Essex Partnership University NHS Foundation Trust

Health and care · NHS trust

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First report 25 Jun 2014•Latest report 1 Jun 2026

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

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

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. Addressed to South Essex Partnership University NHS Foundation Trust, now represented here by Essex Partnership University NHS Foundation Trust.

    City of London

    AI-generated summary

    Karen O’Brien · 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

    Karen O’Brien suffered from chronic pain and depression and had disclosed thoughts of self-harm. After a mental health referral, SEPT determined that a face-to-face assessment was not required; she later jumped into the path of an underground train, and the inquest concluded that she killed herself, with multiple injuries as the medical cause of death. The principal concerns were the lack of further inquiry or face-to-face assessment and the basis on which SEPT overrode the GP’s request, including its interpretation of NICE guidance.

    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 a clear clinical basis for overriding a GP request for patient assessment

    Wider context from the report

    “It is difficult to understand how there can be a clinical determination by SEPT without more inquiry and, preferably, some face-to-face assessment of the patient by a mental health professional. The NICE guidance is stated to be a recommendation. It must therefore be presumed not to be applied slavishly without careful assessment. The patient’s GP had asked for her to be seen. On what basis did SEPT decide to override the GP’s request? ”
    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 adequate clinical inquiry and mental health assessment before making a clinical determination

    Wider context from the report

    “It is difficult to understand how there can be a clinical determination by SEPT without more inquiry and, preferably, some face-to-face assessment of the patient by a mental health professional. The NICE guidance is stated to be a recommendation. It must therefore be presumed not to be applied slavishly without careful assessment. The patient’s GP had asked for her to be seen. On what basis did SEPT decide to override the GP’s request? ”
    Open source report

  2. Addressed to South Essex Partnership University NHS Foundation Trust, now represented here by Essex Partnership University NHS Foundation Trust.

    Bedfordshire and Luton

    AI-generated summary

    Simon Robert ALLISTON · 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

    Simon Robert ALLISTON lived alone and was found deceased in his flat after neighbours had not seen him for approximately a week; paramedics confirmed his death. The concerns included his discharge from mental health services without a formal handover, despite the Community Team considering that he still needed support, with no recorded reason for discharge and no formal Serious Incident Investigation after his death.

    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

    Discharge of patients despite ongoing assessed need for support

    Wider context from the report

    “(2) That he was discharged when the Community Team still considered that he needed support. ”
    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 a formal Serious Incident Investigation

    Wider context from the report

    “(4) That following the death of Simon Alliston there was no formal Serious Incident Investigation ”
    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 a formal handover at discharge

    Wider context from the report

    “(1) That a patient with a long mental health history was discharged without a formal hand over. ”
    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 reason for discharge

    Wider context from the report

    “(3) That the reason for discharge was never recorded. ”
    Open source report

  3. Addressed to North Essex Partnership University NHS Foundation Trust, now represented here by Essex Partnership University NHS Foundation Trust.

    Essex

    AI-generated summary

    Marion Joanne 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

    Marion Joanne Turner, aged 40, was found hanging at her home on 18 January 2013. A concern was raised that a solicitor’s message about concerns for her mental health was left unread in a pigeon hole until the following day.

    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 ensure messages for mental health staff are read promptly

    Wider context from the report

    “(1) Evidence was given that the day before Ms Turner’s death, her solicitor, as a result of concerns about her mental health, had telephoned into the mental health trust office and left a message for Ms Turner’s CPN. This message remained on a slip of paper, unread, in a pigeon hole until sometime the next day. ”
    Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026