust assurance on this matter.”

    Source location

    Response from Essex Partnership NHS Foundation Trust
    Page 4 · response
    Published 5 November 2025

    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 focused face-to-face training on interpreting observations, recording therapeutic engagement and reflecting on learning.

    Verbatim wording from the response

    “To further enhance Trust routine online training, the Ward Manager is providing a number of focused face to face training sessions with ward staff to further gain assurance around interpretation and understanding. This will include highlighting the importance of recording therapeutic engagement and space for reflection on learning. This is due to be completed by the end of December 2025.”

    Source location

    Response from Essex Partnership NHS Foundation Trust
    Page 2 · response
    Published 5 November 2025

    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

    Conduct spot checks of consistently high-compliance audits while reinforcing accurate results and accountability with staff.

    Verbatim wording from the response

    “Response: Reflection has been undertaken on this learning point with key staff including the current Ward Manager and Matron. Staff reflected that audits should be transparent and agreed that it was good practice to acknowledge gaps and take appropriate action in a timely manner. Staff expressed that they would be confident in presenting audits where the findings show gaps and gave recent examples of action taken following audits. The Matron is continuing to work with staff on the importance of accurate audit results and accountability. The matron is also conducting spot checks on audits that consistently report high level compliance as an additional assurance measure.”

    Source location

    Response from Essex Partnership NHS Foundation Trust
    Page 2 · response
    Published 5 November 2025

    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

    Pursue making the electronic engagement field mandatory for level 2, 3 and 4 observations.

    Verbatim wording from the response

    “Finally, it is noted that the e-observations box on the electronic form is the same box wherein engagement would also be documented and is not a mandatory field. A request has been made to Oxehealth asking for this to be mandated box for all observations levels 2, 3 and 4. Oxehealth have confirmed this is achievable and this change is in progress.”

    Source location

    Response from Essex Partnership NHS Foundation Trust
    Page 2 · response
    Published 5 November 2025

    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

    Launch and operate the inpatient Quality Assurance Audit Programme by consolidating audit questions and integrating observation checks into Ward Managers’ Tendable audits.

    Verbatim wording from the response

    “Response: In October 2024, EPUT launched a new Quality Assurance Audit Programme across all inpatient areas. This initiative was driven by feedback highlighting issues with previous paper-based audits, including repetitive and duplicated questions across Tendable audits and other checks conducted outside the platform. There was also inconsistency in understanding who should complete audits and when. Ward Managers and Matrons reported limited visibility of audit results and minimal use of findings for quality improvement.”

    Source location

    Response from Essex Partnership NHS Foundation Trust
    Page 3 · response
    Published 5 November 2025

    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 co-produce the Trust Tendable audit programme with ward matrons, including governance reporting improvements.

    Verbatim wording from the response

    “From a Trust wide learning perspective, a review is already underway of the Trust Tendable audit programme. The current Trust Tendable audit programme has been in place for 12 months and this review was already in progress prior to the inquest. This work will be co-”

    Source location

    Response from Essex Partnership NHS Foundation Trust
    Page 2 · response
    Published 5 November 2025

    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

    Share inquest learning with care-unit quality and safety forums and the Training team to strengthen Oxevision engagement and recording training.

    Verbatim wording from the response

    “As part of the Trustwide learning response, the learning from this inquest has been shared through the care unit quality and safety meeting to ensure shared learning across the wider care unit. This has also been shared with the Training team with a specific focus on Oxevision e-observation training to ensure this training robustly guides staff on engagement techniques and importance of the quality of recording of the engagement. This training was reviewed in February 2025 following the Trust’s recent review of the Oxevision SOP.”

    Source location

    Response from Essex Partnership NHS Foundation Trust
    Page 2 · response
    Published 5 November 2025

    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

    Shift observation practice toward therapeutic engagement through updated guidance and training.

    Verbatim wording from the response

    “Response: In line with the details set out in the Trust’s learning statement filed with the Court, with respect to the Trust’s approach to Observation and Engagement, the Trust continues to shift focus to Therapeutic engagement rather than observation alone. This aligns with the national working group the Trust participated in across 2024 and led to the development of the Mental Health / Learning Disability Nurse Director guidance document.”

    Source location

    Response from Essex Partnership NHS Foundation Trust
    Page 1 · response
    Published 5 November 2025

    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

    Strengthen audit-result reporting through monthly quality and safety meetings and a Power BI dashboard providing organisation-wide visibility.

    Verbatim wording from the response

    “The Trust has since strengthened the reporting of results from audits; with results discussed at the monthly care unit Quality & Safety Meetings and this is supported by the implementation of a Quality & Safety dashboard utilising Power BI (Power BI is a business intelligence tool developed by Microsoft that transforms raw data into visual insights allowing organisations to make data-driven decisions). The dashboard provides the Trust with a range of information, from an overall perspective of results as an organisation.”

    Source location

    Response from Essex Partnership NHS Foundation Trust
    Page 3 · response
    Published 5 November 2025

    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

    Check all staff Observation and Engagement competencies and completion of Oxevision e-observation training.

    Verbatim wording from the response

    “The Ward Manager has also undertaken a check of all staff Observation and Engagement competencies to ensure confidence in current staff practice. As part of this process the Ward Manager checked that all staff have completed Oxevision E-Observation training, which includes training on documenting o-benservations to ensure therapeutic engagement is captured. This ensures a focus on the quality of the therapeutic engagement and observation.”

    Source location

    Response from Essex Partnership NHS Foundation Trust
    Page 2 · response
    Published 5 November 2025

    Open published response

  7. Essex

    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 Partnership University NHS Foundation Trust; 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 Partnership University NHS Foundation Trust; 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 Partnership University NHS Foundation Trust; 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 Partnership University NHS Foundation Trust; 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 Partnership University NHS Foundation Trust; 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 Partnership University NHS Foundation Trust; 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 Partnership University NHS Foundation Trust; 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 Partnership University NHS Foundation Trust; 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 Partnership University NHS Foundation Trust; 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 Partnership University NHS Foundation Trust; 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 Partnership University NHS Foundation Trust; 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 Partnership University NHS Foundation Trust; 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 Partnership University NHS Foundation Trust; 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

    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 information-sharing protocols for collaboration with professionals in other organisations.

    Verbatim wording from the response

    “We have strengthened our governance by reviewing our information-sharing protocols with specific reference to how we work with professionals in other organisations. We have introduced structured communication methods for handovers and shared care plans which we have made accessible to all involved professionals including care home and social care staff. We are working in a more collaborative culture through regular multidisciplinary team meetings which is supporting our patient’s safety and planning. The Trust has relooked at its named”

    Source location

    Response from Essex Partnership University
    Page 1 · response
    Published 14 October 2025

    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

    Address the importance of recording information in care-plan sections through staff meetings, supervision and audit.

    Verbatim wording from the response

    “Response: Since Mrs Steedman’s death, the importance of recording information in the care-plan section has been addressed. This has included discussing in meetings with staff, supervision and audit.”

    Source location

    Response from Essex Partnership University
    Page 2 · response
    Published 14 October 2025

    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

    Hold a post-Inquest debrief with Community and Crisis Response teams to share learning about information sharing.

    Verbatim wording from the response

    “Response: The Trust appreciates the need to ensure information sharing between professionals is carried out in a robust and timely manner. To share the learning on this point, a post-Inquest debrief was held with the Community and the Crisis Response Team teams to discuss the Inquest and the concerns raised with regards to information sharing.”

    Source location

    Response from Essex Partnership University
    Page 1 · response
    Published 14 October 2025

    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

    Carry out joint EPUT-ECC work to improve patient-safety investigations and update the PSIRF Policy.

    Verbatim wording from the response

    “There has been joint work between EPUT and ECC that has led to an improvement in joint working on patients safety investigations, and this is also reflected in the updated PSIRF Policy”

    Source location

    Response from Essex Partnership University
    Page 4 · response
    Published 14 October 2025

    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

    Discuss professional curiosity with teams, remind staff to review care-home paperwork and consult carers, and provide support sessions on asking appropriate questions.

    Verbatim wording from the response

    “Response: We refer to our reply above under concern 4 in respect of care plans and risk assessments. In addition, as part of team reflections in this matter, the importance of professional curiosity was discussed and the team were reminded that they should review care home paperwork (where access is possible) and also speak with carers within the home. Support sessions were provided on asking right questions using professional curiosity and how this would have given more opportunity to understand Mrs Steedman’s needs and risks, whilst acknowledging that the Care Home may in turn approach the Trust with regards to any information or support required.”

    Source location

    Response from Essex Partnership University
    Page 3 · response
    Published 14 October 2025

    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

    Share patient-safety learning through the lessons team with clinical and non-clinical staff.

    Verbatim wording from the response

    “Response The Trust has shared learning through the lessons team available to all clinical and non clinical staff. Information regarding patient care is discussed robustly through MDT’s and supervision, Caseloads are reviewed through audit.”

    Source location

    Response from Essex Partnership University
    Page 3 · response
    Published 14 October 2025

    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 Care Unit Incident Review Group and Patient Safety Lead role within the care unit.

    Verbatim wording from the response

    “Work is ongoing to increase the robustness of the patient safety incident reports, particularly around the setting of Terms of Reference which set the focus for the review. The Care Unit Incident Review Group and the establishment of the Patient Safety Lead role within the care unit has strengthened this process during 2025.”

    Source location

    Response from Essex Partnership University
    Page 4 · response
    Published 14 October 2025

    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

    Introduce structured handovers and shared care plans accessible to involved health, care-home and social-care professionals.

    Verbatim wording from the response

    “We have strengthened our governance by reviewing our information-sharing protocols with specific reference to how we work with professionals in other organisations. We have introduced structured communication methods for handovers and shared care plans which we have made accessible to all involved professionals including care home and social care staff. We are working in a more collaborative culture through regular multidisciplinary team meetings which is supporting our patient’s safety and planning. The Trust has relooked at its named”

    Source location

    Response from Essex Partnership University
    Page 1 · response
    Published 14 October 2025

    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 multi-agency Transfer of Care hub to discuss urgent-care pathway contacts and attribute follow-up actions.

    Verbatim wording from the response

    “Response In this case the CRS assessed the needs of Mrs Steedman and identified that she needed support over the weekend. They were aware she was open to community services. The decision was taken to seek support from Sanctuary who were able to provide non-clinical support, thereby providing Mrs Steedman with another layer of support. There is now a multi agency Transfer of Care hub where any patient who has had contact with the Urgent Care Pathway will be discussed and a follow up action attributed.”

    Source location

    Response from Essex Partnership University
    Page 3 · response
    Published 14 October 2025

    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 named-worker roles and responsibilities to strengthen accountability, and audit compliance.

    Verbatim wording from the response

    “We have strengthened our governance by reviewing our information-sharing protocols with specific reference to how we work with professionals in other organisations. We have introduced structured communication methods for handovers and shared care plans which we have made accessible to all involved professionals including care home and social care staff. We are working in a more collaborative culture through regular multidisciplinary team meetings which is supporting our patient’s safety and planning. The Trust has relooked at its named”

    Source location

    Response from Essex Partnership University
    Page 1 · response
    Published 14 October 2025

    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

    Strengthen patient-safety incident reports, particularly the robustness of Terms of Reference for reviews.

    Verbatim wording from the response

    “Work is ongoing to increase the robustness of the patient safety incident reports, particularly around the setting of Terms of Reference which set the focus for the review. The Care Unit Incident Review Group and the establishment of the Patient Safety Lead role within the care unit has strengthened this process during 2025.”

    Source location

    Response from Essex Partnership University
    Page 4 · response
    Published 14 October 2025

    Open published response

    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

    Essex County Council is responsible for responding to concerns about placement appropriateness and updating the section 117 care plan.

    Verbatim wording from the response

    “Concern 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”

    Source location

    Response from Essex Partnership University
    Page 2 · response
    Published 14 October 2025

    Open published response

  8. Essex

    AI-generated summary

    Resmije Ahmetaj · 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

    Resmije Ahmetaj, also known as Merita Brahimi, died on 30 June 2024 from a traumatic head injury after falling from a height at a multi-storey car park while suffering an exacerbation of psychosis. The report identifies concerns about subtherapeutic antipsychotic medication levels not being acted on, communication and escalation within the mental health team, incomplete record-keeping, medication prescribing confusion, and safety mitigation on the car park’s penultimate floor.

    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Incomplete mental health care records

    Wider context from the report

    “(4) The mental health Trust record-keeping did not contain all relevant information relating to the care and treatment there were omissions relating to symptoms and potential signs of deterioration and compliance with medication. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to escalate and act on markedly subtherapeutic clozapine levels

    Wider context from the report

    “(3) There were issues around communication and escalation within the Trust mental health team. A routine 6-month blood anti-psychotic to check clozapine levels assay was taken on 3 June and the results reported on 7 June were sent to the psychiatrist and showed markedly subtherapeutic blood levels of antipsychotic medication. This subtherapeutic level was not acted upon and was contrary to: a. Ms Ahmetaj insisting she was compliant with her medication b. Ms Ahmetaj did not have any noted risks that would cause interference with her medication. c. Ms Ahmetaj informed EPUT clinicians that: i. On 24 June she thought her medication Clozapine was not working ii. On 27 June she no longer wished to take her prescribed antipsychotic medication , and iii. Did not agree she had Schizophrenia, and iv. wanted to revert to a previous medication Quetiapine. These matters were not escalated to the psychiatrist and Ms Ahmetaj was informed to continue her clozapine and wait for her appointment on 1 July and there was no consideration of the risk of relapse of psychosis. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to consider the risk of psychosis relapse

    Wider context from the report

    “(3) There were issues around communication and escalation within the Trust mental health team. A routine 6-month blood anti-psychotic to check clozapine levels assay was taken on 3 June and the results reported on 7 June were sent to the psychiatrist and showed markedly subtherapeutic blood levels of antipsychotic medication. This subtherapeutic level was not acted upon and was contrary to: a. Ms Ahmetaj insisting she was compliant with her medication b. Ms Ahmetaj did not have any noted risks that would cause interference with her medication. c. Ms Ahmetaj informed EPUT clinicians that: i. On 24 June she thought her medication Clozapine was not working ii. On 27 June she no longer wished to take her prescribed antipsychotic medication , and iii. Did not agree she had Schizophrenia, and iv. wanted to revert to a previous medication Quetiapine. These matters were not escalated to the psychiatrist and Ms Ahmetaj was informed to continue her clozapine and wait for her appointment on 1 July and there was no consideration of the risk of relapse of psychosis. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to verify antidepressant prescription doses

    Wider context from the report

    “(2) There was confusion about the mental health Trust prescribing dose for Ms Ahmetaj antidepressant medication and an overreliance on discussions with her rather than checking the prescription dose and communication with the GP was delayed. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of the mental health team to undertake mental state examinations

    Wider context from the report

    “(1) EPUT mental health team were relying on the clozapine clinic staff to monitor Ms Ahmetaj’s mental health, but this was not the purpose of the clinic. Staff took blood samples and vital signs with a quick chat that took about 5 minutes and were not undertaking a mental state examination. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of fall mitigation on the penultimate car park floor with a pedestrian link walkway

    Wider context from the report

    “(6) The car park has a link walkway to residential housing on the penultimate floor from where Resmije Ahmetaj fell. The top floor has mitigation that would prevent a person from jumping/falling but the penultimate floor that has a pedestrian link walkway does not. There is likely to be more pedestrian footfall on the penultimate floor as a consequence and any fall from this height would inevitably be fatal. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in managing clozapine constipation

    Wider context from the report

    “(5) Clozapine constipation was raised as a serious side effect such that there is a Trust policy to manage this matter. This was not dealt with within the Trust for Ms Ahmetaj, and it took two weeks to raise this for the GP to manage. This did not cause or contribute to Ms Ahmetaj’s death however there is a concern for the long delay for other patients. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in communication with the GP about antidepressant prescribing

    Wider context from the report

    “(2) There was confusion about the mental health Trust prescribing dose for Ms Ahmetaj antidepressant medication and an overreliance on discussions with her rather than checking the prescription dose and communication with the GP was delayed. ”
    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

    Take forward MDT learning on documenting and escalating inconsistencies between clozapine assays, adherence reports and clinical stability.

    Verbatim wording from the response

    “On reflection, while the management of this case was consistent with current guidance, there are learning points regarding communication and escalation. Specifically, inconsistencies between assay findings, patient-reported adherence, and clinical stability should have been explicitly documented and escalated to the consultant psychiatrist at an earlier stage. Doing so would have provided additional assurance around risk management and strengthened the therapeutic dialogue with the patient. This learning is being taken forward by the MDT.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 4 · response
    Published 14 August 2025

    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 dedicated teaching on monitoring and documenting clozapine side effects.

    Verbatim wording from the response

    “We can assure the court that the Trust provides staff with clear guidance in the Clozapine policy last issued in January 2025 on the assessment, monitoring, and documentation of Clozapine-related constipation. The updated policy from January 2025 has been disseminated widely across the medical teams, and a dedicated teaching session took place on 2nd of October 2025 to reinforce best practice in the monitoring and documentation of Clozapine side effects.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 5 · response
    Published 14 August 2025

    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

    Discuss case-related record-keeping requirements with service leads and task service managers with reinforcing their importance to staff.

    Verbatim wording from the response

    “Additionally we can confirm that discussions have been undertaken with service leads with regards to record keeping in respect of this particular case and highlighting importance of timely and detailed record keeping. Service Managers were tasked to emphasise the importance of this service staff.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 4 · response
    Published 14 August 2025

    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

    Reinforce with medical staff the need to communicate medication-dose inconsistencies clearly and promptly.

    Verbatim wording from the response

    “Whilst this discrepancy was not causative of the sad outcome in this matter, reliance on the patient’s report was made in good faith as part of the therapeutic process. I can assure the Court that, moving forward, the importance of clearly communicating and communicating any inconsistencies between a patient’s reported medication dosage and the dosage prescribed by the GP will be reinforced with the medical team, in order to ensure safe and effective prescribing and to minimise the risk of confusion.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 14 August 2025

    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

    Disseminate the January 2025 updated clozapine policy across medical teams to strengthen constipation assessment, monitoring and documentation.

    Verbatim wording from the response

    “We can assure the court that the Trust provides staff with clear guidance in the Clozapine policy last issued in January 2025 on the assessment, monitoring, and documentation of Clozapine-related constipation. The updated policy from January 2025 has been disseminated widely across the medical teams, and a dedicated teaching session took place on 2nd of October 2025 to reinforce best practice in the monitoring and documentation of Clozapine side effects.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 5 · response
    Published 14 August 2025

    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

    Develop clinical record-keeping guidance defining the characteristics of a good clinical record.

    Verbatim wording from the response

    “To further support staff the Trust has developed a new Clinical record keeping guidance to help guide staff on what is a good clinical record.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 4 · response
    Published 14 August 2025

    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

    Continue the Record Keeping Safety Improvement Programme to improve documentation-related patient safety through learning and regular review.

    Verbatim wording from the response

    “The Trust has continued with a Record Keeping Safety Improvement Programme (SIP). This SIP program is focusing on improving patient safety in respect of documentation specifically. The approach will be to support continuous learning and improvement and regular review.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 4 · response
    Published 14 August 2025

    Open published response

    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

    Clinical assessment and the already scheduled psychiatric review were considered sufficient; no earlier appointment was indicated without evidence of deterioration.

    Verbatim wording from the response

    “National and local guidelines emphasise that Clozapine plasma levels are an adjunct to clinical decision-making and should not be used in isolation to guide practice. Clinical assessment of the patient remains the primary determinant of treatment intervention.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 3 · response
    Published 14 August 2025

    Open published response

    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 maximum licensed sertraline dose meant no dose increase was possible, so no additional prescribing action was considered necessary before the planned review.

    Verbatim wording from the response

    “In this case, during the consultation with the doctor on the 22nd May 2024 the patient reported that she was taking sertraline ████████ and this was documented in the clinical notes on the day by the doctor. A brief letter was sent to the GP on the same day requesting an increase in dose of Sertraline (████████). The GP responded on the 24th May 2024 advising that the patient was in fact prescribed and reporting use of sertraline 200 mg. This is the maximum licensed dose. This meant there was no role for recommending a further increase, and the appropriate course of action was to review the patient at her next planned appointment which would be on 1st July 2024 to consider alternative treatment options. At this time there were no indications to suggest a need to bring the appointment forward.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 14 August 2025

    Open published response

    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 clozapine assay showed low plasma levels, not sub-therapeutic prescribing, because the prescribed dose remained unchanged.

    Verbatim wording from the response

    “The plasma Clozapine assay undertaken on 3rd June 2024 and reported on 7th June demonstrated a markedly low levels of clozapine in the plasma. The result was reviewed by the clinical team. It is important to emphasise that this did not reflect sub-therapeutic prescribing, as the patient’s Clozapine dose had remained unchanged since discharge. A previous Clozapine assay undertaken in 2023, at the same dosage, confirmed a therapeutic plasma level of 0.53.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 3 · response
    Published 14 August 2025

    Open published response

  9. Essex

    AI-generated summary

    Carol Taylor · 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

    Carol Taylor, aged 75, was a detained psychiatric patient found unresponsive in her bed on a ward for elderly patients, and resuscitation efforts were attempted. The report raised concerns that staff who were not compliant with mandatory training, including basic life support training, could work on in-patient wards, particularly wards treating elderly patients.

    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to prevent staff non-compliant with mandatory training from working on inpatient wards

    Wider context from the report

    “(1) There is no system that prevents staff that are non- compliant with mandatory training, including basic life support training, from being able to work on EPUT in- patient wards. (2) This is a particular concern generally, but especially in hospitals such as St Margaret’s where at least some of the wards specialise in treating elderly patients who are likely to be at greater risk of medical collapse than the general population. ”
    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

    Manage mandatory-training compliance using ward training trackers, monthly reviews, expiry alerts, booking support and escalation of non-compliant temporary staff.

    Verbatim wording from the response

    “Response: Ward managers are able to access and review the skills of staff on the ward, which includes bank worker training compliance, via a training tracker. If there is a staff shortage then requests may be made for bank and agency staff, identifying the skill set required to ensure those booked onto shift hold the necessary skills / training to deliver the required care competently.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 1 · response
    Published 19 June 2025

    Open published response

    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

    A complete bar on staff lacking mandatory training is not implemented because it risks insufficient staffing levels on wards.

    Verbatim wording from the response

    “A ‘bar’ on temporary staff / substantive working on the ward unless they are compliant with all mandatory training, including basic life support training brings the significant risk in relation to having the necessary number of staff on shift however compliance with mandatory training is vital. To address this Ward Managers actively manage compliance with mandatory training.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 1 · response
    Published 19 June 2025

    Open published response

  10. Essex

    AI-generated summary

    Nicholas Alan Gray · 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

    Nicholas Alan Gray died at home on 24 July 2023 following an overdose of ████████ with the intention to end his life. Before his death, he had made attempts to harm himself and expressed suicidal intent, but was discharged without a psychiatric review or recommended mental health risk assessment. The Trust’s post-death monitoring record also contained inaccurate information and significant omissions about contacts with mental health services and known self-harm concerns.

    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain accurate and complete PSIRF decision-monitoring information

    Wider context from the report

    “(1) The Trust PSIRF Decision Monitoring Tool completed after Mr Gray died contained inaccurate information, the dates of EPUT contact and the substance of the interactions were inaccurate: a. Self-harm was noted as “none known or recorded” b. There was no record of the mental health liaison nurse review on 24 June 2023 and the discharge of Mr Gray from EPUT. The information used to inform a potential investigation requirement contained significant omissions and was not consistent with the information known to the Trust. ”
    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

    Amend and implement the PSIRF Decision Monitoring Tool template.

    Verbatim wording from the response

    “The template that was used to complete the DMT in relation into Mr Gray’s passing has been reviewed and amended. This was as a result of clinical staff feedback about the template’s effectiveness, the risk of duplication and the potential for confusion to be caused.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 2 · response
    Published 17 June 2025

    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

    Apply final scrutiny to Decision Monitoring Tools at sign-off by central Patient Safety and Executive Director-level staff.

    Verbatim wording from the response

    “DMTs are also subject to further final scrutiny at the sign off stage by central Patient Safety and by those at Executive Director level.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 2 · response
    Published 17 June 2025

    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

    Require Care Unit leadership multidisciplinary discussion and sign-off for every completed Decision Monitoring Tool or investigation.

    Verbatim wording from the response

    “Every completed DMT or investigation now has a Care Unit leadership Multi-disciplinary Team discussion and sign off process. This involves checks and challenges regarding the information provided, decision making and scrutiny of the learning identified. This process provides more robust governance and oversight regarding sign off of a DMT from a Care Unit and Trust wide leadership perspective.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 2 · response
    Published 17 June 2025

    Open published response

  11. Essex

    AI-generated summary

    Julie Sheila Beasley · 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

    Julie Sheila Beasley was found deceased at home on 16 March 2023 and died from multiple drug misuse involving a fatal amount of morphine and concomitant prescribed medications. She had deteriorating mental health, increasing suicidal thoughts and plans, and repeatedly requested mental health assessment and a medication review. The report identifies failures to complete required assessments and medication review, inadequate communication and record keeping, and insufficient exploration of information she sought to share about her risks.

    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to communicate discharge actions to the GP

    Wider context from the report

    “(1) Mrs Beasley was seen at home following a call to the mental health crisis team and required a full V4 mental health assessment that did not take place and instead an SBAR review was completed, and the nurse did not scrutinise the medications and medication changes that had been previously made and made errors about the doses. Mrs Beasley was informed she was discharged back to her GP, but no actions were sent by the mental health Trust to the GP. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to review records and identify the need for urgent mental health assessment

    Wider context from the report

    “(3) Mrs Beasley was conveyed to hospital having taken an overdose of medication and was reviewed by the Trust mental health liaison team. Review of the mental health Trust medical records would have shown that Mrs Beasley had an SBAR review rather than a V4 mental health assessment. This should have alerted staff to the fact that an urgent assessment was required when Mrs Beasley attended mental health liaison following an overdose of her medication. This did not happen. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Poor clinical record keeping and documentation of decision-making rationale

    Wider context from the report

    “(5) Multiple experienced members of the mental health teams had contact with Mrs Beasley between January and March and did not make detailed entries into the medical or ask questions of Mrs Beasley about what additional information she had to provide about her risks of harm and suicidal ideation, review of her medication given her deteriorating mental health and calls to the crisis team disclosing increasing suicidal thoughts and ideation accompanied by acts and plans. There was a lack of professional curiosity and poor record keeping and rationale for decision-making. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to record clinically relevant details of telephone contacts

    Wider context from the report

    “(2) Following this Mrs Beasley contacted crisis mental health explaining that she had vital information that she had not shared following a visit by a psychiatric nurse at her home. Mrs Beasley was not asked what the information was. Mrs Beasley contacted the crisis team again a few days later repeating that she had not shared information and again was not asked what the information was and was not given an appointment. Mrs Beasley’s telephone contacts were noted in her medical record with no details recorded as to what the additional information Mrs Beasley wanted to share. Mrs Beasley did not receive the appropriate psychiatric assessment following her contact with the crisis team. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to communicate accurate assessment and appointment information

    Wider context from the report

    “(4) Mrs Beasley had been requesting an urgent appoint and responded immediately to a letter from the Trust informing her she needed an urgent psychiatric appointment. When Mrs Beasley contacted the crisis team, she was again informed incorrectly that she had recently had a V4 psychiatric assessment and did not require an urgent appointment. The crisis team were not communicating effectively either with Mrs Beasley, her GP or internally within their own team. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to scrutinise medication and medication changes

    Wider context from the report

    “(1) Mrs Beasley was seen at home following a call to the mental health crisis team and required a full V4 mental health assessment that did not take place and instead an SBAR review was completed, and the nurse did not scrutinise the medications and medication changes that had been previously made and made errors about the doses. Mrs Beasley was informed she was discharged back to her GP, but no actions were sent by the mental health Trust to the GP. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to complete required comprehensive mental health assessments

    Wider context from the report

    “(1) Mrs Beasley was seen at home following a call to the mental health crisis team and required a full V4 mental health assessment that did not take place and instead an SBAR review was completed, and the nurse did not scrutinise the medications and medication changes that had been previously made and made errors about the doses. Mrs Beasley was informed she was discharged back to her GP, but no actions were sent by the mental health Trust to the GP. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of effective communication within and across mental health services

    Wider context from the report

    “(4) Mrs Beasley had been requesting an urgent appoint and responded immediately to a letter from the Trust informing her she needed an urgent psychiatric appointment. When Mrs Beasley contacted the crisis team, she was again informed incorrectly that she had recently had a V4 psychiatric assessment and did not require an urgent appointment. The crisis team were not communicating effectively either with Mrs Beasley, her GP or internally within their own team. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to elicit additional risk information from patients

    Wider context from the report

    “(2) Following this Mrs Beasley contacted crisis mental health explaining that she had vital information that she had not shared following a visit by a psychiatric nurse at her home. Mrs Beasley was not asked what the information was. Mrs Beasley contacted the crisis team again a few days later repeating that she had not shared information and again was not asked what the information was and was not given an appointment. Mrs Beasley’s telephone contacts were noted in her medical record with no details recorded as to what the additional information Mrs Beasley wanted to share. Mrs Beasley did not receive the appropriate psychiatric assessment following her contact with the crisis team. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to review medication during deteriorating mental health

    Wider context from the report

    “(5) Multiple experienced members of the mental health teams had contact with Mrs Beasley between January and March and did not make detailed entries into the medical or ask questions of Mrs Beasley about what additional information she had to provide about her risks of harm and suicidal ideation, review of her medication given her deteriorating mental health and calls to the crisis team disclosing increasing suicidal thoughts and ideation accompanied by acts and plans. There was a lack of professional curiosity and poor record keeping and rationale for decision-making. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide an appropriate urgent psychiatric appointment

    Wider context from the report

    “(2) Following this Mrs Beasley contacted crisis mental health explaining that she had vital information that she had not shared following a visit by a psychiatric nurse at her home. Mrs Beasley was not asked what the information was. Mrs Beasley contacted the crisis team again a few days later repeating that she had not shared information and again was not asked what the information was and was not given an appointment. Mrs Beasley’s telephone contacts were noted in her medical record with no details recorded as to what the additional information Mrs Beasley wanted to share. Mrs Beasley did not receive the appropriate psychiatric assessment following her contact with the crisis team. ”
    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

    Issue a Trust-wide safety alert reinforcing completion of electronic assessment documentation.

    Verbatim wording from the response

    “Further, the Trust issued a Trust-wide safety alert, in respect of Electronic Assessment Documentation, which re-enforces and reminds colleagues that all sections of the Initial Assessment form should be completed or a clear rationale for why it is not possible to complete a section should be given e.g ‘Patient is unable to provide this information at present due to their current presentation’.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 1 · response
    Published 4 June 2025

    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

    Provide reflective supervision to the staff member involved in the missed communication.

    Verbatim wording from the response

    “By way of further assurance, reflective supervision is being undertaken with the individual staff member who did not speak with Mrs Beasley.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 3 · response
    Published 4 June 2025

    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

    Develop an electronic handover tool documenting follow-up actions and emerging risks.

    Verbatim wording from the response

    “In addition, the Trust has developed a new electronic handover tool process which will aid clearer documentation and clarity in respect of follow up actions.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 2 · response
    Published 4 June 2025

    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

    Remind Mental Health Liaison Service staff to complete V4 assessments for all patients.

    Verbatim wording from the response

    “Response: We refer to the reply set out under concern 1 above, namely that the Trust has continued to review our assessment processes to ensure that the appropriate reviews are undertaken in a timely manner. Additionally, the Mental Health Liaison Service have been reminded of the requirement for a V4 assessment to be completed for all patients. Team Leads will seek the advice of HR in respect of any individual staff concerns as required, in light of the need to ensure correct and adequate documentation is completed in a timely manner. Staff have been advised of the expectation for clear written rationale in circumstances where the documentation has not been completed (as highlighted under response 1 above).”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 3 · response
    Published 4 June 2025

    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

    Require full biopsychosocial mental health assessments, with documented rationale for omissions.

    Verbatim wording from the response

    “Response: The Trust has continued to review our assessment processes to ensure that the appropriate reviews are undertaken in a timely manner and are supported through the MDT approach which then supports a joined up approach to patient assessments. Staff in the Mental Health Crisis team are required to undertake a mental health assessment for all patients, which is monitored and audited via supervision meetings and compliance reviews.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 1 · response
    Published 4 June 2025

    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

    Provide three senior leads to support the crisis team.

    Verbatim wording from the response

    “Psychiatrist review requests are now all sent to an MDT email address rather than to individual psychiatrists, so that this may be actively, and in a timely way attended to by the MDT review. The team is now supported by three senior leads within the team.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 4 · response
    Published 4 June 2025

    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

    Send patient contact details and highlighted actions to GPs through administrative support.

    Verbatim wording from the response

    “By way of evidence provided to the Court, the team have clear processes for GPs to be emailed following any patient contact. Clinical staff are supported by the Team administrative personnel who are tasked with sending assessment details to GP’s, which includes highlighted actions.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 2 · response
    Published 4 June 2025

    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

    Route crisis-team communications and psychiatrist review requests to multidisciplinary team mailboxes.

    Verbatim wording from the response

    “A process has also been initiated whereby communication is not sent to an individual, but will be sent to the MDT. This ensures there are no delays in communication / actions requiring attention.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 2 · response
    Published 4 June 2025

    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

    Conduct monthly evidence-based assessment quality audits and provide feedback on findings.

    Verbatim wording from the response

    “Monitoring of the quality of assessments, noting the concerns above has been enhanced with monthly assessment quality audits. The audits are evidence based (NICE Guidance) and undertaken by each lead reviewing 10 cases each month. The lead will feedback to staff the themes they have found, good practice and areas for improvement, as a means of ‘spot checking’ the assessments that are being carried out. In addition to the team monthly audits, an EPUT wide audit carried out in April 2025 for urgent care, showed overall for the 5 teams, sections regarding Patient Details, Consent & Capacity, Carers, Referral Details and Assessment attained results at 91% or above regarding compliance.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 2 · response
    Published 4 June 2025

    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

    Continue reviewing urgent-care learning, deadlines and impact through monthly quality and safety meetings.

    Verbatim wording from the response

    “This event was led by the Director of Quality and Safety and Operational Associate Director on the 19th August 2024 with a focus on assessment and family involvement. A follow up Urgent care away day took place on 1st May 2025 to review all learning, data and incident reporting across 2023- 2024 for urgent care to ensure joined up thematic learning and review. The scrutiny of deadlines and impact continues to be reviewed at the monthly Urgent care Quality and safety meetings.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 2 · response
    Published 4 June 2025

    Open published response

  12. Essex

    AI-generated summary

    DARREN NEIL TURNER · 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

    Darren Neil Turner was admitted to an acute psychiatric unit on 26 September 2023 after a serious mental health crisis involving suicidal behaviour, alcohol misuse and an attempted house fire. His Section 2 detention was rescinded and he was discharged on 17 October 2023; he likely took his own life by hanging the following morning and was found deceased on 20 October 2023. The report identified concerns including failures in care planning, documentation, risk assessment, care-coordinator allocation, communication with family, and discharge planning.

    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to liaise with family to establish discharge suitability and safety

    Wider context from the report

    “(e) Failures in Communication including a failure to appropriately liaise with the deceased’s Family and, specifically, Darren’s mother to establish the suitability and safety of a discharge to her address not least in the context of Darren’s disclosure that discharge to his mother’s home might “make him feel worse” at a point in time that he later acknowledged “would be overwhelming” for him. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to appropriately update and document care plans

    Wider context from the report

    “(a) Failures in Care Planning: specifically, a failure to appropriately up-date and document matters relating to Darren’s Care Plan consistent with Trust policy. The last up-date to his Care Plan was 12 days prior to discharge. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to allocate a Care Coordinator under the Care Programme Approach

    Wider context from the report

    “(d) Failure to allocate a Care Coordinator as required under the Care Programme Approach (CPA) and as mandated by EPUT policy. This failure (resulting from significant human error not detected by an insufficiently robust system and not therefore corrected prior to the death - and in respect of which no DATIX was ever raised) was a feature that contributed to the serious failure in discharge planning in this case. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequacy of electronic clinical records

    Wider context from the report

    “(b) Failures in Documentation: in a number of acknowledged respects the electronic records were inadequate - and inconsistent with EPUT policy - with evidence of the ‘cutting and pasting’ of entries including Darren’s initial 72-hour care plan containing details of another patient entirely. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain accurate patient-specific clinical records

    Wider context from the report

    “(b) Failures in Documentation: in a number of acknowledged respects the electronic records were inadequate - and inconsistent with EPUT policy - with evidence of the ‘cutting and pasting’ of entries including Darren’s initial 72-hour care plan containing details of another patient entirely. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to appropriately update and document risk assessments

    Wider context from the report

    “(c) Failures in Risk Assessments: specifically, failures to appropriately up-date and document matters relating to Darren’s risk assessment consistent with Trust policy. Relevant passive and active risk factors were not formally reflected in his documented risk assessments. Evidence from his Responsible Consultant Psychiatrist and the discharging Psychiatrist confirmed that, had they been aware of a disclosure made by Darren to his key worker/nurse prior to discharge, the Section 2 detention would not have been rescinded, he would not have been discharged on the 17th October and, accordingly, it is likely that he would not have taken his own life the following day. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Chaotic and unsupported discharge execution

    Wider context from the report

    “(f) Failures in Discharge Planning and Execution: specifically, in addition to the features above, a failure to actively reconsider the safety of the discharge on the afternoon of the 17th October in light of the disclosure from Darren’s mother that she would not, as had been previously indicated, be able to either collect Darren from the Ward or be at her home when he was discharged. There was no evidence of how, in fact, Darren even left the Unit. It is likely that the chaotic and unsupported nature of Darren’s discharge from Gosfield Ward, also in breach of Trust policy, more than minimally contributed to his death some 18 hours after discharge. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to actively reconsider discharge safety when arrangements change

    Wider context from the report

    “(f) Failures in Discharge Planning and Execution: specifically, in addition to the features above, a failure to actively reconsider the safety of the discharge on the afternoon of the 17th October in light of the disclosure from Darren’s mother that she would not, as had been previously indicated, be able to either collect Darren from the Ward or be at her home when he was discharged. There was no evidence of how, in fact, Darren even left the Unit. It is likely that the chaotic and unsupported nature of Darren’s discharge from Gosfield Ward, also in breach of Trust policy, more than minimally contributed to his death some 18 hours after discharge. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of systems to detect and correct significant human error

    Wider context from the report

    “(d) Failure to allocate a Care Coordinator as required under the Care Programme Approach (CPA) and as mandated by EPUT policy. This failure (resulting from significant human error not detected by an insufficiently robust system and not therefore corrected prior to the death - and in respect of which no DATIX was ever raised) was a feature that contributed to the serious failure in discharge planning in this case. ”
    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

    Strengthen care-coordinator referral and allocation through shared referral-inbox access, weekly monitoring and a weekly Flow and Capacity Meeting.

    Verbatim wording from the response

    “On admission, where appropriate, a referral is made for a care coordinator. Community services are using a zoning template which clearly flags new referrals from inpatient services. At the weekly community MH team locality meeting all referrals are discussed for allocation and in-reach planning.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 4 · response
    Published 17 March 2025

    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

    Implement the unified NOVA electronic patient record to integrate systems and carry forward risk information.

    Verbatim wording from the response

    “Essex Partnership University Trust and Mid and South Essex NHS Foundation Trust (MSEFT) are working together to implement ‘NOVA’, a new and single Electronic Patient Record (EPR) system across our services, which will pull through risk information which will negate need to repeat information.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 17 March 2025

    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

    Develop and pilot standardised multidisciplinary-team communication, recording and documentation principles across four sites.

    Verbatim wording from the response

    “The Trust has initiated a MDT Communication SIP due to the findings from patient safety incident investigations. A working group has been established consisting of senior clinicians and service directors to develop key principles for effective MDT working/communication and documentation. This group will considered the concerns raised by this PFD to ensure this learning is considered as part of the project.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 3 · response
    Published 17 March 2025

    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

    Assign a registered nurse to coordinate each patient’s safe-discharge preparation, travel, support, follow-up and crisis-contingency plans.

    Verbatim wording from the response

    “Additionally, on discharge, an allocated registered nurse on shift will take responsibility for working with the patient to prepare for safe discharge including home travel plans, ensuring support network plan is in place, contact / follow up advice and crisis contingency plan.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 6 · response
    Published 17 March 2025

    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

    Recruit a Community and Inpatient Liaison Nurse to coordinate inpatient referrals and support safe discharge.

    Verbatim wording from the response

    “The Gables SMHT are currently in the process of recruiting a Community and Inpatient Liaison Nurse lead band 6 Community Psychiatric Nurse (CPN). The post holder is to work directly with inpatient services. All inpatients who are referred to the Gables SMHT will be allocated to this CPN. It is envisaged that the staff member will meet with the patients on the ward, attend ward review and work closely with the inpatient team to ensure a safe discharge, improve communication and provide a more seamless service.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 5 · response
    Published 17 March 2025

    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

    Provide ward-wide digital clinical dashboards displaying quality, performance and risk-assessment information.

    Verbatim wording from the response

    “The Trust has developed new digital clinical dashboards available in all wards which displays a range of ‘at a glance’ quality/performance information. This includes monitoring of risk assessments. All staff have access to this dashboard.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 4 · response
    Published 17 March 2025

    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

    Provide each ward with an aligned Practice Nurse Educator to support staff skills and care-plan quality.

    Verbatim wording from the response

    “Wards now have a Practice Nurse Educator (PNE) aligned to the ward, to help guide and support ward staff. This includes ongoing skills development including in relation to quality of care plans.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 17 March 2025

    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

    Discuss care plans at weekly multidisciplinary team meetings and after incidents or changes.

    Verbatim wording from the response

    “We can provide assurance that there is an expectation that care plans are reviewed as a minimum weekly or following any incidents or change. To further support this changes are being made to ensure care plans are discussed at weekly MDTs.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 1 · response
    Published 17 March 2025

    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

    Invite the appropriate Home Treatment Team to attend ward reviews on the day of discharge.

    Verbatim wording from the response

    “Going forward the appropriate Home Treatment Team will be invited to attend ward review meeting on day of discharge to ensure they have the most up to date information in relation to planned discharges.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 6 · response
    Published 17 March 2025

    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

    Mobilise the new inpatient operating model and its implementation plan for proactive, safe and effective discharge across adult and older-adult wards.

    Verbatim wording from the response

    “This 10 year thematic review of in-patient deaths informed the Discharge SIP and contributed to the development of a new in patient operating model in 2024. This along with newly published NHSE guidance for in-patient wards for working age and older people has provided an opportunity for a full review of the culture, systems and process to maximise the patient and staff experience, improve quality and safety and align with community mental health and system partners. The model incorporates four chapters – ‘Purposeful Admission’, ‘Therapeutic Benefit’, ‘Trauma Informed Care’ and ‘Proactive, Safe and Effective Discharge’ which is supported by a detailed implementation plan, which is currently being mobilised across all adult and older adult wards. Community services and Family & Carer engagement is key within the Proactive, Safe and Effective Discharge chapter.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 6 · response
    Published 17 March 2025

    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

    Complete a thematic review of inpatient deaths to inform discharge safety improvements.

    Verbatim wording from the response

    “The Trust has initiated a Discharge SIP (Safety Improvement Plan). The Urgent Care and Inpatient Care Unit leadership team through the PSIRF process carried out a table top exercise in April 2024 to review inpatient safety incidents where unexpected death had occurred over the last 10 years (2014 – 2024) from an operational, and quality and safety lens.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 6 · response
    Published 17 March 2025

    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

    Pilot individualised care-plan templates informed by patient focus groups and evaluate them through patient workshops.

    Verbatim wording from the response

    “A Quality Improvement Project has been undertaken on Gosfield Ward with support from the Trust QI Hub. The aim has been to review care plans to ensure they are individualised, of value to our patients and in a supportive template for continual review. The project has included focus groups with patients to understand what must be included in their care plans. Patient feedback has been recorded, and this has informed the content of the care plan templates being piloted on Gosfield Ward.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 17 March 2025

    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

    Disseminate requirements for DATIX reporting and facilitate refresher training where supervisors identify staff training needs.

    Verbatim wording from the response

    “With regards to DATIX not having been raised in relation to this incidence, a memo has been issued to all Clinical Managers in Mid Essex to distribute to all their staff and discuss in their respective Business meetings the requirement for DATIX Incident reporting to be completed for all adverse incidents, adverse events and near misses. Additionally, all supervisors are to ensure that all there supervisees are confident in using the DATIX system and where training need is identified, such refreshers are to be facilitated via the Risk Management Team”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 5 · response
    Published 17 March 2025

    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 a Trust communication reminding staff to review care plans regularly.

    Verbatim wording from the response

    “To support staff in meeting this expectation a further Trust communication will be circulated reminding staff of the importance of regular review of the care plan.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 1 · response
    Published 17 March 2025

    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

    Assign Family Ambassadors to support family engagement, information sharing and recording family information for multidisciplinary consideration.

    Verbatim wording from the response

    “The Trust has established family ambassadors on the wards who are a key point of contact for families and are responsible for ensuring information shared by families is recorded and considered by the MDT.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 3 · response
    Published 17 March 2025

    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

    Operate the Record Keeping Safety Improvement Programme to investigate copying and pasting and develop systems addressing documentation risks.

    Verbatim wording from the response

    “The Trust has initiated a Record Keeping Safety Improvement Programme (SIP). Part of this includes considering how to address issues of copying and pasting. This SIP program is focusing on improving patient safety in respect of documentation specifically. The SIP is aiming to understand motivations for copying and pasting and putting systems in to address these. The approach will be to support continuous learning and improvement and regular review.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 17 March 2025

    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

    Audit care-plan quality through ward, Practice Nurse Educator and person-centred audits, and share or escalate findings through governance and supervision.

    Verbatim wording from the response

    “The Ward manager undertakes weekly oversight of all care plans for inpatients through auditing (via the Trust Tendable system) and the quality of care planning is discussed at supervision. The outcome of such audits is shared via the Care Unit Local Quality and Safety Group and is visible via the Trust Tendable dashboard and through to the Care Unit Accountability Meeting and Trust Quality Committee.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 1 · response
    Published 17 March 2025

    Open published response

  13. Essex

    AI-generated summary

    DAVID WAYNE BENNETT · 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

    David Wayne Bennett died by hanging on 13 June 2023 after being found suspended by a ligature, with cocaine and alcohol ingestion. He had a history of drug-induced psychosis and had sought help for deteriorating mental health, psychosis and lack of sleep before his death. Concerns included inadequate sharing and recording of mental-health and primary-care information, unclear urgent-care pathways, failures to escalate requests for urgent medication review, and insufficient mental-health assessment and liaison at hospital.

    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of mental health liaison to undertake the mental health risk assessment

    Wider context from the report

    “(7) The mental health liaison nurse asked the acute Trust nurse to undertake the risk assessment for Mr Bennett’s mental health. This is the role and purpose of mental health liaison. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to identify and escalate unrequested antipsychotic medication

    Wider context from the report

    “(5) Mr Bennett had an open prescription for antipsychotic medication on his GP record that was not being requested and the primary care mental health nurse did not ask about this and the nurse did not inform the GP or seek any advice from her line manager who was a nurse prescriber. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of appropriate access by mental health crisis staff to primary care mental health records

    Wider context from the report

    “(1) Evidence was heard that the mental health crisis staff do not appear to have appropriate access to the primary care mental health System One records and there is a risk that vital information is not being shared. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Unclear and implementation-inconsistent mental health urgent care pathways

    Wider context from the report

    “(2) The Operational Policy Mental Health Urgent Care Department pathways Appendices are not clear and do not appear to accord with the implementation. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to share all available information with the acute Trust nurse

    Wider context from the report

    “(6) Mr Bennett attended the acute hospital Trust for his deteriorating mental health. The acute Trust hospital nurse sought advice from the mental health liaison nurse. The acute Trust nurse did not have access to the mental health or GP records and not all available information was shared with the acute Trust nurse. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to escalate urgent medication review requests to an appropriate clinician

    Wider context from the report

    “(4) Mr Bennett requested a GP appointment; a telephone appointment was made with the primary care mental health nurse. The primary care mental health nurse on 1ˢᵗ June did not escalate Mr Bennett to the GP or Community Psychiatrist when Mr Bennett was adamant he wanted to see a doctor and required an urgent medication review for his deteriorating mental health. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to accurately record contact and suicidal ideation in mental health records

    Wider context from the report

    “(3) Recent contact with the primary care mental health records did not appear to be accurately recorded in the System One Records with suicidal ideation not recorded. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of acute Trust nurse access to mental health and GP records

    Wider context from the report

    “(6) Mr Bennett attended the acute hospital Trust for his deteriorating mental health. The acute Trust hospital nurse sought advice from the mental health liaison nurse. The acute Trust nurse did not have access to the mental health or GP records and not all available information was shared with the acute Trust nurse. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to share vital mental health information

    Wider context from the report

    “(1) Evidence was heard that the mental health crisis staff do not appear to have appropriate access to the primary care mental health System One records and there is a risk that vital information is not being shared. ”
    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

    Develop a unified electronic patient record across EPUT and MSEFT, including bidirectional primary-care integration.

    Verbatim wording from the response

    “Response: We respectfully advise that MSEFT are best placed to respond to this concern, regarding access to GP records. With regards to access to the mental health records, the Trust in partnership with MSEFT are currently developing a new unified Electronic Patient record system across EPUT and MSEFT. The strategic ambition to unify care pathways remains at the centre of the programmes commitment including the bidirectional integration with primary care. The new UEPR (NOVA) is expected to go live across the Trust in February 2027.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 3 · response
    Published 18 February 2025

    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

    Move towards a collaborative Safety Planning approach to keeping people safe.

    Verbatim wording from the response

    “In line with other Mental Health Trusts we are moving towards a “Safety Planning” approach to keeping people safe. This approach is welcomed and championed by those with mental health needs. This approach promotes a collaborative approach to keeping patient’s safe. It would be impractical and a failure of the use of learned and professional expertise to have mental health nurses only carrying out risk assessments. Again, mental health risk assessments is a joint responsibility.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 3 · response
    Published 18 February 2025

    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 Mental Health Practitioners to locate current and historical prescriptions in SystmOne.

    Verbatim wording from the response

    “Response: Current and historic prescriptions can be viewed on SystmOne by practitioners based within a GP practice, hence prescriptions / history are available to view as required by attending practitioners. Planned training for Basildon and Brentwood MHP’s will ensure all MHP’s are aware of where to allocate current and historical prescriptions in SystmOne. In addition the team is working with the local private provider on exploring if there are additional modules available on Systmone which will further support care delivery pathways.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 2 · response
    Published 18 February 2025

    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 focused SystmOne training on recording suicidal ideation and review template completion fields with Mental Health Practitioners.

    Verbatim wording from the response

    “Response: SystmOne has a template to complete to record the Mental Health Assessment and also a template for risk assessment for the primary care nurse to complete. On the risk assessment there are boxes to check for suicidal thought and self-harm. If these are checked a dialogue box opens up for further information to be added. If the patient is not suicidal there will not be any information recorded. Although SystmOne training is mandatory for it to be used, the Trust will now arrange ensuring training on how to use the system for recording suicidal ideation specifically as a focus. We can confirm that a training session for Basildon and Brentwood Mental Health Practitioners planned for the 29 April 2025, where fields for completion in the templates used on SystmOne will be reviewed to ensure all MHPs are proficient in using SystmOne.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 2 · response
    Published 18 February 2025

    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 the Mental Health Urgent Care Department policy and associated standard operating procedure to improve pathway clarity and consistency.

    Verbatim wording from the response

    “Response: We are undertaking a periodical review of the policy and associated standard operating procedure for the Mental Health Urgent Care Department and will reflect this”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 1 · response
    Published 18 February 2025

    Open published response

    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

    Onward appointment processes are at each GP surgery’s discretion, rather than being determined by the Trust.

    Verbatim wording from the response

    “Response: The pathway is that the patient calls the GP, the GP care navigator makes the decision whether to book the appointment with a GP or directly books the patient in to see the Mental Health Practitioner (MHP) for a telephone consultation. If the MHP assesses there to be a need for psychiatric review they will take this to the First Response Team Multi-Disciplinary Team (MDT) and request their input (for example, if the Nurse Prescriber considers the patient’s medication need is out of his/her prescribing remit). If the need is physical the MHP will advise the patient to make an appointment with the GP. In this case the patient had wanted to see the GP and was duly advised to go back to the GP.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 2 · response
    Published 18 February 2025

    Open published response

    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

    Mental health risk assessment is a joint responsibility, not exclusively the role of mental health liaison staff.

    Verbatim wording from the response

    “Concern 7) The mental health liaison nurse asked the acute Trust nurse to undertake the risk assessment for Mr Bennett’s mental health. This is the role and purpose of mental health liaison.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 3 · response
    Published 18 February 2025

    Open published response

    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

    Mid and South Essex NHS Foundation Trust is best placed to address acute hospital access to GP records.

    Verbatim wording from the response

    “Response: We respectfully advise that MSEFT are best placed to respond to this concern, regarding access to GP records. With regards to access to the mental health records, the Trust in partnership with MSEFT are currently developing a new unified Electronic Patient record system across EPUT and MSEFT. The strategic ambition to unify care pathways remains at the centre of the programmes commitment including the bidirectional integration with primary care. The new UEPR (NOVA) is expected to go live across the Trust in February 2027.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 3 · response
    Published 18 February 2025

    Open published response

    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 Line Manager would not have prescribed medication because prescribing for this case was outside the manager’s remit.

    Verbatim wording from the response

    “As set out in evidence, the MHP ought to have discussed this case with a Nurse Prescriber or the Line Manager, the request for medication could have been looked into further. Whilst this would provide insight into medication history, the Line Manager has confirmed that he would not have prescribed any medication for Mr Bennett in light of the fact this is out of his remit. Mr Bennett’s case would have been presented at the First Response Team’s (FRT)”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 2 · response
    Published 18 February 2025

    Open published response

    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

    Mental Health Crisis staff had access to SystmOne records; only the Mental Health Liaison team lacked access at the relevant time.

    Verbatim wording from the response

    “Concern 1) Evidence was heard that the mental health crisis staff do not appear to have appropriate access to the primary care mental health SystmOne records and there is a risk that vital information is not being shared.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 1 · response
    Published 18 February 2025

    Open published response

  14. Essex

    AI-generated summary

    Mr Warren James Green · 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

    Mr Warren James Green, who was receiving care in an acute hospital following a serious attempt on his life, died on 20 August 2024 after jumping through a gap in a four-storey stairwell and sustaining a skull fracture and traumatic subdural haemorrhage. The concerns identified included delays in securing a psychiatric bed, inadequate supervision and safeguarding for a patient at high risk of self-harm, patients being able to leave the acute ward without appropriate assessment or staff awareness, and unclear escalation to consultant psychiatric oversight.

    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of Consultant Psychiatrist oversight for vulnerable patients

    Wider context from the report

    “(1) The evidence identified a risk of patients at high risk of self-harm being able to leave the acute ward without appropriate risk assessment (2) The evidence identified a risk of patients at high risk of self-harm being able to leave the acute ward without the knowledge of the hospital staff The above shows a lacuna in terms of patients’ safety and safeguarding. (3) The evidence showed that the Mental Health Liaison Service relies on nurses to conduct initial assessments and follow up reviews of patients suffering with mental health issues and the mechanism by which escalation to a Consultants Psychiatric is decided and the factors to be taken into account for escalation are not at all clear. This leads to lack of Consultants oversight for these vulnerable patients. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to complete appropriate risk assessments before high-risk patients leave the acute ward

    Wider context from the report

    “(1) The evidence identified a risk of patients at high risk of self-harm being able to leave the acute ward without appropriate risk assessment (2) The evidence identified a risk of patients at high risk of self-harm being able to leave the acute ward without the knowledge of the hospital staff The above shows a lacuna in terms of patients’ safety and safeguarding. (3) The evidence showed that the Mental Health Liaison Service relies on nurses to conduct initial assessments and follow up reviews of patients suffering with mental health issues and the mechanism by which escalation to a Consultants Psychiatric is decided and the factors to be taken into account for escalation are not at all clear. This leads to lack of Consultants oversight for these vulnerable patients. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure hospital staff know when high-risk patients leave the acute ward

    Wider context from the report

    “(1) The evidence identified a risk of patients at high risk of self-harm being able to leave the acute ward without appropriate risk assessment (2) The evidence identified a risk of patients at high risk of self-harm being able to leave the acute ward without the knowledge of the hospital staff The above shows a lacuna in terms of patients’ safety and safeguarding. (3) The evidence showed that the Mental Health Liaison Service relies on nurses to conduct initial assessments and follow up reviews of patients suffering with mental health issues and the mechanism by which escalation to a Consultants Psychiatric is decided and the factors to be taken into account for escalation are not at all clear. This leads to lack of Consultants oversight for these vulnerable patients. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of clear mechanisms and criteria for escalation to a Consultant Psychiatrist

    Wider context from the report

    “(1) The evidence identified a risk of patients at high risk of self-harm being able to leave the acute ward without appropriate risk assessment (2) The evidence identified a risk of patients at high risk of self-harm being able to leave the acute ward without the knowledge of the hospital staff The above shows a lacuna in terms of patients’ safety and safeguarding. (3) The evidence showed that the Mental Health Liaison Service relies on nurses to conduct initial assessments and follow up reviews of patients suffering with mental health issues and the mechanism by which escalation to a Consultants Psychiatric is decided and the factors to be taken into account for escalation are not at all clear. This leads to lack of Consultants oversight for these vulnerable patients. ”
    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

    Monitor the consultant-oversight provisions to assess whether they contribute to patient safety and therapeutic care.

    Verbatim wording from the response

    “I hope that I have provided reassurances around the steps that we have taken to address the issues of concern contained within your report. We know there is an acute need to embed and effect change, hence we will monitor the above provisions to ensure these are contributing to our overall aim of keeping patents safe and delivering therapeutic care.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 4 · response
    Published 20 January 2026

    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 the Liaison Service Standard Operating Procedure to incorporate the described consultant-oversight provisions, completing the review by May 2026.

    Verbatim wording from the response

    “The Trust is currently reviewing its Standard Operating Procedure (SOP) in order to cover the above provisions. This will be completed by May 2026 we would be happy to share a copy of the same with the Court if required.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 4 · response
    Published 20 January 2026

    Open published response

    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

    MSE is responsible for responding to the risk of high-risk self-harm patients leaving the acute ward without appropriate risk assessment.

    Verbatim wording from the response

    “Concern 1) The evidence identified a risk of patients at high risk of self-harm being able to leave the acute ward without appropriate risk assessment”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 1 · response
    Published 20 January 2026

    Open published response

    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

    MSE is responsible for responding to the risk of high-risk self-harm patients leaving the acute ward without hospital staff knowing.

    Verbatim wording from the response

    “Concern 2) The evidence identified a risk of patients at high risk of self-harm being able to leave the acute ward without the knowledge of the hospital staff”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 1 · response
    Published 20 January 2026

    Open published response

    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

    Existing Core 24, multidisciplinary review, referral, escalation and on-call arrangements provide sufficient Consultant oversight for liaison patients.

    Verbatim wording from the response

    “Response: In line with the assurance evidence presented to Court, we confirm that the ‘Core 24’ model is a nationally endorsed NHS best-practice standard for 24/7 liaison mental health services in acute hospitals. This model was applied in respect of the care afforded to Mr Green.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 20 January 2026

    Open published response

  15. Essex

    AI-generated summary

    Jamie Harding · 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

    Jamie Harding attended Basildon Hospital on 3 June 2022 in crisis, with worsening psychotic symptoms, suicidal ideation and several days without sleep. He was discharged home rather than admitted as an inpatient and took his own life within hours after falling from a window. The substantive concerns included failures in assessment, follow-up, medication review, multidisciplinary working, risk assessment, record keeping and communication, alongside weaknesses in systems supporting the First Response Team and access to the Dual Diagnosis pathway.

    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of the FRT caseload system to ensure efficient follow-up of referrals and queries

    Wider context from the report

    “(a) The accepted absence of effective formal, compulsory training for clinicians regarding the Dual Diagnosis (DD) pathway and what it does and does not provide, how to access it and the potential benefits of it. The evidence confirmed that practitioners outside of the DD workers/pathway were unaware how they could contact them, including directly. (b) In addition to weak record keeping and poor communication with patients and their families, the evidence revealed the lack of a robust and reliable system to ensure that the FRT deals with its caseload efficiently and effectively and that particularity when it flags and then follows up referrals to and queries from other services/clinicians contributing, in turn and on the facts of this case, to the significant failure to hold an MDT. The FRT did not follow up (as it was accepted it should have) the referral (via a self-referral) to Open Road or the referrals for a medication review. Had there been such follow up, EPUT evidence confirmed that there would likely have been a discussion of Jamie’s case at a full MDT with the likely allocation of a Care Coordinator, the likely involvement of the Dual Diagnosis pathway and the likely use of the RAG rating system to ensure on-going risk assessment. In my opinion these features give rise to a clear risk of future deaths and must be addressed. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Poor communication with patients and their families

    Wider context from the report

    “(a) The accepted absence of effective formal, compulsory training for clinicians regarding the Dual Diagnosis (DD) pathway and what it does and does not provide, how to access it and the potential benefits of it. The evidence confirmed that practitioners outside of the DD workers/pathway were unaware how they could contact them, including directly. (b) In addition to weak record keeping and poor communication with patients and their families, the evidence revealed the lack of a robust and reliable system to ensure that the FRT deals with its caseload efficiently and effectively and that particularity when it flags and then follows up referrals to and queries from other services/clinicians contributing, in turn and on the facts of this case, to the significant failure to hold an MDT. The FRT did not follow up (as it was accepted it should have) the referral (via a self-referral) to Open Road or the referrals for a medication review. Had there been such follow up, EPUT evidence confirmed that there would likely have been a discussion of Jamie’s case at a full MDT with the likely allocation of a Care Coordinator, the likely involvement of the Dual Diagnosis pathway and the likely use of the RAG rating system to ensure on-going risk assessment. In my opinion these features give rise to a clear risk of future deaths and must be addressed. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Weak record keeping

    Wider context from the report

    “(a) The accepted absence of effective formal, compulsory training for clinicians regarding the Dual Diagnosis (DD) pathway and what it does and does not provide, how to access it and the potential benefits of it. The evidence confirmed that practitioners outside of the DD workers/pathway were unaware how they could contact them, including directly. (b) In addition to weak record keeping and poor communication with patients and their families, the evidence revealed the lack of a robust and reliable system to ensure that the FRT deals with its caseload efficiently and effectively and that particularity when it flags and then follows up referrals to and queries from other services/clinicians contributing, in turn and on the facts of this case, to the significant failure to hold an MDT. The FRT did not follow up (as it was accepted it should have) the referral (via a self-referral) to Open Road or the referrals for a medication review. Had there been such follow up, EPUT evidence confirmed that there would likely have been a discussion of Jamie’s case at a full MDT with the likely allocation of a Care Coordinator, the likely involvement of the Dual Diagnosis pathway and the likely use of the RAG rating system to ensure on-going risk assessment. In my opinion these features give rise to a clear risk of future deaths and must be addressed. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of formal compulsory clinician training on the Dual Diagnosis pathway and access to it

    Wider context from the report

    “(a) The accepted absence of effective formal, compulsory training for clinicians regarding the Dual Diagnosis (DD) pathway and what it does and does not provide, how to access it and the potential benefits of it. The evidence confirmed that practitioners outside of the DD workers/pathway were unaware how they could contact them, including directly. (b) In addition to weak record keeping and poor communication with patients and their families, the evidence revealed the lack of a robust and reliable system to ensure that the FRT deals with its caseload efficiently and effectively and that particularity when it flags and then follows up referrals to and queries from other services/clinicians contributing, in turn and on the facts of this case, to the significant failure to hold an MDT. The FRT did not follow up (as it was accepted it should have) the referral (via a self-referral) to Open Road or the referrals for a medication review. Had there been such follow up, EPUT evidence confirmed that there would likely have been a discussion of Jamie’s case at a full MDT with the likely allocation of a Care Coordinator, the likely involvement of the Dual Diagnosis pathway and the likely use of the RAG rating system to ensure on-going risk assessment. In my opinion these features give rise to a clear risk of future deaths and must be addressed. ”
    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

    Provide Dual Diagnosis training covering referral processes and access to support for adults with alcohol or substance misuse issues.

    Verbatim wording from the response

    “Additionally, the Trust provides Dual Diagnosis training within EPUT which covers the referral process and how to access support for an adult who has alcohol/substance misuse issues. This currently does not fall within the core requirement of all EPUT staff and the Trust is looking to extend this to all registered clinical staff within EPUT. The current expectation is for training to be completed once and the Trust is exploring the benefit to changing the requirement to be undertaken every 3 years.”

    Source location

    Response from Essex Partnership NHS Foundation Trust
    Page 2 · response
    Published 7 November 2024

    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

    Implement the MaST caseload-management tool with electronic risk, disengagement and RAG indicators supporting MDT prioritisation, and monitor its use through regular audits.

    Verbatim wording from the response

    “The Trust has implemented the Management and Supervision Tool (MaST) caseload management tool, which is improving how our care coordinators (and their supervisors) electronically manage their caseloads.”

    Source location

    Response from Essex Partnership NHS Foundation Trust
    Page 3 · response
    Published 7 November 2024

    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

    Explore changing the Dual Diagnosis training requirement from one-off completion to completion every three years.

    Verbatim wording from the response

    “Additionally, the Trust provides Dual Diagnosis training within EPUT which covers the referral process and how to access support for an adult who has alcohol/substance misuse issues. This currently does not fall within the core requirement of all EPUT staff and the Trust is looking to extend this to all registered clinical staff within EPUT. The current expectation is for training to be completed once and the Trust is exploring the benefit to changing the requirement to be undertaken every 3 years.”

    Source location

    Response from Essex Partnership NHS Foundation Trust
    Page 2 · response
    Published 7 November 2024

    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

    Extend Dual Diagnosis training to all registered clinical staff within the Trust.

    Verbatim wording from the response

    “Additionally, the Trust provides Dual Diagnosis training within EPUT which covers the referral process and how to access support for an adult who has alcohol/substance misuse issues. This currently does not fall within the core requirement of all EPUT staff and the Trust is looking to extend this to all registered clinical staff within EPUT. The current expectation is for training to be completed once and the Trust is exploring the benefit to changing the requirement to be undertaken every 3 years.”

    Source location

    Response from Essex Partnership NHS Foundation Trust
    Page 2 · response
    Published 7 November 2024

    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

    Disseminate Trust-wide information and maintain quick-access intranet guidance explaining how staff can access Dual Diagnosis support.

    Verbatim wording from the response

    “In carrying out our review of this case, it has been noted that the First Response Team (FRT) are aware on the process for contacting / accessing Dual Diagnosis support. However in light of the findings in this case, the FRT / the wider Trust have been reminded via Trust wide communications of the available support streams which includes access to the Trust’s quick access intranet page for dual diagnosis which gives clear guidance for staff.”

    Source location

    Response from Essex Partnership NHS Foundation Trust
    Page 2 · response
    Published 7 November 2024

    Open published response

  16. East London

    AI-generated summary

    Danny Jay Anderson · 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

    Danny Jay Anderson, who had chronic mental health difficulties and was discharged from hospital to inadequate accommodation without a comprehensive risk assessment or safety plan, was found hanging in his room on 30 March 2023 and pronounced dead at the scene. The report identifies concerns about inadequate risk formulation, over-reliance on Danny’s responses about suicidal ideation, insufficient consideration of his history and circumstances, and the absence of a safety plan before discharge from hospital or community mental health services.

    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient staff understanding of risk assessment and management

    Wider context from the report

    “There was no evidence of any adequate formulation of risk prior to Danny’s discharge from hospital on the 14 December 2022 and no evidence of any adequate risk formulation prior to Danny’s discharge from the community mental health team in January 2023. The statement “Danny does not present with any suicidal ideation or self-harming behaviour“ was copied and pasted multiple times throughout the risk assessment template on the 14 December 2022. There was no analysis or formulation of risk for Danny. From review of the records throughout the admission, I am concerned that there was an over-reliance upon Danny’s answer to questions posed about suicidal ideation and intent. At the point of discharge, there was no evidence of information gathering around Danny’s mental state, behaviour, psychiatric history, history of abuse, social situation – and evidence that this information was used to form a judgement about the likelihood or probability of an adverse or harmful outcome (in accordance with the Trust’s risk policy). There was no evidence of any consideration of Danny’s historical factors and experiences, more recent problems and existing strengths and resources (in accordance with the NICE guidelines 2022). Witnesses from consultant level to care co-ordinator level, were unable to describe a robust risk assessment process. I am concerned that staff do not fully understand how to assess and manage risk. There was no safety plan on discharge from hospital, or prior to discharge from the community team, to address the clear risks that Danny posed. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to consider historical factors, recent problems, strengths and resources in risk assessment

    Wider context from the report

    “There was no evidence of any adequate formulation of risk prior to Danny’s discharge from hospital on the 14 December 2022 and no evidence of any adequate risk formulation prior to Danny’s discharge from the community mental health team in January 2023. The statement “Danny does not present with any suicidal ideation or self-harming behaviour“ was copied and pasted multiple times throughout the risk assessment template on the 14 December 2022. There was no analysis or formulation of risk for Danny. From review of the records throughout the admission, I am concerned that there was an over-reliance upon Danny’s answer to questions posed about suicidal ideation and intent. At the point of discharge, there was no evidence of information gathering around Danny’s mental state, behaviour, psychiatric history, history of abuse, social situation – and evidence that this information was used to form a judgement about the likelihood or probability of an adverse or harmful outcome (in accordance with the Trust’s risk policy). There was no evidence of any consideration of Danny’s historical factors and experiences, more recent problems and existing strengths and resources (in accordance with the NICE guidelines 2022). Witnesses from consultant level to care co-ordinator level, were unable to describe a robust risk assessment process. I am concerned that staff do not fully understand how to assess and manage risk. There was no safety plan on discharge from hospital, or prior to discharge from the community team, to address the clear risks that Danny posed. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of safety planning before discharge

    Wider context from the report

    “There was no evidence of any adequate formulation of risk prior to Danny’s discharge from hospital on the 14 December 2022 and no evidence of any adequate risk formulation prior to Danny’s discharge from the community mental health team in January 2023. The statement “Danny does not present with any suicidal ideation or self-harming behaviour“ was copied and pasted multiple times throughout the risk assessment template on the 14 December 2022. There was no analysis or formulation of risk for Danny. From review of the records throughout the admission, I am concerned that there was an over-reliance upon Danny’s answer to questions posed about suicidal ideation and intent. At the point of discharge, there was no evidence of information gathering around Danny’s mental state, behaviour, psychiatric history, history of abuse, social situation – and evidence that this information was used to form a judgement about the likelihood or probability of an adverse or harmful outcome (in accordance with the Trust’s risk policy). There was no evidence of any consideration of Danny’s historical factors and experiences, more recent problems and existing strengths and resources (in accordance with the NICE guidelines 2022). Witnesses from consultant level to care co-ordinator level, were unable to describe a robust risk assessment process. I am concerned that staff do not fully understand how to assess and manage risk. There was no safety plan on discharge from hospital, or prior to discharge from the community team, to address the clear risks that Danny posed. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to gather and use comprehensive information in risk assessment

    Wider context from the report

    “There was no evidence of any adequate formulation of risk prior to Danny’s discharge from hospital on the 14 December 2022 and no evidence of any adequate risk formulation prior to Danny’s discharge from the community mental health team in January 2023. The statement “Danny does not present with any suicidal ideation or self-harming behaviour“ was copied and pasted multiple times throughout the risk assessment template on the 14 December 2022. There was no analysis or formulation of risk for Danny. From review of the records throughout the admission, I am concerned that there was an over-reliance upon Danny’s answer to questions posed about suicidal ideation and intent. At the point of discharge, there was no evidence of information gathering around Danny’s mental state, behaviour, psychiatric history, history of abuse, social situation – and evidence that this information was used to form a judgement about the likelihood or probability of an adverse or harmful outcome (in accordance with the Trust’s risk policy). There was no evidence of any consideration of Danny’s historical factors and experiences, more recent problems and existing strengths and resources (in accordance with the NICE guidelines 2022). Witnesses from consultant level to care co-ordinator level, were unable to describe a robust risk assessment process. I am concerned that staff do not fully understand how to assess and manage risk. There was no safety plan on discharge from hospital, or prior to discharge from the community team, to address the clear risks that Danny posed. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of adequate risk formulation before discharge

    Wider context from the report

    “There was no evidence of any adequate formulation of risk prior to Danny’s discharge from hospital on the 14 December 2022 and no evidence of any adequate risk formulation prior to Danny’s discharge from the community mental health team in January 2023. The statement “Danny does not present with any suicidal ideation or self-harming behaviour“ was copied and pasted multiple times throughout the risk assessment template on the 14 December 2022. There was no analysis or formulation of risk for Danny. From review of the records throughout the admission, I am concerned that there was an over-reliance upon Danny’s answer to questions posed about suicidal ideation and intent. At the point of discharge, there was no evidence of information gathering around Danny’s mental state, behaviour, psychiatric history, history of abuse, social situation – and evidence that this information was used to form a judgement about the likelihood or probability of an adverse or harmful outcome (in accordance with the Trust’s risk policy). There was no evidence of any consideration of Danny’s historical factors and experiences, more recent problems and existing strengths and resources (in accordance with the NICE guidelines 2022). Witnesses from consultant level to care co-ordinator level, were unable to describe a robust risk assessment process. I am concerned that staff do not fully understand how to assess and manage risk. There was no safety plan on discharge from hospital, or prior to discharge from the community team, to address the clear risks that Danny posed. ”
    Open source report

  17. Central and South East Kent

    AI-generated summary

    Phephisa MABUZA · 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

    Phephisa MABUZA, who had psychosis and had not taken prescribed olanzapine for several months, was found at the base of a location in Dover after apparently falling from height. He had been hearing voices before his death, but the inquest evidence did not establish how he fell or his intention at the time. Concerns included local crisis-response guidance allowing a seven-day response for some presentations when national guidance stated 72 hours, and an operational policy containing incorrect triage response codes.

    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of the Crisis Response Service operational policy to accurately reflect triage codes D and E

    Wider context from the report

    “(2) Essex Partnership University NHS Foundation Trust's existing standard operational policy document for the Crisis Response Service incorrectly states triage codes D and E on the appendix as 'within 24 hours- same day response@ and do not reflect the scale on the 111 Triage form or the national guidance. I delayed issuing this report so that the Trust could inform me of the current position and whether any remedial action had been taken. A memo has been sent to all staff to notify them that the operational policy has been wrongly coded but a decision had not yet been taken as to whether and how the Trust intended to move forward in respect of the departure from the national guidance ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of local category D response guidance to reflect the national 72-hour timeframe

    Wider context from the report

    “(1) Essex Partnership University NHS Foundation Trust Crisis Response Service follows the UK Mental Health Triage scale in classifying the urgency and service response requirements of clinical presentations at the point of contact. The scale is embedded within the 111 Triage form utilised by clinicians in their clinical decision making following a triage. The Trust has departed from the national guidance for category D presentations such that the local guidance has been amended to reflect a 7 day response when the national guidance states 72 hours ”
    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

    Correct the erroneous triage response times in the Crisis Response Service Standard Operational Policy.

    Verbatim wording from the response

    “The existing Standard Operational Policy in place is only for use by the Crisis Response Services across the Trust. It is acknowledged that the triage response times on Triage Codes D and E on the appendix were incorrectly stated as “Within 24 hours – Same Day” response, and do not reflect the scale on the form in use on the clinical system. This was owing to a typing error when the policy was completed, and that was unfortunately not picked up before the document went live. The Trust sincerely apologises for missing this, and the confusion it caused to both the Court and to the family.”

    Source location

    Response from Essex Partnership NHS
    Page 2 · response
    Published 11 September 2024

    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 consistent clinical rationale frameworks and safe response timeframes for patients presenting to Crisis Response Services.

    Verbatim wording from the response

    “amended to reflect 7 days. During our investigations, the Trust was unable identify exactly why the decision was taken, however it appears to have been done to align with our community services in their operational frameworks, as the Trust embedded CRS into its services. In light of this, the senior management in the CRS and the Business Partners, have met to take forward this point. We now have clear clinical rationale frameworks, consistently and appropriate and safe time frames for our patients coming through CRS.”

    Source location

    Response from Essex Partnership NHS
    Page 2 · response
    Published 11 September 2024

    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

    Align Trust policies with national standards for Crisis Response Services.

    Verbatim wording from the response

    “Additionally work is underway in order to ensure Trust Policies align with national standards as required.”

    Source location

    Response from Essex Partnership NHS
    Page 2 · response
    Published 11 September 2024

    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

    Disseminate a reminder to clinicians and other Crisis Response Service leads to use the UK Mental Health Triage Scale in clinical decision-making.

    Verbatim wording from the response

    “The Standard Operational Policy has been reviewed and the identified errors rectified. A memo has been sent to all clinicians within the service reminding them of the use of the UK Mental Health Triage Scale in informing their clinical judgment in the decision making process. This has also been shared with the leads covering the other CRS teams.”

    Source location

    Response from Essex Partnership NHS
    Page 2 · response
    Published 11 September 2024

    Open published response

  18. Essex

    AI-generated summary

    Aaron James DEELEY · 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

    Aaron James Deeley died after deliberately exiting a defective second-floor hospital window on 14 January 2022, sustaining multiple traumatic injuries. The report identified concerns about safeguarding and the removal of 1:1 observation, as well as gaps and confusion in arrangements for patients awaiting a Mental Health Act assessment while receiving physical healthcare.

    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Confusing and incomplete policy for placing patients awaiting Mental Health Act assessment under 1:1 observation

    Wider context from the report

    “While a patient is admitted to an acute Trust ward for treatment for physical health treatment and is being held under section 5 (2) Mental Health Act for a Mental Health Act assessment due to concerns the patient presents a risk to themselves or others with a mental disorder, it permits the patient to be held for a maximum period of 72 hours. a. Patients admitted into the Accident & Emergency department detained under various sections of the Mental Health Act have a Responsible Clinician allocated. Patients who are not under section have access to the Mental Health Liaison Team. b. Patients admitted onto a ward at the acute Trust detained under various sections of the Mental Health Act have an allocated Responsible Clinician. As section 5 (2) is a holding power only, there is no Responsible Clinician allocated for a vulnerable patient being held pending assessment for consideration for detention under the Mental health Act. c. During the waiting period of up to 72 hours, Mental Health Liaison will not attend the acute ward or make assessment of the presenting risks of self-harm. d. The acute care healthcare professionals do not have specialist mental health training to conduct a mental health assessment and the consequential presenting harm. e. There was confusion at the acute Trust as to what regime was required to ensure that a patient awaiting Mental Health Act assessment could be put under 1:1 observation. The Trust policy was confusing and did not cover patients like Aaron Deeley. f. There is no joint protocol to cover the working between the two Trusts on this issue as the referral for Mental Health Act assessment goes outside of both organisations. There is a lacuna for patients awaiting Mental Health Act assessment and requiring simultaneous physical healthcare when a significant risk has been identified such that a patient may require detention for their own safety. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a joint protocol for working between the two Trusts on Mental Health Act assessment referrals

    Wider context from the report

    “While a patient is admitted to an acute Trust ward for treatment for physical health treatment and is being held under section 5 (2) Mental Health Act for a Mental Health Act assessment due to concerns the patient presents a risk to themselves or others with a mental disorder, it permits the patient to be held for a maximum period of 72 hours. a. Patients admitted into the Accident & Emergency department detained under various sections of the Mental Health Act have a Responsible Clinician allocated. Patients who are not under section have access to the Mental Health Liaison Team. b. Patients admitted onto a ward at the acute Trust detained under various sections of the Mental Health Act have an allocated Responsible Clinician. As section 5 (2) is a holding power only, there is no Responsible Clinician allocated for a vulnerable patient being held pending assessment for consideration for detention under the Mental health Act. c. During the waiting period of up to 72 hours, Mental Health Liaison will not attend the acute ward or make assessment of the presenting risks of self-harm. d. The acute care healthcare professionals do not have specialist mental health training to conduct a mental health assessment and the consequential presenting harm. e. There was confusion at the acute Trust as to what regime was required to ensure that a patient awaiting Mental Health Act assessment could be put under 1:1 observation. The Trust policy was confusing and did not cover patients like Aaron Deeley. f. There is no joint protocol to cover the working between the two Trusts on this issue as the referral for Mental Health Act assessment goes outside of both organisations. There is a lacuna for patients awaiting Mental Health Act assessment and requiring simultaneous physical healthcare when a significant risk has been identified such that a patient may require detention for their own safety. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of Responsible Clinician allocation for vulnerable patients held pending Mental Health Act assessment

    Wider context from the report

    “While a patient is admitted to an acute Trust ward for treatment for physical health treatment and is being held under section 5 (2) Mental Health Act for a Mental Health Act assessment due to concerns the patient presents a risk to themselves or others with a mental disorder, it permits the patient to be held for a maximum period of 72 hours. a. Patients admitted into the Accident & Emergency department detained under various sections of the Mental Health Act have a Responsible Clinician allocated. Patients who are not under section have access to the Mental Health Liaison Team. b. Patients admitted onto a ward at the acute Trust detained under various sections of the Mental Health Act have an allocated Responsible Clinician. As section 5 (2) is a holding power only, there is no Responsible Clinician allocated for a vulnerable patient being held pending assessment for consideration for detention under the Mental health Act. c. During the waiting period of up to 72 hours, Mental Health Liaison will not attend the acute ward or make assessment of the presenting risks of self-harm. d. The acute care healthcare professionals do not have specialist mental health training to conduct a mental health assessment and the consequential presenting harm. e. There was confusion at the acute Trust as to what regime was required to ensure that a patient awaiting Mental Health Act assessment could be put under 1:1 observation. The Trust policy was confusing and did not cover patients like Aaron Deeley. f. There is no joint protocol to cover the working between the two Trusts on this issue as the referral for Mental Health Act assessment goes outside of both organisations. There is a lacuna for patients awaiting Mental Health Act assessment and requiring simultaneous physical healthcare when a significant risk has been identified such that a patient may require detention for their own safety. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of specialist mental health training among acute care healthcare professionals for mental health assessment

    Wider context from the report

    “While a patient is admitted to an acute Trust ward for treatment for physical health treatment and is being held under section 5 (2) Mental Health Act for a Mental Health Act assessment due to concerns the patient presents a risk to themselves or others with a mental disorder, it permits the patient to be held for a maximum period of 72 hours. a. Patients admitted into the Accident & Emergency department detained under various sections of the Mental Health Act have a Responsible Clinician allocated. Patients who are not under section have access to the Mental Health Liaison Team. b. Patients admitted onto a ward at the acute Trust detained under various sections of the Mental Health Act have an allocated Responsible Clinician. As section 5 (2) is a holding power only, there is no Responsible Clinician allocated for a vulnerable patient being held pending assessment for consideration for detention under the Mental health Act. c. During the waiting period of up to 72 hours, Mental Health Liaison will not attend the acute ward or make assessment of the presenting risks of self-harm. d. The acute care healthcare professionals do not have specialist mental health training to conduct a mental health assessment and the consequential presenting harm. e. There was confusion at the acute Trust as to what regime was required to ensure that a patient awaiting Mental Health Act assessment could be put under 1:1 observation. The Trust policy was confusing and did not cover patients like Aaron Deeley. f. There is no joint protocol to cover the working between the two Trusts on this issue as the referral for Mental Health Act assessment goes outside of both organisations. There is a lacuna for patients awaiting Mental Health Act assessment and requiring simultaneous physical healthcare when a significant risk has been identified such that a patient may require detention for their own safety. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of Mental Health Liaison to attend acute wards and assess presenting self-harm risks during the assessment waiting period

    Wider context from the report

    “While a patient is admitted to an acute Trust ward for treatment for physical health treatment and is being held under section 5 (2) Mental Health Act for a Mental Health Act assessment due to concerns the patient presents a risk to themselves or others with a mental disorder, it permits the patient to be held for a maximum period of 72 hours. a. Patients admitted into the Accident & Emergency department detained under various sections of the Mental Health Act have a Responsible Clinician allocated. Patients who are not under section have access to the Mental Health Liaison Team. b. Patients admitted onto a ward at the acute Trust detained under various sections of the Mental Health Act have an allocated Responsible Clinician. As section 5 (2) is a holding power only, there is no Responsible Clinician allocated for a vulnerable patient being held pending assessment for consideration for detention under the Mental health Act. c. During the waiting period of up to 72 hours, Mental Health Liaison will not attend the acute ward or make assessment of the presenting risks of self-harm. d. The acute care healthcare professionals do not have specialist mental health training to conduct a mental health assessment and the consequential presenting harm. e. There was confusion at the acute Trust as to what regime was required to ensure that a patient awaiting Mental Health Act assessment could be put under 1:1 observation. The Trust policy was confusing and did not cover patients like Aaron Deeley. f. There is no joint protocol to cover the working between the two Trusts on this issue as the referral for Mental Health Act assessment goes outside of both organisations. There is a lacuna for patients awaiting Mental Health Act assessment and requiring simultaneous physical healthcare when a significant risk has been identified such that a patient may require detention for their own safety. ”
    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

    Develop a joint EPUT–MSE working protocol defining responsibilities for patients awaiting Mental Health Act assessment.

    Verbatim wording from the response

    “As set out in evidence by EPUT during the course of this Inquest; a patient is placed on a section 5(2) MHA by the Acute Trust, there is a requirement for the mental health liaison team at EPUT to be informed to ensure that appropriate mental health support is in place.”

    Source location

    Response from Essex Partnership NHS
    Page 2 · response
    Published 26 June 2024

    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

    Update and ratify the Mental Health Liaison Service Operational Policy and SOP to address risk management and support for patients awaiting assessment.

    Verbatim wording from the response

    “In support of the collaborative approach that both Trusts are taking forward, the service matron has confirmed MSE leads that EPUT will be supportive of an active role in the ratification of this policy. Further, the EPUT Mental Health Liaison Service Operational Policy has been updated to include the support and advice to acute providers regarding risk management of patient’s presenting as requiring assessment under the Mental Health Act 2007. A Standard Operating Procedure (SOP) was presented at the Liaison Services steering group on the 30th July 2024, final copy for comments has been circulated for comments by 5th August 2024; the Policy is now due for final ratification.”

    Source location

    Response from Essex Partnership NHS
    Page 3 · response
    Published 26 June 2024

    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

    Share the reviewed Mental Health Liaison SOP with all Liaison Team staff to promote awareness and consistent practice.

    Verbatim wording from the response

    “In light of this Regulation 28 Report, a review of the Mental Health Liaison SOP has been undertaken. The SOP now provides a clearer direction for the Mental Health Liaison Team staff to support and assist patients and acute colleagues in the management of patients who are awaiting formal assessment under the Mental Health Act. With Mental Health Liaison Staff particularly supporting in the identification and management of risk. The recent review of this SOP is being shared with all MHLT staff in order to ensure awareness and consistency throughout the service.”

    Source location

    Response from Essex Partnership NHS
    Page 4 · response
    Published 26 June 2024

    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

    Continue delivering training to MSE on available support and Mental Health Liaison Team roles.

    Verbatim wording from the response

    “Further, whilst the project group takes forward the joint protocol, EPUT’s Mental Health Act office continues to deliver training to MSE which includes the support available and role of the Mental Health Liaison team.”

    Source location

    Response from Essex Partnership NHS
    Page 2 · response
    Published 26 June 2024

    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

    Provide EPUT input and support to MSE’s ratification of its acute-hospital mental health admission and treatment policy.

    Verbatim wording from the response

    “In support of the collaborative approach that both Trusts are taking forward, the service matron has confirmed MSE leads that EPUT will be supportive of an active role in the ratification of this policy. Further, the EPUT Mental Health Liaison Service Operational Policy has been updated to include the support and advice to acute providers regarding risk management of patient’s presenting as requiring assessment under the Mental Health Act 2007. A Standard Operating Procedure (SOP) was presented at the Liaison Services steering group on the 30th July 2024, final copy for comments has been circulated for comments by 5th August 2024; the Policy is now due for final ratification.”

    Source location

    Response from Essex Partnership NHS
    Page 3 · response
    Published 26 June 2024

    Open published response

    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 Acute Trust is responsible for responding to concerns about the regime and policy for one-to-one observation pending Mental Health Act assessment.

    Verbatim wording from the response

    “With respect to the Learned Coroner, the answer to this particular concern will be for the Acute Trust to respond to. However, by way of completeness, the planned updates to the Mental Health Liaison Service Operational Policy will include provisions around support and advice to Acute providers regarding care planning and risk management.”

    Source location

    Response from Essex Partnership NHS
    Page 4 · response
    Published 26 June 2024

    Open published response

    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 Code of Practice does not require a Responsible Clinician for patients held under section 5(2), and the Trust complied with applicable provisions.

    Verbatim wording from the response

    “The Mental Health Act 1983 Code of Practice at paragraph 36.1 refers to the identification of Responsible Clinician for patients being assessed and treated under the Act (i.e. section 2 for assessment and treatment, section 3 for treatment). There is no mention of the need for the identification of a Responsible Clinician requirement for patients who are subject to a holding power under section 5 (2). It is therefore respectfully submitted that the Trust adhered to the above provisions when applying the requirements of the Mental Health Act 1983 to the care and treatment of Mr Deeley.”

    Source location

    Response from Essex Partnership NHS
    Page 2 · response
    Published 26 June 2024

    Open published response

  19. Essex

    AI-generated summary

    Georgia Dehaney-Perkins · 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

    Georgia Dehaney-Perkins was found deceased on 6 September 2022 on Latton Common, Harlow, after a history of mental health difficulties, self-harm and suicidal ideation. The medical cause of death was recorded as combined alcohol and drug toxicity. Concerns included the suitability and safety of her ward bathroom, incomplete risk assessment and incident recording, insufficient documentation and communication about medication and alcohol risks, and a lack of action after family raised concerns about her leaving home with medication.

    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to discuss alcohol and medication interaction risks

    Wider context from the report

    “(2) Medication was appropriately withheld on 28 August when Ms Dehaney-Perkins returned to the ward intoxicated due to potential interaction with alcohol that can cause increased sedation, (3) arrhythmia and fatality. a. This risk of consuming alcohol with her specific medication was not discussed with the Ms Dehaney-Perkins or family. b. Not all incidents of consumption of alcohol on return from leave were recorded and risk assessments were not updated. c. Ms Dehaney-Perkins had agreed to mitigations of medication management by her family that were not recorded on the care plan on discharge on 2 September. Ms Dehaney-Perkins demanded control of her medication on 4 September against concerns of her family who were forced to return medication. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to update risk assessments after alcohol consumption incidents

    Wider context from the report

    “(2) Medication was appropriately withheld on 28 August when Ms Dehaney-Perkins returned to the ward intoxicated due to potential interaction with alcohol that can cause increased sedation, (3) arrhythmia and fatality. a. This risk of consuming alcohol with her specific medication was not discussed with the Ms Dehaney-Perkins or family. b. Not all incidents of consumption of alcohol on return from leave were recorded and risk assessments were not updated. c. Ms Dehaney-Perkins had agreed to mitigations of medication management by her family that were not recorded on the care plan on discharge on 2 September. Ms Dehaney-Perkins demanded control of her medication on 4 September against concerns of her family who were forced to return medication. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Incomplete recording of alcohol consumption incidents after leave

    Wider context from the report

    “(2) Medication was appropriately withheld on 28 August when Ms Dehaney-Perkins returned to the ward intoxicated due to potential interaction with alcohol that can cause increased sedation, (3) arrhythmia and fatality. a. This risk of consuming alcohol with her specific medication was not discussed with the Ms Dehaney-Perkins or family. b. Not all incidents of consumption of alcohol on return from leave were recorded and risk assessments were not updated. c. Ms Dehaney-Perkins had agreed to mitigations of medication management by her family that were not recorded on the care plan on discharge on 2 September. Ms Dehaney-Perkins demanded control of her medication on 4 September against concerns of her family who were forced to return medication. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of risk assessment of room suitability for a patient with a self-harming history

    Wider context from the report

    “(1) On 28 August Ms Dehaney-Perkins was agitated and distressed on return to the ward from leave and had consumed alcohol that was known to increase her risk of self-harm. ████████. Staff found Ms Dehaney-Perkins and removed the ligature. a. Ms Dehaney-Perkins was admitted to a room with an assisted bathroom (this was not a requirement for her) with a fault in the anti-ligature safety mechanism meant that the safety feature could not be implemented. b. There was no risk assessment about the suitability of this room for Ms Dehaney-Perkins a patient with a self-harming history at the time of the admission. c. The fixed-point ligature was not appropriately updated in the risk assessment and was not discussed at a discharge planning meeting. d. The Trust Datix Report was incomplete ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to record agreed family medication-management mitigations in the discharge care plan

    Wider context from the report

    “(2) Medication was appropriately withheld on 28 August when Ms Dehaney-Perkins returned to the ward intoxicated due to potential interaction with alcohol that can cause increased sedation, (3) arrhythmia and fatality. a. This risk of consuming alcohol with her specific medication was not discussed with the Ms Dehaney-Perkins or family. b. Not all incidents of consumption of alcohol on return from leave were recorded and risk assessments were not updated. c. Ms Dehaney-Perkins had agreed to mitigations of medication management by her family that were not recorded on the care plan on discharge on 2 September. Ms Dehaney-Perkins demanded control of her medication on 4 September against concerns of her family who were forced to return medication. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to update and communicate fixed-point ligature risks in discharge planning

    Wider context from the report

    “(1) On 28 August Ms Dehaney-Perkins was agitated and distressed on return to the ward from leave and had consumed alcohol that was known to increase her risk of self-harm. ████████. Staff found Ms Dehaney-Perkins and removed the ligature. a. Ms Dehaney-Perkins was admitted to a room with an assisted bathroom (this was not a requirement for her) with a fault in the anti-ligature safety mechanism meant that the safety feature could not be implemented. b. There was no risk assessment about the suitability of this room for Ms Dehaney-Perkins a patient with a self-harming history at the time of the admission. c. The fixed-point ligature was not appropriately updated in the risk assessment and was not discussed at a discharge planning meeting. d. The Trust Datix Report was incomplete ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to act on family concerns about medication access after leaving home

    Wider context from the report

    “(4) The Home First Treatment Team attended a scheduled appointment on 4 September and Ms Dehaney-Perkins appeared stable and updated the risk assessment that the risk of self-harm remained significant when alcohol was consumed. No action was taken following a call raising some queries and concerns from family that evening that Ms Dehaney-Perkins had left her home with her medication. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of an assisted-bathroom anti-ligature safety mechanism

    Wider context from the report

    “(1) On 28 August Ms Dehaney-Perkins was agitated and distressed on return to the ward from leave and had consumed alcohol that was known to increase her risk of self-harm. ████████. Staff found Ms Dehaney-Perkins and removed the ligature. a. Ms Dehaney-Perkins was admitted to a room with an assisted bathroom (this was not a requirement for her) with a fault in the anti-ligature safety mechanism meant that the safety feature could not be implemented. b. There was no risk assessment about the suitability of this room for Ms Dehaney-Perkins a patient with a self-harming history at the time of the admission. c. The fixed-point ligature was not appropriately updated in the risk assessment and was not discussed at a discharge planning meeting. d. The Trust Datix Report was incomplete ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Incomplete incident reporting

    Wider context from the report

    “(1) On 28 August Ms Dehaney-Perkins was agitated and distressed on return to the ward from leave and had consumed alcohol that was known to increase her risk of self-harm. ████████. Staff found Ms Dehaney-Perkins and removed the ligature. a. Ms Dehaney-Perkins was admitted to a room with an assisted bathroom (this was not a requirement for her) with a fault in the anti-ligature safety mechanism meant that the safety feature could not be implemented. b. There was no risk assessment about the suitability of this room for Ms Dehaney-Perkins a patient with a self-harming history at the time of the admission. c. The fixed-point ligature was not appropriately updated in the risk assessment and was not discussed at a discharge planning meeting. d. The Trust Datix Report was incomplete ”
    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

    Check assisted-bathroom handrail mechanisms every shift and conduct management, fixture, and ligature audits.

    Verbatim wording from the response

    “There is a prompt on the handover sheet to ensure that the Nurse In-Charge checks the handrails mechanism remains in a locked and upright position. This is checked and signed for every shift. Regular audit and assurance are completed by the Ward Manager and Ward Clerk to check that this is being completed. Regular inspections of all room fixtures including handrails are done as part of Ligature audits to ensure compliance with EPUT safety protocols.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 14 February 2024

    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

    Carry out room-suitability risk assessments on admission and obtain multidisciplinary information about self-harm history and associated risk factors.

    Verbatim wording from the response

    “Thorough risk assessments are being carried out using EPUT risk assessment tools including suitability of rooms for all patients on admission. There is collaboration with mental health professionals, including psychiatrists, psychologists, community mental health nurses, GP’s and social workers to gather comprehensive information regarding the patient’s history of self-harm and associated risk factors.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 14 February 2024

    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 the incident sign-off process to improve completion of patient-safety Datix reports.

    Verbatim wording from the response

    “The Matron has made urgent contact with the risk management team in relation to the Datix Report for this matter – the datix report was approved by the Patient Incident Team on 26th March 2024. A further review of the process is being undertaken to improve sign off where there is a patient safety incident.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 14 February 2024

    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

    Refer patients at high risk of alcohol misuse to drug and alcohol services and document discussions of alcohol-related medication risks with patients and, where consented, families.

    Verbatim wording from the response

    “Response: If a patient is identified as at high risk of alcohol misuse they are referred to the Drug and alcohol service. It is also discussed with the patient advising them of the risks of using alcohol whilst on medication. Where consent is given family are invited to ward reviews and discharge planning meetings and discussion around medication, risks and compliance is part of those meetings. This is documented in the patients’ notes.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 14 February 2024

    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

    Support patients and carers who raise risk concerns by contacting patients, exploring concerns, and managing them accordingly.

    Verbatim wording from the response

    “Response: The Home First Team will support patients and carers when they contact the team raising concerns around risk. The patient will be contacted by a member of the team who will explore the concern and manage it accordingly.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 3 · response
    Published 14 February 2024

    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

    Share discharge plans with involved professionals and consented families or carers, and prompt staff to check agreed medication plans.

    Verbatim wording from the response

    “In order to strengthen safety measures in relation to this concern the wards now have in place that post each discharge meeting, discharge plans are shared with all health professionals and family/carers (with consent) involved in the care of the patient. A prompt is now written in the diary to remind staff to check the discharge plan that has been agreed for that patient including medication plans.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 3 · response
    Published 14 February 2024

    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

    Undertake multidisciplinary discussions to develop and review individualised care plans and risk assessments during discharge planning.

    Verbatim wording from the response

    “The General Workplace Risk Assessment has been updated to include the fixed-point ligature. Multi-disciplinary team discussions are being undertaken to develop and to review individualised care plans and risk assessments as part of discharge planning.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 14 February 2024

    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

    Update the General Workplace Risk Assessment to include the fixed-point ligature.

    Verbatim wording from the response

    “The General Workplace Risk Assessment has been updated to include the fixed-point ligature. Multi-disciplinary team discussions are being undertaken to develop and to review individualised care plans and risk assessments as part of discharge planning.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 14 February 2024

    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

    Complete leave risk assessments, offer post-leave engagement, record incidents through Datix, update risk assessments, and share relevant information with involved professionals.

    Verbatim wording from the response

    “A risk assessment is completed prior to a patient going on leave. Upon the patient returning from leave one to one engagement is offered to the patient, if any incident has occurred whilst the patient has been on leave this is reported via Datix and the risk assessment is updated accordingly. The incident is also documented within the patients’ notes and information is shared with all health professionals involved in the care of the patient during handover, Multidisciplinary Team meetings and ward reviews.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 14 February 2024

    Open published response

  20. Essex

    AI-generated summary

    Nadia Wyatt · 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

    Nadia Wyatt, a 53-year-old woman experiencing severe anxiety, separation anxiety and depression, died by hanging on 26 July 2023 after taking sleeping tablets and apparently drinking wine. The principal concerns included failures in record-keeping, care planning, risk assessment and risk management, including inappropriate copying from another patient’s care plan and potential over-reliance on her husband as a carer.

    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of bespoke care plans tailored to individual needs

    Wider context from the report

    “(1) Failure to update Nadia’s records with the outcomes of referrals that were made and whether such referrals were accepted or declined, either for Nadia or her carer. (2) Failure to include within her records considerations and professional opinions reached on the prospect, or not, of readmission for in-patient treatment together with the final decision and rationale. (3) Lack of bespoke care plans tailored to Nadia’s needs. Notwithstanding the fact Nadia had begun to disengage and declined to be involved in her care planning, more personalised plans could have been drafted taking into account her personal characteristics, needs and past medical history. (4) Evidence of “cutting and pasting” into Nadia’s care plan from another patient’s care plan. (5) Failing to undertake risk assessments at all relevant and appropriate stages and/or failure to record that such an assessment had in fact taken place and what the outcome was. (6) Failing to provide a “RAG” rating to risk assessments and/or to indicate where required that a risk exists. (7) Failure to include risk management and contingency planning within Nadia’s care plans as well as key elements of her condition at that time, including her recent inpatient admission. (8) The potential for over-reliance on Nadia’s husband, albeit he was only too willing to support her and care for her, and the need to balance maintaining Nadia’s care and treatment in the community with the need to support her carer as well. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to balance community care for the patient with support for the carer

    Wider context from the report

    “(1) Failure to update Nadia’s records with the outcomes of referrals that were made and whether such referrals were accepted or declined, either for Nadia or her carer. (2) Failure to include within her records considerations and professional opinions reached on the prospect, or not, of readmission for in-patient treatment together with the final decision and rationale. (3) Lack of bespoke care plans tailored to Nadia’s needs. Notwithstanding the fact Nadia had begun to disengage and declined to be involved in her care planning, more personalised plans could have been drafted taking into account her personal characteristics, needs and past medical history. (4) Evidence of “cutting and pasting” into Nadia’s care plan from another patient’s care plan. (5) Failing to undertake risk assessments at all relevant and appropriate stages and/or failure to record that such an assessment had in fact taken place and what the outcome was. (6) Failing to provide a “RAG” rating to risk assessments and/or to indicate where required that a risk exists. (7) Failure to include risk management and contingency planning within Nadia’s care plans as well as key elements of her condition at that time, including her recent inpatient admission. (8) The potential for over-reliance on Nadia’s husband, albeit he was only too willing to support her and care for her, and the need to balance maintaining Nadia’s care and treatment in the community with the need to support her carer as well. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to record readmission considerations, decision and rationale

    Wider context from the report

    “(1) Failure to update Nadia’s records with the outcomes of referrals that were made and whether such referrals were accepted or declined, either for Nadia or her carer. (2) Failure to include within her records considerations and professional opinions reached on the prospect, or not, of readmission for in-patient treatment together with the final decision and rationale. (3) Lack of bespoke care plans tailored to Nadia’s needs. Notwithstanding the fact Nadia had begun to disengage and declined to be involved in her care planning, more personalised plans could have been drafted taking into account her personal characteristics, needs and past medical history. (4) Evidence of “cutting and pasting” into Nadia’s care plan from another patient’s care plan. (5) Failing to undertake risk assessments at all relevant and appropriate stages and/or failure to record that such an assessment had in fact taken place and what the outcome was. (6) Failing to provide a “RAG” rating to risk assessments and/or to indicate where required that a risk exists. (7) Failure to include risk management and contingency planning within Nadia’s care plans as well as key elements of her condition at that time, including her recent inpatient admission. (8) The potential for over-reliance on Nadia’s husband, albeit he was only too willing to support her and care for her, and the need to balance maintaining Nadia’s care and treatment in the community with the need to support her carer as well. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to record risk assessment completion and outcomes

    Wider context from the report

    “(1) Failure to update Nadia’s records with the outcomes of referrals that were made and whether such referrals were accepted or declined, either for Nadia or her carer. (2) Failure to include within her records considerations and professional opinions reached on the prospect, or not, of readmission for in-patient treatment together with the final decision and rationale. (3) Lack of bespoke care plans tailored to Nadia’s needs. Notwithstanding the fact Nadia had begun to disengage and declined to be involved in her care planning, more personalised plans could have been drafted taking into account her personal characteristics, needs and past medical history. (4) Evidence of “cutting and pasting” into Nadia’s care plan from another patient’s care plan. (5) Failing to undertake risk assessments at all relevant and appropriate stages and/or failure to record that such an assessment had in fact taken place and what the outcome was. (6) Failing to provide a “RAG” rating to risk assessments and/or to indicate where required that a risk exists. (7) Failure to include risk management and contingency planning within Nadia’s care plans as well as key elements of her condition at that time, including her recent inpatient admission. (8) The potential for over-reliance on Nadia’s husband, albeit he was only too willing to support her and care for her, and the need to balance maintaining Nadia’s care and treatment in the community with the need to support her carer as well. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to include key current clinical information in care plans

    Wider context from the report

    “(1) Failure to update Nadia’s records with the outcomes of referrals that were made and whether such referrals were accepted or declined, either for Nadia or her carer. (2) Failure to include within her records considerations and professional opinions reached on the prospect, or not, of readmission for in-patient treatment together with the final decision and rationale. (3) Lack of bespoke care plans tailored to Nadia’s needs. Notwithstanding the fact Nadia had begun to disengage and declined to be involved in her care planning, more personalised plans could have been drafted taking into account her personal characteristics, needs and past medical history. (4) Evidence of “cutting and pasting” into Nadia’s care plan from another patient’s care plan. (5) Failing to undertake risk assessments at all relevant and appropriate stages and/or failure to record that such an assessment had in fact taken place and what the outcome was. (6) Failing to provide a “RAG” rating to risk assessments and/or to indicate where required that a risk exists. (7) Failure to include risk management and contingency planning within Nadia’s care plans as well as key elements of her condition at that time, including her recent inpatient admission. (8) The potential for over-reliance on Nadia’s husband, albeit he was only too willing to support her and care for her, and the need to balance maintaining Nadia’s care and treatment in the community with the need to support her carer as well. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Copying content from another patient’s care plan

    Wider context from the report

    “(1) Failure to update Nadia’s records with the outcomes of referrals that were made and whether such referrals were accepted or declined, either for Nadia or her carer. (2) Failure to include within her records considerations and professional opinions reached on the prospect, or not, of readmission for in-patient treatment together with the final decision and rationale. (3) Lack of bespoke care plans tailored to Nadia’s needs. Notwithstanding the fact Nadia had begun to disengage and declined to be involved in her care planning, more personalised plans could have been drafted taking into account her personal characteristics, needs and past medical history. (4) Evidence of “cutting and pasting” into Nadia’s care plan from another patient’s care plan. (5) Failing to undertake risk assessments at all relevant and appropriate stages and/or failure to record that such an assessment had in fact taken place and what the outcome was. (6) Failing to provide a “RAG” rating to risk assessments and/or to indicate where required that a risk exists. (7) Failure to include risk management and contingency planning within Nadia’s care plans as well as key elements of her condition at that time, including her recent inpatient admission. (8) The potential for over-reliance on Nadia’s husband, albeit he was only too willing to support her and care for her, and the need to balance maintaining Nadia’s care and treatment in the community with the need to support her carer as well. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to record referral outcomes and acceptance or decline decisions

    Wider context from the report

    “(1) Failure to update Nadia’s records with the outcomes of referrals that were made and whether such referrals were accepted or declined, either for Nadia or her carer. (2) Failure to include within her records considerations and professional opinions reached on the prospect, or not, of readmission for in-patient treatment together with the final decision and rationale. (3) Lack of bespoke care plans tailored to Nadia’s needs. Notwithstanding the fact Nadia had begun to disengage and declined to be involved in her care planning, more personalised plans could have been drafted taking into account her personal characteristics, needs and past medical history. (4) Evidence of “cutting and pasting” into Nadia’s care plan from another patient’s care plan. (5) Failing to undertake risk assessments at all relevant and appropriate stages and/or failure to record that such an assessment had in fact taken place and what the outcome was. (6) Failing to provide a “RAG” rating to risk assessments and/or to indicate where required that a risk exists. (7) Failure to include risk management and contingency planning within Nadia’s care plans as well as key elements of her condition at that time, including her recent inpatient admission. (8) The potential for over-reliance on Nadia’s husband, albeit he was only too willing to support her and care for her, and the need to balance maintaining Nadia’s care and treatment in the community with the need to support her carer as well. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide risk ratings or indicate identified risks

    Wider context from the report

    “(1) Failure to update Nadia’s records with the outcomes of referrals that were made and whether such referrals were accepted or declined, either for Nadia or her carer. (2) Failure to include within her records considerations and professional opinions reached on the prospect, or not, of readmission for in-patient treatment together with the final decision and rationale. (3) Lack of bespoke care plans tailored to Nadia’s needs. Notwithstanding the fact Nadia had begun to disengage and declined to be involved in her care planning, more personalised plans could have been drafted taking into account her personal characteristics, needs and past medical history. (4) Evidence of “cutting and pasting” into Nadia’s care plan from another patient’s care plan. (5) Failing to undertake risk assessments at all relevant and appropriate stages and/or failure to record that such an assessment had in fact taken place and what the outcome was. (6) Failing to provide a “RAG” rating to risk assessments and/or to indicate where required that a risk exists. (7) Failure to include risk management and contingency planning within Nadia’s care plans as well as key elements of her condition at that time, including her recent inpatient admission. (8) The potential for over-reliance on Nadia’s husband, albeit he was only too willing to support her and care for her, and the need to balance maintaining Nadia’s care and treatment in the community with the need to support her carer as well. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to undertake risk assessments at relevant stages

    Wider context from the report

    “(1) Failure to update Nadia’s records with the outcomes of referrals that were made and whether such referrals were accepted or declined, either for Nadia or her carer. (2) Failure to include within her records considerations and professional opinions reached on the prospect, or not, of readmission for in-patient treatment together with the final decision and rationale. (3) Lack of bespoke care plans tailored to Nadia’s needs. Notwithstanding the fact Nadia had begun to disengage and declined to be involved in her care planning, more personalised plans could have been drafted taking into account her personal characteristics, needs and past medical history. (4) Evidence of “cutting and pasting” into Nadia’s care plan from another patient’s care plan. (5) Failing to undertake risk assessments at all relevant and appropriate stages and/or failure to record that such an assessment had in fact taken place and what the outcome was. (6) Failing to provide a “RAG” rating to risk assessments and/or to indicate where required that a risk exists. (7) Failure to include risk management and contingency planning within Nadia’s care plans as well as key elements of her condition at that time, including her recent inpatient admission. (8) The potential for over-reliance on Nadia’s husband, albeit he was only too willing to support her and care for her, and the need to balance maintaining Nadia’s care and treatment in the community with the need to support her carer as well. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to include risk management and contingency planning in care plans

    Wider context from the report

    “(1) Failure to update Nadia’s records with the outcomes of referrals that were made and whether such referrals were accepted or declined, either for Nadia or her carer. (2) Failure to include within her records considerations and professional opinions reached on the prospect, or not, of readmission for in-patient treatment together with the final decision and rationale. (3) Lack of bespoke care plans tailored to Nadia’s needs. Notwithstanding the fact Nadia had begun to disengage and declined to be involved in her care planning, more personalised plans could have been drafted taking into account her personal characteristics, needs and past medical history. (4) Evidence of “cutting and pasting” into Nadia’s care plan from another patient’s care plan. (5) Failing to undertake risk assessments at all relevant and appropriate stages and/or failure to record that such an assessment had in fact taken place and what the outcome was. (6) Failing to provide a “RAG” rating to risk assessments and/or to indicate where required that a risk exists. (7) Failure to include risk management and contingency planning within Nadia’s care plans as well as key elements of her condition at that time, including her recent inpatient admission. (8) The potential for over-reliance on Nadia’s husband, albeit he was only too willing to support her and care for her, and the need to balance maintaining Nadia’s care and treatment in the community with the need to support her carer as well. ”
    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

    Remind Crisis Response and Home Treatment Service staff in team meetings about documentation and record-keeping requirements.

    Verbatim wording from the response

    “Response: The Trust has revised line management supervision forms to include quality of record keeping, their professional responsibilities, Trust policy and values, and NMC accountability frameworks in respect of record keeping. In addition to discussions during supervision the Crisis Response and Home Treatment Service has been reminded of this in their team meetings.”

    Source location

    Response from Essex Partnership NHS
    Page 1 · response
    Published 19 January 2024

    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

    Audit Home Treatment Team records regularly and share findings to reduce copying and pasting and improve individualised clinical notes.

    Verbatim wording from the response

    “Response: In order to ensure that clinical notes are individualised, and copy and pasting is not part of the team culture, regular audits on Home Treatment Team record keeping will be undertaken and the findings shared with the team to continuously improve practice. The Home Treatment weekly multi-disciplinary meeting where patients care is reviewed, also provides opportunity for notes to be reviewed and any action required to be taken forward.”

    Source location

    Response from Essex Partnership NHS
    Page 2 · response
    Published 19 January 2024

    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

    Implement the International Fundamentals of Care Framework in urgent and inpatient care, including its principles in Newman’s care-planning form.

    Verbatim wording from the response

    “Response: The Trust’s Urgent Care and Inpatient Care Unit is implementing a new initiative ‘International Fundamentals of Care Framework’, which is a nursing framework that supports transition and care planning based on trustworthy relationship, integration of care and context of care. The Home Treatment Team in Mid and South have added the framework principles to the Newman’s form that is given to patients to develop and assist with their view and planning of their care and treatment needs. The Newman’s form is based on the Newman’s model of care, which encourages individuals to be involved and interact with their health needs.”

    Source location

    Response from Essex Partnership NHS
    Page 2 · response
    Published 19 January 2024

    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

    Randomly audit patient records monthly for discrepancies in RAG-rated risk assessments and take action where discrepancies are found.

    Verbatim wording from the response

    “The Trust also randomly audits patients’ records on a monthly basis to identify any concerns with RAG rating of risk assessments in order for actions to be taken where discrepancies are found.”

    Source location

    Response from Essex Partnership NHS
    Page 3 · response
    Published 19 January 2024

    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

    Arrange bespoke documentation training for all staff working in the urgent care pathway.

    Verbatim wording from the response

    “Bespoke training on the importance of documentation is being arranged for all staff working in the urgent care pathway in April 2024.”

    Source location

    Response from Essex Partnership NHS
    Page 1 · response
    Published 19 January 2024

    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

    Remind staff and Carer Leads to document carers’ views and needs and offer or make consent-based referrals for carer support.

    Verbatim wording from the response

    “All staff have been reminded via Team meetings to ensure case discussion in the multi-disciplinary team meeting document carer’s views and carer’s needs. The Team Carer’s Leads have been reminded to offer referrals for carers support, and refer on where consent given by carer and the importance of documenting carer’s views clearly.”

    Source location

    Response from Essex Partnership NHS
    Page 4 · response
    Published 19 January 2024

    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

    Revise line-management supervision forms to cover record-keeping quality, responsibilities, policy, values and professional accountability.

    Verbatim wording from the response

    “Response: The Trust has revised line management supervision forms to include quality of record keeping, their professional responsibilities, Trust policy and values, and NMC accountability frameworks in respect of record keeping. In addition to discussions during supervision the Crisis Response and Home Treatment Service has been reminded of this in their team meetings.”

    Source location

    Response from Essex Partnership NHS
    Page 1 · response
    Published 19 January 2024

    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

    Audit Home Treatment Team assessments regularly and share findings with the team to improve assessment documentation.

    Verbatim wording from the response

    “In order to ensure the assessments undertaken by the Home Treatment Team are comprehensive and the findings (including the rationale for the decisions made) are clearly documented, regular audits on Home Treatment Team assessments will be undertaken and the findings shared with the team to continuously improve practice.”

    Source location

    Response from Essex Partnership NHS
    Page 1 · response
    Published 19 January 2024

    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 Storm training to Teams to enhance risk-assessment skills.

    Verbatim wording from the response

    “Response: Assessments and clinical notes are reviewed with individuals during their one to one supervision to focus on the quality of their record keeping including risk assessment. Storm training has commenced with Teams to enhance risk assessment skills.”

    Source location

    Response from Essex Partnership NHS
    Page 3 · response
    Published 19 January 2024

    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

    Use the Admission Checklist to support care planning, timely escalation and referrals, and reduce missed actions.

    Verbatim wording from the response

    “The Admission Checklist in place will also support staff to plan care, escalate required support and referrals in a timely way, and reduces risk levels in respect of avoidance of actions being missed.”

    Source location

    Response from Essex Partnership NHS
    Page 2 · response
    Published 19 January 2024

    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

    Discuss patients’ RAG ratings during daily multidisciplinary reviews and safety huddles to improve record accuracy.

    Verbatim wording from the response

    “Response: The Teams discuss all patients including their ‘RAG’ rating during their daily multi-disciplinary meeting case reviews and safety huddles to ensure accuracy of records.”

    Source location

    Response from Essex Partnership NHS
    Page 3 · response
    Published 19 January 2024

    Open published response

  21. Essex

    AI-generated summary

    Amanda Hitch · 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

    Amanda Hitch died on 12 February 2022 after deliberately jumping in front of a train intending to die. She was receiving community mental health treatment. Concerns included important clinical information not being visible to the care team, structured risk-management tools not being specifically considered, and railway-station attendances not being reliably passed to her care coordinator under a multi-agency support plan.

    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to use structured risk management tools alongside clinical experience and judgment

    Wider context from the report

    “(2) The evidence was such that neither the care co- Ordinator nor the consultant psychiatrist as the medical lead of the service specifically considered the structured risk management tools that the Trust operates, preferring to rely on clinical experience and judgment alone. There may be a risk that not using such risk management tools in combination with clinical experience and judgment, particularly if this is being done by one clinician at an appointment rather than multidisciplinary discussion of changes in presentation, may lead to information being missed. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to conduct multidisciplinary discussion of changes in presentation

    Wider context from the report

    “(2) The evidence was such that neither the care co- Ordinator nor the consultant psychiatrist as the medical lead of the service specifically considered the structured risk management tools that the Trust operates, preferring to rely on clinical experience and judgment alone. There may be a risk that not using such risk management tools in combination with clinical experience and judgment, particularly if this is being done by one clinician at an appointment rather than multidisciplinary discussion of changes in presentation, may lead to information being missed. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of the clinical record to present information as a continuous chronological running record

    Wider context from the report

    “(1) During the inquest, it became clear that one significant entry in the clinical notes made by someone in a separate service commissioned by the Essex Partnership University Trust, and which expressed a very specific and imminent intention from the deceased to end her life, was not seen by others in the clinical team. This was almost certainly because the clinical record does not present on computer screens as a continuous chronological running record, but is instead viewed thematically. That means that readers are likely to look at entries made within their particular clinical team, rather than see what others have recorded more recently. There is an obvious risk that critical and important information garnered by others and put into the medical records will not be seen, and that those making clinical decisions on risk management will thus be unaware of potentially very significant information. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of the multi-agency support plan to clearly state limitations on information from unstaffed station attendances

    Wider context from the report

    “(3) There was also evidence about the measures that the British Transport Police had taken, seeking to provide additional support by setting up multi- agency support plan, which provided a system for alerting a number of people including the deceased’s care co-ordinator, when she attended at railway stations. In fact, for various reasons, although there are several known attendances at railway stations, none were passed on to the care co- Ordinator. The evidence at the inquest was that British Transport Police does not have the resources always to provide information about attendance at unstaffed stations (although in fact, one such attendance had been known about but was not passed on). The plan as presented does not make it entirely clear what the limitations in relation to information from attendances at unstaffed stations may be, and should it remain the position that BTP lacks the resources to identify all such attendances at railway stations by persons at specific risk of suicide on the railway, there is a risk that those expecting to receive information under such a plan may not realise that the plan will often not assist where its subject is attending unmanned stations. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Unavailability of resources to identify and provide information about all unstaffed railway station attendances

    Wider context from the report

    “(3) There was also evidence about the measures that the British Transport Police had taken, seeking to provide additional support by setting up multi- agency support plan, which provided a system for alerting a number of people including the deceased’s care co-ordinator, when she attended at railway stations. In fact, for various reasons, although there are several known attendances at railway stations, none were passed on to the care co- Ordinator. The evidence at the inquest was that British Transport Police does not have the resources always to provide information about attendance at unstaffed stations (although in fact, one such attendance had been known about but was not passed on). The plan as presented does not make it entirely clear what the limitations in relation to information from attendances at unstaffed stations may be, and should it remain the position that BTP lacks the resources to identify all such attendances at railway stations by persons at specific risk of suicide on the railway, there is a risk that those expecting to receive information under such a plan may not realise that the plan will often not assist where its subject is attending unmanned stations. ”
    Open source report

  22. Essex

    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. The report was sent to Essex Partnership University NHS Foundation Trust; 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 Partnership University NHS Foundation Trust; 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 Partnership University NHS Foundation Trust; 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 Partnership University NHS Foundation Trust; 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 Partnership University NHS Foundation Trust; 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 Partnership University NHS Foundation Trust; 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 Partnership University NHS Foundation Trust; 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 Partnership University NHS Foundation Trust; 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 Partnership University NHS Foundation Trust; 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 Partnership University NHS Foundation Trust; 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 Partnership University NHS Foundation Trust; 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

    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

    Provide Food and Fluid Refresher training to inpatient nursing staff.

    Verbatim wording from the response

    “All inpatient nursing staff are completing the Food and Fluid Refresher training delivered by the Professional Development Team.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 7 · response
    Published 28 December 2023

    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
    Page 6 · response
    Published 28 December 2023

    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

    Develop and circulate a learning briefing on restricted items and other high-risk items.

    Verbatim wording from the response

    “The EPUT Culture of Learning Lessons Team are developing and circulating a learning briefing to clarify correct process and share learning regarding restricted items and highlight other high risk items not included on the list. The learning brief is to be informed by existing policy.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 5 · response
    Published 28 December 2023

    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

    Update the PSIRF policy to set learning-response timescales, sign-off requirements, safety-action-plan management and organisation-wide learning dissemination.

    Verbatim wording from the response

    “▪ The PSIRF Policy is being updated to reflect best practice. The policy includes time scale for completion of a learning response review and timely sign off. The policy also includes process for the management of safety action plan and cascading of learning across the trust.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 3 · response
    Published 28 December 2023

    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

    Roll out electronic observations across all wards with daily audit functionality and project-board oversight.

    Verbatim wording from the response

    “We have rolled out ‘e-observations’, across all wards, which is a mobile tablet (IPAD) electronic observation recording system; which records the patient observation with detail of patient presentation and engagement in the moment. There is an audit function within the system to enable ward managers to audit the quality of recording and engagement on a daily basis. There is an Oxehealth E-observations Project Board that has oversight of implementation, delivery and outcomes.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 7 · response
    Published 28 December 2023

    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
    Page 6 · response
    Published 28 December 2023

    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

    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
    Page 6 · response
    Published 28 December 2023

    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

    Introduce post-incident protocols for collating staff statements and triangulating written evidence with CCTV, Oxevision and body-worn-camera data.

    Verbatim wording from the response

    “▪ Further, following a patient safety incident the following new ‘post incident immediate actions protocol’ will ensure that security measures in relation to the signing in and out of patient related records are immediately collated:”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 3 · response
    Published 28 December 2023

    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

    Refine patient-safety incident processes and reporting templates.

    Verbatim wording from the response

    “Improvement activities include:”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 28 December 2023

    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

    Provide ward security leads and numbered, traceable security passes for staff, including temporary staff, with shift sign-in and sign-out controls.

    Verbatim wording from the response

    “○ All wards have an allocated security lead/nurse 24/7 on each shift to support the Nurse in Charge and ensure that all ward staff have their own security passes (ACT), at the beginning of a shift.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 3 · response
    Published 28 December 2023

    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
    Page 6 · response
    Published 28 December 2023

    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

    Implement an inpatient care framework with named-nurse responsibilities and personalised leave plans reviewed by clinical teams.

    Verbatim wording from the response

    “EPUT are adopting and implementing an evidence based framework within inpatient services to support engagement, care planning and therapeutic intervention. This is an internationally recognised framework which will support a positive cultural change across all our ward environments around therapeutic engagement, holistic care planning (including leave plans), whilst considering the context of care. This will include re-establishing the ‘named nurse’ function and responsibilities.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 5 · response
    Published 28 December 2023

    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
    Page 6 · response
    Published 28 December 2023

    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 multidisciplinary safety huddles and improve handovers through a nurse-in-charge checklist and task allocation.

    Verbatim wording from the response

    “Communication will be improved within the multi - disciplinary team by reviewing the impact of the multi-disciplinary team safety huddles through a Qi methodology. As well as implementing improvements in the handover process with the introduction of the nurse in charge checklist and task allocation.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 5 · response
    Published 28 December 2023

    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

    Update and disseminate restrictive-practice guidance, prohibited-item lists and handover forms using individualised risk assessment.

    Verbatim wording from the response

    “The Trust’s Global restrictive practice Guideline on the use of Global Restrictive Practices in In-Patient Units and the Restricted and Prohibited Items List – Inpatient Units CG92 – Appendix 1 has been updated and the restricted items reviewed through the Trust’s Restrictive Practice Trust Steering Group and Co-Production in December 2022.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 4 · response
    Published 28 December 2023

    Open published response

    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

    Belts need not be added to the prohibited-items list because individualized risk assessments and care plans address self-harm risks.

    Verbatim wording from the response

    “The Trust’s Global restrictive practice Guideline on the use of Global Restrictive Practices in In-Patient Units and the Restricted and Prohibited Items List – Inpatient Units CG92 – Appendix 1 has been updated and the restricted items reviewed through the Trust’s Restrictive Practice Trust Steering Group and Co-Production in December 2022.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 4 · response
    Published 28 December 2023

    Open published response

  23. Essex

    AI-generated summary

    WILLIAM BRIAN KIN GRAY · 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

    William had poorly controlled asthma and experienced a life-threatening asthma attack on 29 May 2021, followed by respiratory and cardiac arrest and a brain injury not compatible with life. The report identified multiple concerns, including failures to assess, review, escalate and treat his asthma, ambulance treatment and airway-management issues, gaps in investigation and training, and limitations in asthma and emergency-care services.

    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of ambulance investigations to compare attendances and identify learning

    Wider context from the report

    “(3) Learning and sharing lessons learned is a function of investigation. The Trust investigation report did not: (a) scrutinise the ambulance attendance to William on 27 October 2020 in comparison to the attendance on 29 May 2021 and missed an opportunity to understand: i. the timeliness of the administration of adrenalin during a life-threatening asthma attack in accordance with the JRCALC guidelines and that there may be additional training needs. Two paramedics attended both on 27 October 2020 and 29 May 2021 but did not consider the administration of intramuscular adrenalin on the second occasion. ii. Whilst life-threatening asthma in children is an extremely rare call, the same two paramedics attended on 27 October and 29 May and initial treatment given differed during a life-threatening asthma attack iii. that ambulance crew focused on the airway to exclusion of other treatment options and did not recognise the significant amount of inflation pressures that are required to manage the airway of an asthmatic child in respiratory arrest. Crew were misled in thinking that the airway adjunct equipment was not the correct size as a consequence, and were swapping the adjuncts iv. that the same paramedic was left managing an airway throughout the arrest despite the arrival of more experienced colleagues that arrived as backup, including an LMO until HEMS took over. The Trust did not address the issues at 3 (a) i-iv above in their annual training following William’s death and no alerts or learning notes have been circulated. (b) East of England Ambulance NHS Trust investigation did not identify a number of risks and omissions its investigation of this child death: i. inflation pressure being a potential cause of failure to secure a paediatric airway adjunct in life threatening asthma the consequence of this being increased ventilations pressure would be required ii. Intramuscular adrenalin was not administered for life threatening asthma for a child in respiratory arrest in accordance with JRCALC iii. Intravenous adrenalin was not given or attempted when the patient went into cardiac arrest in accordance with the resuscitation guidelines and Intraosseous access was not attempted for a child in cardiac arrest for at least 10 minutes and only when the patient was in the ambulance. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide guidance on inflation pressure when securing a paediatric airway adjunct in life-threatening asthma

    Wider context from the report

    “(2) Life threatening childhood asthma is a rare occurrence for ambulance paramedics and the Joint Royal Colleges Ambulances Liaison Committee (JRCALC) Guidelines sets out treatment for it, however as paramedics rarely attend: a. Clarity is required on what should be categorised as a life-threatening asthma. With guidance to enter the algorithm immediately to administer intramuscular adrenalin the purpose being to avoid cardiac arrest. Paramedics are more familiar with administration of intravenous adrenaline during resuscitation once cardiac arrest has occurred b. does not contain clear guidance or advice on what to do when crew cannot ventilate, cannot oxygenate, or cannot intubate c. when to abort repeated unsuccessful attempts to secure an airway and progress to hospital d. inflation pressure being a potential cause of failure to secure a paediatric airway adjunct in life threatening asthma the consequence of this being increased ventilations pressure would be required ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to assess, audit and plan for disruption to children’s asthma service access

    Wider context from the report

    “(6) The Asthma & Allergy Childrens and Young Persons Service (the Service) a. At the time of William’s initial referral to the Service in 2018 this consisted of one nurse for approximately 2000 children, and this increased to two nurses in November 2020. The evidence heard is that whilst the number of nurses has increased so has the geographical area that the Service covers, and that there are ongoing plans to increase this further. The Service remains under resourced whilst attempting to expand. b. The Service continued to operate during the pandemic and did not introduce video calls when they could not make face-to-face attendances. There was no risk assessment of the impact on the Service, and no audit of whether this was sufficient to manage the Service. There is no contingency plan in place should this issue arise again. c. The Service relied on telephone contact Nurses did not speak to William although he was old enough to be involved in his care. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Under-resourcing of the asthma and allergy children’s service

    Wider context from the report

    “(6) The Asthma & Allergy Childrens and Young Persons Service (the Service) a. At the time of William’s initial referral to the Service in 2018 this consisted of one nurse for approximately 2000 children, and this increased to two nurses in November 2020. The evidence heard is that whilst the number of nurses has increased so has the geographical area that the Service covers, and that there are ongoing plans to increase this further. The Service remains under resourced whilst attempting to expand. b. The Service continued to operate during the pandemic and did not introduce video calls when they could not make face-to-face attendances. There was no risk assessment of the impact on the Service, and no audit of whether this was sufficient to manage the Service. There is no contingency plan in place should this issue arise again. c. The Service relied on telephone contact Nurses did not speak to William although he was old enough to be involved in his care. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of hospital paediatric doctors to recognise intramuscular adrenaline treatment for life-threatening asthma

    Wider context from the report

    “(1) Experienced hospital paediatric doctors all gave evidence that they were unaware that administration of intramuscular adrenaline by paramedics is part of the Joint Royal Colleges Ambulances Liaison Committee JRCALC protocol for life-threatening asthma. The beneficial effects of the administration adrenalin was not considered, William’s presentation on arrival at hospital was falsely reassuring. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of ambulance investigations to identify omitted emergency treatments and access

    Wider context from the report

    “(3) Learning and sharing lessons learned is a function of investigation. The Trust investigation report did not: (a) scrutinise the ambulance attendance to William on 27 October 2020 in comparison to the attendance on 29 May 2021 and missed an opportunity to understand: i. the timeliness of the administration of adrenalin during a life-threatening asthma attack in accordance with the JRCALC guidelines and that there may be additional training needs. Two paramedics attended both on 27 October 2020 and 29 May 2021 but did not consider the administration of intramuscular adrenalin on the second occasion. ii. Whilst life-threatening asthma in children is an extremely rare call, the same two paramedics attended on 27 October and 29 May and initial treatment given differed during a life-threatening asthma attack iii. that ambulance crew focused on the airway to exclusion of other treatment options and did not recognise the significant amount of inflation pressures that are required to manage the airway of an asthmatic child in respiratory arrest. Crew were misled in thinking that the airway adjunct equipment was not the correct size as a consequence, and were swapping the adjuncts iv. that the same paramedic was left managing an airway throughout the arrest despite the arrival of more experienced colleagues that arrived as backup, including an LMO until HEMS took over. The Trust did not address the issues at 3 (a) i-iv above in their annual training following William’s death and no alerts or learning notes have been circulated. (b) East of England Ambulance NHS Trust investigation did not identify a number of risks and omissions its investigation of this child death: i. inflation pressure being a potential cause of failure to secure a paediatric airway adjunct in life threatening asthma the consequence of this being increased ventilations pressure would be required ii. Intramuscular adrenalin was not administered for life threatening asthma for a child in respiratory arrest in accordance with JRCALC iii. Intravenous adrenalin was not given or attempted when the patient went into cardiac arrest in accordance with the resuscitation guidelines and Intraosseous access was not attempted for a child in cardiac arrest for at least 10 minutes and only when the patient was in the ambulance. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to incorporate investigation learning into training and alerts

    Wider context from the report

    “(3) Learning and sharing lessons learned is a function of investigation. The Trust investigation report did not: (a) scrutinise the ambulance attendance to William on 27 October 2020 in comparison to the attendance on 29 May 2021 and missed an opportunity to understand: i. the timeliness of the administration of adrenalin during a life-threatening asthma attack in accordance with the JRCALC guidelines and that there may be additional training needs. Two paramedics attended both on 27 October 2020 and 29 May 2021 but did not consider the administration of intramuscular adrenalin on the second occasion. ii. Whilst life-threatening asthma in children is an extremely rare call, the same two paramedics attended on 27 October and 29 May and initial treatment given differed during a life-threatening asthma attack iii. that ambulance crew focused on the airway to exclusion of other treatment options and did not recognise the significant amount of inflation pressures that are required to manage the airway of an asthmatic child in respiratory arrest. Crew were misled in thinking that the airway adjunct equipment was not the correct size as a consequence, and were swapping the adjuncts iv. that the same paramedic was left managing an airway throughout the arrest despite the arrival of more experienced colleagues that arrived as backup, including an LMO until HEMS took over. The Trust did not address the issues at 3 (a) i-iv above in their annual training following William’s death and no alerts or learning notes have been circulated. (b) East of England Ambulance NHS Trust investigation did not identify a number of risks and omissions its investigation of this child death: i. inflation pressure being a potential cause of failure to secure a paediatric airway adjunct in life threatening asthma the consequence of this being increased ventilations pressure would be required ii. Intramuscular adrenalin was not administered for life threatening asthma for a child in respiratory arrest in accordance with JRCALC iii. Intravenous adrenalin was not given or attempted when the patient went into cardiac arrest in accordance with the resuscitation guidelines and Intraosseous access was not attempted for a child in cardiac arrest for at least 10 minutes and only when the patient was in the ambulance. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of clear ambulance guidance for recognising and managing life-threatening childhood asthma and failed airway management

    Wider context from the report

    “(2) Life threatening childhood asthma is a rare occurrence for ambulance paramedics and the Joint Royal Colleges Ambulances Liaison Committee (JRCALC) Guidelines sets out treatment for it, however as paramedics rarely attend: a. Clarity is required on what should be categorised as a life-threatening asthma. With guidance to enter the algorithm immediately to administer intramuscular adrenalin the purpose being to avoid cardiac arrest. Paramedics are more familiar with administration of intravenous adrenaline during resuscitation once cardiac arrest has occurred b. does not contain clear guidance or advice on what to do when crew cannot ventilate, cannot oxygenate, or cannot intubate c. when to abort repeated unsuccessful attempts to secure an airway and progress to hospital d. inflation pressure being a potential cause of failure to secure a paediatric airway adjunct in life threatening asthma the consequence of this being increased ventilations pressure would be required ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to involve children directly in asthma service consultations

    Wider context from the report

    “(6) The Asthma & Allergy Childrens and Young Persons Service (the Service) a. At the time of William’s initial referral to the Service in 2018 this consisted of one nurse for approximately 2000 children, and this increased to two nurses in November 2020. The evidence heard is that whilst the number of nurses has increased so has the geographical area that the Service covers, and that there are ongoing plans to increase this further. The Service remains under resourced whilst attempting to expand. b. The Service continued to operate during the pandemic and did not introduce video calls when they could not make face-to-face attendances. There was no risk assessment of the impact on the Service, and no audit of whether this was sufficient to manage the Service. There is no contingency plan in place should this issue arise again. c. The Service relied on telephone contact Nurses did not speak to William although he was old enough to be involved in his care. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Limited availability of trained paediatric endotracheal intubation capability

    Wider context from the report

    “(4) The Trust issued a Clinical Instruction on 17 September 2020 that paramedics must not insert endotracheal tubes as a safety measure to avoid adverse incidents as there was a difficulty in keeping paramedics skills up to a level of competency. Evidence was heard that the Trust has since revised its policy and reintroduced endotracheal intubation for a specialist cohort of paramedic crew: i. The Trust treatment for those aged 12 and over permits endotracheal intubation by those ambulance crew with specialist qualifications however, they cannot intubate children under 12 who are entirely reliant on HEMS arriving in sufficient time if the airway cannot be sufficiently managed. ii. Essex is a large county and there are very few paramedics trained on any one shift to provide endotracheal intubation iii. there is a difference in provision of life-saving treatment in Essex between those over 12 and for children under 12 and HEMS is a charity with very limited resource across a very large county. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Non-mandatory asthma training for health professionals caring for children and young people

    Wider context from the report

    “(5) Training for health professionals who care for children and young people is not mandatory The National Capabilities Framework for Professionals who care for Children and Young People with Asthma (NHS Health Education England) contains tiers of training and national capabilities but is not mandatory ”
    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

    Review and update operating procedures, business continuity arrangements, assessment templates, care plans, symptom-management plans and correspondence templates.

    Verbatim wording from the response

    “• Reviewing the SOP and Service Business Continuity Plan”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 3 · response
    Published 12 December 2023

    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

    Continue reviewing service capacity and working with commissioners on additional resources while transforming the service within current staffing.

    Verbatim wording from the response

    “Whilst the total patient caseload has remained similar to previous years the number of patient contacts (face to face and non-face to face contacts) has increased substantially -by 75.5% in 2023 compared to 2018. The service strives to remain accessible but to maintain a safe and efficient level of service provision, a review of the existing support issued by the ICB has been commenced.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 12 December 2023

    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

    Develop and implement Asthma Friendly Schools training and primary-care asthma education funded through the service expansion programme.

    Verbatim wording from the response

    “Due to the close working relationship between the Service and the ICB and the ideas generated for service development, NHS England has awarded monies to develop and implement the following:”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 3 · response
    Published 12 December 2023

    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

    Upskill asthma and allergy nurses in non-medical prescribing, Tier 4 asthma care and accredited spirometry.

    Verbatim wording from the response

    “Since 2018 the service has seen an increase in the complexity of need in the local population and observed challenges for patients and parents accessing timely support from both primary and secondary care. In collaboration with the Commissioner and Secondary Care, the service has responded to system pressures by upskilling our nurses in non-medical prescribing, Tier 4 Asthma training and Association for Respiratory Technology & Physiology (ARTP) accredited Spirometry training. This has afforded the service users the option of opting to access the service more frequently as it is more accessible- for example for prescriptions, preventative inhalers, and spirometry assessments and for support to progress secondary care referrals.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 12 December 2023

    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

    Use AccuRx video consultations within a blended assessment timetable and update contingency arrangements with risk-assessed face-to-face venues.

    Verbatim wording from the response

    “• Implemented the use of video conferencing (AccuRx) to visually perform remote assessment, although please note this does not afford the opportunity to perform chest auscultation which would indicate the presence of wheeze. This method of virtual assessment can demonstrate the teaching of peak flow and inhaler technique and enable”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 3 · response
    Published 12 December 2023

    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

    Maintain three additional Band 6 nursing roles to expand community asthma and allergy service capacity.

    Verbatim wording from the response

    “The Commissioners agreed to support the development of a business case for additional investment. The service reviewed the national models of good practice and with the support of the Commissioner, prepared a business case for additional investment into the existing service. Unfortunately due to the Covid pandemic, this was delayed as the Commissioners were redeployed to alternative roles. Subsequently, an opportunity arose to apply to NHS England for pilot monies to expand the integration into primary care networks and to promote the ‘Asthma Friendly Schools Initiative’. The business case prepared for the expansion of the existing team at the previously co-hosted workshop was submitted to NHS England requesting an additional 8.0 wte Band 6s to deliver an enhanced service in South East Essex.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 12 December 2023

    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

    Request to speak with children during consultations and record their views in the electronic patient record.

    Verbatim wording from the response

    “Response: Current practice is to ensure all nurses request to speak with the child, if they are old enough, at all consultations - whether this is via telephone or video. During face to face clinic”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 4 · response
    Published 12 December 2023

    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

    Require nurses to speak with sufficiently mature children and record children’s views in electronic patient records.

    Verbatim wording from the response

    “Response: Current practice is to ensure all nurses request to speak with the child, if they are old enough, at all consultations - whether this is via telephone or video. During face to face clinic”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 4 · response
    Published 12 December 2023

    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

    Implement blended AccuRx video consultations, update business continuity procedures and provide risk-assessed alternative assessment venues.

    Verbatim wording from the response

    “Following a successful pilot of the AccuRx, the service has now implemented its use and blended this into the timetable of review assessments, offering service users an initial face to face clinic assessment, followed by a review assessment utilising AccuRx. With the option of an additional telephone review assessment. The app helps improve communication between the Service and service users. The patient image feature in AccuRx is designed to enable patients to attach images to provide clinicians with the additional information to inform their care. The Business Continuity Plan has been updated which now includes the use of video consultations and alongside new and additional aerosol generating safe venues for face to face assessments such as the bespoke Clinician at Rochford Hospital and specially identified clinic spaces in primary care settings risk assessed to be covid secure.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 4 · response
    Published 12 December 2023

    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

    Upskill GP practice nurses and enhance GPs’ knowledge of evidence-based asthma medicines management.

    Verbatim wording from the response

    “Due to the close working relationship between the Service and the ICB and the ideas generated for service development, NHS England has awarded monies to develop and implement the following:”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 3 · response
    Published 12 December 2023

    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

    Upskill service nurses in non-medical prescribing, Tier 4 asthma care and ARTP-accredited spirometry.

    Verbatim wording from the response

    “Since 2018 the service has seen an increase in the complexity of need in the local population and observed challenges for patients and parents accessing timely support from both primary and secondary care. In collaboration with the Commissioner and Secondary Care, the service has responded to system pressures by upskilling our nurses in non-medical prescribing, Tier 4 Asthma training and Association for Respiratory Technology & Physiology (ARTP) accredited Spirometry training. This has afforded the service users the option of opting to access the service more frequently as it is more accessible- for example for prescriptions, preventative inhalers, and spirometry assessments and for support to progress secondary care referrals.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 12 December 2023

    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 remodel service eligibility, procedures, pathways, caseload criteria, assessment documentation and care-management templates with system partners.

    Verbatim wording from the response

    “The service developed an internal service development plan and a project group with the full engagement and support of the ICB Commissioner, who has also been advised of the content of this Regulation 28 Report.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 3 · response
    Published 12 December 2023

    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

    Recruit three additional Band 6 nurses to expand the community asthma and allergy service.

    Verbatim wording from the response

    “The Commissioners agreed to support the development of a business case for additional investment. The service reviewed the national models of good practice and with the support of the Commissioner, prepared a business case for additional investment into the existing service. Unfortunately due to the Covid pandemic, this was delayed as the Commissioners were redeployed to alternative roles. Subsequently, an opportunity arose to apply to NHS England for pilot monies to expand the integration into primary care networks and to promote the ‘Asthma Friendly Schools Initiative’. The business case prepared for the expansion of the existing team at the previously co-hosted workshop was submitted to NHS England requesting an additional 8.0 wte Band 6s to deliver an enhanced service in South East Essex.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 12 December 2023

    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

    Provide evidence-based medical-device education and training to paediatric staff through ward training and an acute asthma clinical nurse specialist.

    Verbatim wording from the response

    “a) To ensure evidenced-based education and training for all MSE paediatric staff regarding medical devices involved in the management of Asthma. This was completed accordingly with the ward staff at Southend Hospital and then the subsequent employment of the acute clinical nurse specialist for asthma has continued with this for all acute paediatric staff.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 5 · response
    Published 12 December 2023

    Open published response

    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

    Urgent and emergency asthma care remains the responsibility of primary and secondary care, not the supportive specialist service.

    Verbatim wording from the response

    “Prior to this Inquest, the service had already recognised improvements were required to effectively and safely improve the efficacy of clinical practice and continues to do so on a daily basis:”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 3 · response
    Published 12 December 2023

    Open published response

    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 service was not awarded the requested eight additional nursing posts and must transform provision within its current staffing capacity.

    Verbatim wording from the response

    “The Commissioners agreed to support the development of a business case for additional investment. The service reviewed the national models of good practice and with the support of the Commissioner, prepared a business case for additional investment into the existing service. Unfortunately due to the Covid pandemic, this was delayed as the Commissioners were redeployed to alternative roles. Subsequently, an opportunity arose to apply to NHS England for pilot monies to expand the integration into primary care networks and to promote the ‘Asthma Friendly Schools Initiative’. The business case prepared for the expansion of the existing team at the previously co-hosted workshop was submitted to NHS England requesting an additional 8.0 wte Band 6s to deliver an enhanced service in South East Essex.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 12 December 2023

    Open published response

  24. Essex

    AI-generated summary

    KATHARINE ANNE FOX · 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

    Katharine Fox died by hanging in October 2022 after being discharged from hospital, having been unable to access community psychology services during the following months. Concerns related to the lack of handover and continuity between hospital and community psychology services, substantial waiting times, and possible inability of clinicians to access notes held on different computer systems.

    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in the provision of psychology sessions

    Wider context from the report

    “(1) I am concerned that the disconnection between the provision of psychology services to patients in hospital and the provision of similar psychology services to patients in the community, including the fact that the community psychology service does not receive any form of handover and that there is a substantial wait for the provision of psychology sessions which may well require continuity to be delivered effectively. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide continuity and handover between hospital and community psychology services

    Wider context from the report

    “(1) I am concerned that the disconnection between the provision of psychology services to patients in hospital and the provision of similar psychology services to patients in the community, including the fact that the community psychology service does not receive any form of handover and that there is a substantial wait for the provision of psychology sessions which may well require continuity to be delivered effectively. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide psychology clinicians with access to clinical notes across hospitals and county locations

    Wider context from the report

    “(2) I am concerned about the fact, if that is indeed right, that some clinicians in the psychology service may not be able to access notes made by clinicians in either other hospitals or other parts of the county. I was told that the deceased actually managed to procure psychology sessions that the new psychologist may not have been able to read the notes of their predecessor if they were on a different computer system. ”
    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

    Embed a clinical information-sharing mechanism through a joint forum incorporating formal handover of required inpatient and community information.

    Verbatim wording from the response

    “Further, the Court is advised that it is commissioning a unified Electronic Medical Records System, in the interim Psychological Services will now have access to all of the required clinical systems and will also embed a new mechanism to ensure robust clinical information sharing between inpatient and community clinicians. This will be achieved through the aforementioned joint forum which will incorporate a formal handover of all required information. Should access to more detailed clinical information be required, this can be requested.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 3 · response
    Published 12 December 2023

    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

    Undertake regular telephone contact with people waiting for psychological assessment or treatment.

    Verbatim wording from the response

    “With regards to community wait times, the current demand for psychological treatments exceeds capacity, which is unfortunately not unusual within the NHS at this time. However, going forward the system of clinical prioritisation following case-specific discussion/handover will determine if urgency of need and risk warrants prioritisation. In relation to this, the Court is advised that in order to mitigate against any risk for those waiting for treatment in the community, the Psychological Services team implemented a new clinical process in 2023 which involves undertaking regular telephone contact with those waiting for psychological assessment and/or treatment.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 12 December 2023

    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

    Commission a unified electronic medical records system.

    Verbatim wording from the response

    “Further, the Court is advised that it is commissioning a unified Electronic Medical Records System, in the interim Psychological Services will now have access to all of the required clinical systems and will also embed a new mechanism to ensure robust clinical information sharing between inpatient and community clinicians. This will be achieved through the aforementioned joint forum which will incorporate a formal handover of all required information. Should access to more detailed clinical information be required, this can be requested.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 3 · response
    Published 12 December 2023

    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

    Embed clinical prioritisation for community psychological treatment, record prioritisation decisions electronically, and monitor waiting-time data.

    Verbatim wording from the response

    “Whilst it is noted that patients do not always require immediate on-going psychological therapy upon discharge from hospital, Psychological Services will, going forward, embed a mechanism for clinical prioritisation in order to ensure that the most urgent cases are appropriately identified and prioritised in the community, ensuring continuity of psychological treatment and minimising waiting times as much as is practicably possible. This will be monitored through the waiting time data that is collected by each service team, and which is reported through our Trust Accountability Framework process.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 12 December 2023

    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

    Provide formal handovers from inpatient psychologists to community psychological practitioners and coordinate follow-on care with community mental health teams.

    Verbatim wording from the response

    “Every patient who is receiving psychological intervention on an inpatient unit and is in need of continued psychological intervention post discharge, will have a handover of care from the inpatient psychologist (verbal/in writing) to the Community Team psychological practitioner. The Community Team psychological practitioner will discuss the care and treatment with the community mental health team to ensure the patient receives appropriate care and support in the community. The care in the community can be provided by the psychological practitioner or other appropriate team member under the supervision of a qualified registered psychological practitioner.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 1 · response
    Published 12 December 2023

    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

    Introduce locality-based joint inpatient-community consultations, formal pre-discharge handovers, and electronic recording of handover information.

    Verbatim wording from the response

    “The new process will include a joint consultation between the inpatient and community psychological services in order to aid care planning and formal handover of appropriate inpatient cases prior to discharge across each locality in Essex. Handover will be recorded on the patient’s electronic notes.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 12 December 2023

    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

    Regularly audit handovers to verify safe transfer of psychological care to community teams.

    Verbatim wording from the response

    “The process of handover will be regularly audited to ensure that the care is safely transferred to the Community Team.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 12 December 2023

    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 the operational model for transitions and handovers between inpatient and community psychological services.

    Verbatim wording from the response

    “Further, the Unit is currently reviewing the operational model to improve the transition and handover of care between inpatient and community psychological services, with the aim of streamlining this provision.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 12 December 2023

    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

    Enable Adult Community Psychological Services clinicians to access PARIS, MOBIUS, and Health Information Exchange records.

    Verbatim wording from the response

    “The Court is respectfully advised that EPUT (like a number of NHS Trusts) uses multiple Electronic Medical Records Systems, which includes PARIS and MOBIUS. Staff within the Inpatient Psychological Services team have access to both systems, as well as Health Information Exchange (HIE) and can therefore access all records/reports. Our IT department has recently confirmed that all clinical staff in Adult Community Psychological Services can also access both systems.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 12 December 2023

    Open published response

    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

    Relevant clinical records are accessible to inpatient and community psychological staff through existing electronic systems and the Health Information Exchange.

    Verbatim wording from the response

    “The Court is respectfully advised that EPUT (like a number of NHS Trusts) uses multiple Electronic Medical Records Systems, which includes PARIS and MOBIUS. Staff within the Inpatient Psychological Services team have access to both systems, as well as Health Information Exchange (HIE) and can therefore access all records/reports. Our IT department has recently confirmed that all clinical staff in Adult Community Psychological Services can also access both systems.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 12 December 2023

    Open published response

    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

    Patients do not always require immediate ongoing psychological therapy after discharge; treatment urgency should be determined by clinical need.

    Verbatim wording from the response

    “Whilst it is noted that patients do not always require immediate on-going psychological therapy upon discharge from hospital, Psychological Services will, going forward, embed a mechanism for clinical prioritisation in order to ensure that the most urgent cases are appropriately identified and prioritised in the community, ensuring continuity of psychological treatment and minimising waiting times as much as is practicably possible. This will be monitored through the waiting time data that is collected by each service team, and which is reported through our Trust Accountability Framework process.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 12 December 2023

    Open published response

  25. Essex

    AI-generated summary

    Johanne Blackwood · 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

    Johanne Blackwood, known as Jo, died by suicide on 12 June 2021 after placing herself in the path of a train. The report identified concerns about unclear Care Coordinator handovers and responsibility for oversight after discharge, the absence of an allocated Care Coordinator for several weeks, failure to update her risk assessment, care plan and security plan, and inappropriate over-reliance on family members to keep her safe.

    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of clarity in formal handovers of Care Coordinator responsibility

    Wider context from the report

    “1. Evidence confirmed a conspicuous lack of clarity as to when, where and by (or between) whom any formal handover of responsibility as Care Coordinator (CC) for Jo took place as between a number of CCs allocated to Jo over a period of many months from the lead up to and following her discharge as an in-patient back to the community team on December 18ᵗʰ 2020 and through to early May 2021. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to update community risk, care and security plans

    Wider context from the report

    “4. The community Risk Assessment, Care Plan and Security Plan for Jo were not updated by a Care Coordinator between December 2020 and Jo’s death. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of clarity about responsibility for oversight of patient care following discharge

    Wider context from the report

    “3. Evidence confirmed a conspicuous lack of clarity as to who, amongst EPUT clinicians/staff, has the responsibility for oversight of patient care following discharge, including responsibility for ensuring adequate and appropriate safety-netting is in place in the event of relapse, where a Care Coordinator is no longer in place/has not been replaced. Please note that this 3ʳᵈ concern was previously raised by me with ████████ CEO of EPUT (and in very similar terms) in a PFDR dated 25.02.2022 following the death of Stephanie Moyce. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Unavailability of an allocated Care Coordinator

    Wider context from the report

    “2. Consequently , the evidence confirmed, despite her clear vulnerabilities, Jo did not have an allocated Care Coordinator for several weeks up to the beginning of May 2021. The evidence also confirmed that the lack of clarity as to the timing and conduct of CC handovers and the absence of an allocated CC to work with Jo (and by extension, her family) was informed by lack of a formal policy or procedure requiring that a full, detailed, formal record of handover between Care Coordinators is to be placed on EPUT electronic records. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a formal policy or procedure requiring recording of Care Coordinator handovers

    Wider context from the report

    “2. Consequently , the evidence confirmed, despite her clear vulnerabilities, Jo did not have an allocated Care Coordinator for several weeks up to the beginning of May 2021. The evidence also confirmed that the lack of clarity as to the timing and conduct of CC handovers and the absence of an allocated CC to work with Jo (and by extension, her family) was informed by lack of a formal policy or procedure requiring that a full, detailed, formal record of handover between Care Coordinators is to be placed on EPUT electronic records. ”
    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 Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure safety-netting when a Care Coordinator is absent

    Wider context from the report

    “3. Evidence confirmed a conspicuous lack of clarity as to who, amongst EPUT clinicians/staff, has the responsibility for oversight of patient care following discharge, including responsibility for ensuring adequate and appropriate safety-netting is in place in the event of relapse, where a Care Coordinator is no longer in place/has not been replaced. Please note that this 3ʳᵈ concern was previously raised by me with ████████ CEO of EPUT (and in very similar terms) in a PFDR dated 25.02.2022 following the death of Stephanie Moyce. ”
    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

    Implement and use a Trust-wide electronic Care Coordinator to Care Coordinator Transfer of Care Document for structured handovers and continuity oversight.

    Verbatim wording from the response

    “As part of the Inquest hearing, it was recommended by yourself, as the presiding Coroner, that the operational management at Essex Partnership University Foundation Trust (EPUT) consider establishing a mechanism and process for a formal structured handover between care coordinators. The service manager took this recommendation on board and has been working with colleagues and departments to produce a purposeful template that will form part of the Patient Electronic Record specific to the care coordinators’ handover. This document has been approved, for implementation Trust wide, following a process of consultation and with comments gathered from all community services.”

    Source location

    Response from Essex Partnership University NHS Fondation Trust
    Page 1 · response
    Published 28 July 2023

    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

    Provide direct clinician contact and prioritised MDT support, including safe-hours overtime, for patients awaiting an allocated care coordinator.

    Verbatim wording from the response

    “In the event that a new care coordinator is not available, the team ensure that those patients without an allocated care coordinator have direct contact from clinicians within the team. This is done through a clinical MDT approach; patients are prioritised according to their presenting need and contact is through the use of creating from the Duty Person and Buddy worker System. In addition the staff have opportunities to work additional safe hours, by way of overtime which includes weekends and evenings so that all patients have a timely review by a practitioner avoiding any extended gaps in care whilst a care coordinator is appointed.”

    Source location

    Response from Essex Partnership University NHS Fondation Trust
    Page 3 · response
    Published 28 July 2023

    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

    Increase Grays Hall staffing through substantive recruitment and regular agency staffing to improve care coordinator capacity.

    Verbatim wording from the response

    “This provides an opportunity to introduce the new care coordinator to all their patients face to face and also get to know the patients’ care and needs in more detail. On a positive note, the team has recently been able to recruit more substantive staff which will reduce the reliance on temporary/agency staff.”

    Source location

    Response from Essex Partnership University NHS Fondation Trust
    Page 2 · response
    Published 28 July 2023

    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

    Attempt prompt recruitment and arrange at least two weeks’ overlap when a care coordinator gives notice, supporting effective handover and continuity of care.

    Verbatim wording from the response

    “In addition, where notice has been given by any care coordinator (of their departure from the Trust) the team will promptly make an attempt to recruit another member of staff with an aim of ensuring an overlap of at least two weeks, to allow for effective handover and continuity of care, again Trust wide.”

    Source location

    Response from Essex Partnership University NHS Fondation Trust
    Page 2 · response
    Published 28 July 2023

    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

    Add two permanent care coordinators to the Grays Hall staffing establishment in October 2023.

    Verbatim wording from the response

    “Grays Hall staffing establishment has significantly improved over the last year with the recruitment of two Band 6 and one Band 7 permanent staff and the use of regular agency staff. There are two more permanent care coordinators starting in October 2023.”

    Source location

    Response from Essex Partnership University NHS Fondation Trust
    Page 3 · response
    Published 28 July 2023

    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

    Use MaST performance information in monthly management updates and supervision to identify and escalate overdue care plans, risk assessments and other care standards.

    Verbatim wording from the response

    “The team manager and team leads now receive monthly performance updates with regards to the various care standards compliance which include care plan and risk assessment which are then shared with the care coordinators for action. In addition, during supervision sessions with care coordinators, the supervisor will conduct a highlight review from MaST which provide clear options for care coordinators caseload for that particular supervisee.”

    Source location

    Response from Essex Partnership University NHS Fondation Trust
    Page 3 · response
    Published 28 July 2023

    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

    RAG-rate caseload patients, review ratings through multidisciplinary discussion, and trigger early allocation actions for patients awaiting care coordinators.

    Verbatim wording from the response

    “The Grays Hall / Trust wide CMHT’s teams have a process in place where all patients under their caseload are RAG rated according to their level of needs. This document is used as part of the Multi-Disciplinary Team (MDT) discussion in order to establish any change required or review for the patients, when these are brought to the attention of the MDT. Where there is indication that a new care coordinator is required, this patient will be ‘Red’ rag rated which will act as a highlight and prompt an overview to members of the MDT. The team leads and manager will determine early actions, including any capacity considerations, to facilitate allocation of a new care coordinator.”

    Source location

    Response from Essex Partnership University NHS Fondation Trust
    Page 2 · response
    Published 28 July 2023

    Open published response

    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

    Existing caseload oversight, risk prioritisation and clinician contact arrangements satisfactorily address gaps when patients lack an allocated care coordinator.

    Verbatim wording from the response

    “The Community Mental Health Team (CMHT) based at Grays Hall, as well as CMHT teams across the Trust have access to the Team caseloads via the Trust Intranet system “Client Information Website” which provides a breakdown of all patients open to the team. The feature provides further information on the full team case list which denotes allocated care coordinators and those who have not assigned a care coordinator yet. The team manager and team leads, are able to utilise this tool to have an oversight of team caseloads alongside the Management and Supervision Tool (MaST). This system allows for Trust wide access and scrutiny on case load requirements.”

    Source location

    Response from Essex Partnership University NHS Fondation Trust
    Page 2 · response
    Published 28 July 2023

    Open published response
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

66%
66%All other recipients 58%
0%100%

How actions were described at the time

This respondent
58%26%14%1%
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026