7 May 2023 Bency Joseph · Prevention of Future Deaths report Essex
View report summary
Concerns raised 4 Failure to involve the deceased patient's family in the Trust investigation View source Delays and failures in prescribing and administering therapeutic medication for first-episode psychosis View source Failure to involve the senior pharmacist in the Trust investigation View source Failure to action family concerns and escalations about urgent medication View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Bency Joseph · 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
Bency Joseph died instantly on 27 May 2022 from a traumatic head injury after falling headfirst from an upstairs window at home during a severe psychotic episode. The concerns included delays in prescribing and providing therapeutic medication, failure to act on the family’s attempts to escalate the issue, and shortcomings in the Trust’s investigation, including not involving the family or Senior Pharmacist.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to involve the deceased patient's family in the Trust investigation
Wider context from the report “(2) The Trust investigation did not:
a. Inform or involve the Trust Senior Pharmacist who was unaware of the death and had no opportunity to be involved in the internal investigation.
b. Involve the Family of the deceased
c. Lost an opportunity to understand concerns that the Family had been trying to access additional urgent medication prescribed on 26 May 2022 without success and had been telephoning the Trust to raise an alert .
” 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 and failures in prescribing and administering therapeutic medication for first-episode psychosis
Wider context from the report “(1) Essex Partnership NHS Foundation Trust Mental Health Liaison Psychiatrist assessed Bency Joseph as suffering from a first episode psychosis when she attended hospital on 23rd May as an emergency and there was a delay in prescribing and administering therapeutic medication required for a first episode of psychosis with delusions .
a. ████████ Lorazepam was prescribed and administered on 25 May 2022 at hospital and evidence was that this was sub-therapeutic . One dose of medication was administered and Bency Joseph was discharged under the care of the Home Treatment Team.
b. On 26 May the Home Treatment Team consultant psychiatrist found that Bency Joseph did not have capacity, had deteriorated and prescribed urgent medication to be provided on the same day. The medication was not provided .
c. It is unclear if the urgent prescription was received and processed.
d. The Family’s concerns and attempts to escalate the failure to provide the medication were not actioned by the Trust and the death occurred in the early morning of 27 May as the Family were making arrangements to take Bency Joseph back to accident and emergency due to the omission to provide medication and further 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 involve the senior pharmacist in the Trust investigation
Wider context from the report “(2) The Trust investigation did not:
a. Inform or involve the Trust Senior Pharmacist who was unaware of the death and had no opportunity to be involved in the internal investigation.
b. Involve the Family of the deceased
c. Lost an opportunity to understand concerns that the Family had been trying to access additional urgent medication prescribed on 26 May 2022 without success and had been telephoning the Trust to raise an alert.
” 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 action family concerns and escalations about urgent medication
Wider context from the report “(1) Essex Partnership NHS Foundation Trust Mental Health Liaison Psychiatrist assessed Bency Joseph as suffering from a first episode psychosis when she attended hospital on 23rd May as an emergency and there was a delay in prescribing and administering therapeutic medication required for a first episode of psychosis with delusions.
a. ████████ Lorazepam was prescribed and administered on 25 May 2022 at hospital and evidence was that this was sub-therapeutic. One dose of medication was administered and Bency Joseph was discharged under the care of the Home Treatment Team.
b. On 26 May the Home Treatment Team consultant psychiatrist found that Bency Joseph did not have capacity, had deteriorated and prescribed urgent medication to be provided on the same day. The medication was not provided.
c. It is unclear if the urgent prescription was received and processed.
d. The Family’s concerns and attempts to escalate the failure to provide the medication were not actioned by the Trust and the death occurred in the early morning of 27 May as the Family were making arrangements to take Bency Joseph back to accident and emergency due to the omission to provide medication and further deterioration.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share learning about involving pharmacy expertise in clinical review investigations with the Clinical Review Group chair.
Verbatim wording from the response “Following notification of Mrs Joseph’s death, the Trust’s Clinical Review Group reviewed details of the incident on 14 June 2022 and requested that a Clinical Review be completed. The Group directed that the scope of the review should be from Mrs Joseph’s first contact with the Trust until her death and that any questions from the family should also be answered. At that point in time, it was not evident that involvement from the Trust’s Director of Pharmacy would be required, however the Trust acknowledges that when the report was reviewed by the Clinical Review Group, the Group should have picked up on this point and requested input prior to final approval of the report. This learning has been shared with the Chair of the Clinical Review Group.” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review urgent-care medication needs to determine whether to expand nurse-accessible PGD medicines.
Verbatim wording from the response “As patients are often referred to MHLT and HTT with varying symptoms. The Trust is currently considering the need to expand the number and types of medications available for nurses to use via PGD. In order to inform these considerations, the Trust’s Director of Pharmacy and Service Managers for urgent care pathways are collaboratively reviewing the medication needs for the services.” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop organisation-wide urgent-care resources reinforcing initial FP10 use for patients requiring urgent symptom-relief medication.
Verbatim wording from the response “Resources are being developed for urgent care services across the organisation to re-enforce the expectation that an FP10 should be used initially for patients who require urgent medications to manage their symptoms. We aim to have the resources available by the end of July 2023. Supply via PGD would be used where there is an urgent need and no access to a” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
27 Feb 2023 Sharon Elizabeth Langley · Prevention of Future Deaths report Essex
View report summary
Concerns raised 16 Failure to ensure closure of doors to high-risk areas View source Delays in calling emergency services and relaying basic emergency information View source Failure of trained staff to provide basic life support assistance View source Failure to share safety information across the Trust View source Failure to investigate bath plug storage and control issues View source Incomplete recording of multidisciplinary decisions, observation rationale and risk-management plans View source Failure to maintain reliable investigation conclusions when presented with unrequested and uncertain evidence View source Failure to activate emergency alarms immediately View source Failure to promptly inform and coordinate with the site co-ordinator during emergencies View source Lack of training on reporting door closure issues View source Failure to scrutinise staff movements and available door logs during investigations View source Failure to appropriately mitigate known safety risks View source Confusion and unreliable control over storage and retrieval of the bath plug View source Inaccurate and outdated risk information in ward records View source Failure to report door closure issues to ward and maintenance functions View source Failure to investigate emergency response and information-sharing concerns View source See 13 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 17
Action
Conduct a medical-emergency simulation with Derwent Centre staff and share incident learning for incorporation into current training.
Stated in progressThe respondent said that this action was in progress when they made their response on 7 March 2023. View source
Action
Roll out electronic observations across the Trust while maintaining review and assurance of observation records and multidisciplinary observation-level decisions.
Stated in progressThe respondent said that this action was in progress when they made their response on 7 March 2023. View source
Action
Share emergency-response learning through basic-life-support and grab-bag training, including prompt notification of the Site Coordinator and Doctor.
Stated in progressThe respondent said that this action was in progress when they made their response on 7 March 2023. View source
Action
Disseminate record-keeping guidance through an animated video, live learning event and Safety Learning Alert, with managers completing resulting actions.
Stated in progressThe respondent said that this action was in progress when they made their response on 7 March 2023. View source
Action
Deliver drop-in refresher life-support training for clinical and administrative staff, emphasizing immediate help-seeking and pinpoint-alarm use.
Stated in progressThe respondent said that this action was in progress when they made their response on 7 March 2023. View source
Action
Fit key-operated locks to Chelmer and Stort bathroom doors and to the patient store and staff room to restrict patient access to high-risk areas.
Stated completedThe respondent said that this action was complete when they made their response on 7 March 2023. View source
Action
Record bath and bath-plug risks and mitigations in ward workplace risk assessments and consider amending the ligature inspection tool.
Stated plannedThe respondent said that this action was planned when they made their response on 7 March 2023. View source
Action
Develop and launch an emergency communication tool containing essential patient and site information for ambulance calls across all wards.
Stated in progressThe respondent said that this action was in progress when they made their response on 7 March 2023. View source
Action
Use the Patient Safety Incident Response Framework and current response plan to investigate incidents with revised methodology and fuller chronology and triangulation.
Stated completedThe respondent said that this action was complete when they made their response on 7 March 2023. View source
Action
Conduct local clinical-record spot checks and daily-huddle and supervision reviews to identify and address inappropriate copying and pasting.
Stated completedThe respondent said that this action was complete when they made their response on 7 March 2023. View source
Action
Review the business case for creating an in-house faculty to deliver Immediate Life Support training and consider faculty development system-wide.
Stated plannedThe respondent said that this action was planned when they made their response on 7 March 2023. View source
Action
Undertake horizon scanning on multidisciplinary-team communication and patient-risk management, then review findings and take required actions.
Stated in progressThe respondent said that this action was in progress when they made their response on 7 March 2023. View source
Action
Keep bath plugs secured and control their use with Trust-wide signing-in and signing-out records documenting staff, patient and bathroom-locking details.
Stated completedThe respondent said that this action was complete when they made their response on 7 March 2023. View source
Action
Operate a Safety and Learning Command Call and Lessons Team process to communicate significant learning across the Trust and monitor actions to completion.
Stated completedThe respondent said that this action was complete when they made their response on 7 March 2023. View source
Action
Distribute risk-item Safety Alerts through Datix, communicate required mitigations, and monitor resulting actions through the Ligature Risk Reduction Group.
Stated completedThe respondent said that this action was complete when they made their response on 7 March 2023. View source
Action
Audit inpatient and urgent-care record keeping, identify copying-and-pasting issues, and agree follow-up actions for affected care groups.
Stated in progressThe respondent said that this action was in progress when they made their response on 7 March 2023. View source
Action
Use daily safety huddles to identify and escalate door-closure and other environmental concerns, assign mitigation actions, and involve Estates staff weekly.
Stated completedThe respondent said that this action was complete when they made their response on 7 March 2023. View source See 14 more actions
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AI-generated summary
Sharon Elizabeth Langley · 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
Sharon Elizabeth Langley, an inpatient with Severe Depressive Disorder and Psychosis, died by immersion in water while unsupervised in an assisted bathroom at Princess Alexandra Hospital on 10 August 2019. The principal concerns included failures in the immediate emergency response, inadequate communication and coordination, shortcomings in bathroom and high-risk-area safety measures, confusion about bath-plug controls, unreliable investigation and learning processes, and inadequate record keeping and risk documentation.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure closure of doors to high-risk areas
Wider context from the report “(3) The Trust was on notice of issues on Chelmer ward with doors to high-risk areas not closing that included the Staff Room and Patient Storeroom.
a. At the time of Sharon’s death, the mitigation on the ward was for staff to push doors to see if they were locked, this was action even though evidence was heard that these doors had keylocks and staff had keys that could have been used.
b. The Patient Storeroom contains items removed from patients as they pose a significant self-harm risk and/or suicide.
c. Staff Room that contains items that pose a risk to patients
Self-closure mechanisms have not been fitted to these doors in a high-risk environment of a secure psychiatric ward even though the risk is known . Evidence was heard from patient safety that it is sufficient to have maintenance manually adjust doors if there are closure issues.
” 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 calling emergency services and relaying basic emergency information
Wider context from the report “(1) Essex Partnership NHS Foundation Trust staff immediate emergency response was not followed:
a. pinpoint alarms were not activated immediately on finding Sharon Langley unresponsive
b. there was a delay calling the ambulance and basic key information about the type of the emergency was not relayed :
i. by qualified nurses who made the 999 calls , or
ii. to paramedics on attendance
c. there was a delay informing the site co-ordinator of the emergency even though she was based on the ward and there was a lack of co-ordination of the emergency resulting in the ambulance being called a second time by the site co-ordinator
d. staff trained in basic life support did not assist the two nurses who were attempting to resuscitate Sharon Langley
” 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 trained staff to provide basic life support assistance
Wider context from the report “(1) Essex Partnership NHS Foundation Trust staff immediate emergency response was not followed:
a. pinpoint alarms were not activated immediately on finding Sharon Langley unresponsive
b. there was a delay calling the ambulance and basic key information about the type of the emergency was not relayed:
i. by qualified nurses who made the 999 calls, or
ii. to paramedics on attendance
c. there was a delay informing the site co-ordinator of the emergency even though she was based on the ward and there was a lack of co-ordination of the emergency resulting in the ambulance being called a second time by the site co-ordinator
d. staff trained in basic life support did not assist the two nurses who were attempting to resuscitate Sharon Langley
” 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 safety information across the Trust
Wider context from the report “(2) There was a difference in the safety measures fitted to the bathroom door on the adjoining Stort Ward that had a self-closure mechanism at the time of Sharon’s death. This mechanism has now been fitted to Chelmer Ward. There is a concern that safety information is not shared across the Trust and known risks are not mitigated appropriately.
” 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 investigate bath plug storage and control issues
Wider context from the report “(6) There is concern about the reliability of the Trust investigation and how the Trust learns lessons. The investigation report did not:
a. scrutinise the movements of staff even though the door logs were available or raise any issues for further investigation
b. raise any issues around the bath plug or where it should be kept
c. investigate concerns raised around the Trust staff emergency response or failure to provide basic information on the incident to paramedics
” 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 multidisciplinary decisions, observation rationale and risk-management plans
Wider context from the report “(8) Quality of record keeping was not deemed to be appropriate by senior staff during evidence:
a. Significant examples of cut and paste including out-of-date risk information at all grades of ward staff, and
b. omissions in multi-disciplinary decision-making and risk of self-harm with no rationale for the level of observations set for the patient and a plan for how risks should be managed
” 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 reliable investigation conclusions when presented with unrequested and uncertain evidence
Wider context from the report “(7) The Trust investigation author changed the conclusion of his report during the inquest when he received statements provided by staff that were not requested and contained timing information that in evidence staff stated they did not know .
” 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 activate emergency alarms immediately
Wider context from the report “(1) Essex Partnership NHS Foundation Trust staff immediate emergency response was not followed:
a. pinpoint alarms were not activated immediately on finding Sharon Langley unresponsive
b. there was a delay calling the ambulance and basic key information about the type of the emergency was not relayed:
i. by qualified nurses who made the 999 calls, or
ii. to paramedics on attendance
c. there was a delay informing the site co-ordinator of the emergency even though she was based on the ward and there was a lack of co-ordination of the emergency resulting in the ambulance being called a second time by the site co-ordinator
d. staff trained in basic life support did not assist the two nurses who were attempting to resuscitate Sharon Langley
” 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 promptly inform and coordinate with the site co-ordinator during emergencies
Wider context from the report “(1) Essex Partnership NHS Foundation Trust staff immediate emergency response was not followed:
a. pinpoint alarms were not activated immediately on finding Sharon Langley unresponsive
b. there was a delay calling the ambulance and basic key information about the type of the emergency was not relayed:
i. by qualified nurses who made the 999 calls, or
ii. to paramedics on attendance
c. there was a delay informing the site co-ordinator of the emergency even though she was based on the ward and there was a lack of co-ordination of the emergency resulting in the ambulance being called a second time by the site co-ordinator
d. staff trained in basic life support did not assist the two nurses who were attempting to resuscitate Sharon Langley
” 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 training on reporting door closure issues
Wider context from the report “(4) Chelmer Ward staff did not always report door closure issues either on the ward to the Nurse in Charge or to maintenance. Following the death of Sharon Langley there has been no training on how to report door closure issues reported.
” 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 staff movements and available door logs during investigations
Wider context from the report “(6) There is concern about the reliability of the Trust investigation and how the Trust learns lessons. The investigation report did not:
a. scrutinise the movements of staff even though the door logs were available or raise any issues for further investigation
b. raise any issues around the bath plug or where it should be kept
c. investigate concerns raised around the Trust staff emergency response or failure to provide basic information on the incident to paramedics
” 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 mitigate known safety risks
Wider context from the report “(2) There was a difference in the safety measures fitted to the bathroom door on the adjoining Stort Ward that had a self-closure mechanism at the time of Sharon’s death. This mechanism has now been fitted to Chelmer Ward. There is a concern that safety information is not shared across the Trust and known risks are not mitigated appropriately .
” 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 Confusion and unreliable control over storage and retrieval of the bath plug
Wider context from the report “(5) Evidence was heard that the bath plug was required to be kept in the ward office when not in use as the bathroom was a high-risk area. There was no evidence that staff had to obtain this from the office on the day Sharon Langley died . There still appears to be confusion around the requirement .
” 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 Inaccurate and outdated risk information in ward records
Wider context from the report “(8) Quality of record keeping was not deemed to be appropriate by senior staff during evidence:
a. Significant examples of cut and paste including out-of-date risk information at all grades of ward staff , and
b. omissions in multi-disciplinary decision-making and risk of self-harm with no rationale for the level of observations set for the patient and a plan for how risks should be managed
” 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 door closure issues to ward and maintenance functions
Wider context from the report “(4) Chelmer Ward staff did not always report door closure issues either on the ward to the Nurse in Charge or to maintenance . Following the death of Sharon Langley there has been no training on how to report door closure issues reported.
” 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 investigate emergency response and information-sharing concerns
Wider context from the report “(6) There is concern about the reliability of the Trust investigation and how the Trust learns lessons. The investigation report did not:
a. scrutinise the movements of staff even though the door logs were available or raise any issues for further investigation
b. raise any issues around the bath plug or where it should be kept
c. investigate concerns raised around the Trust staff emergency response or failure to provide basic information on the incident to paramedics
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct a medical-emergency simulation with Derwent Centre staff and share incident learning for incorporation into current training.
Verbatim wording from the response “- The issue of calling for help as soon as possible is also shared during the weekly ‘virtual’ drop-in sessions which focus on the deteriorating patient. Head of Deteriorating Patient Pathways and Resuscitation Training Officer will continue to work with staff at the Derwent Centre to conduct a medical emergency simulation with the team and the importance of calling for help at the earliest possible opportunity is relayed during the post simulation feedback. In addition, the Trust’s training team have shared details of the learning from this incident and request for incorporation and sharing within the current training programme (1b, 1c).” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out electronic observations across the Trust while maintaining review and assurance of observation records and multidisciplinary observation-level decisions.
Verbatim wording from the response “- In relation to completion of engagement and supportive observation records, local procedure is in place whereby the observation is completed by the assigned staff member in full. The Nurse in Charge at the end of the shift will sign the observations chart off. These are checked by the ward manager for assurance they’ve been completed accurately and in full before being uploaded to the electronic clinical records system. EPUT has piloted the use of electronic observations (e-obs) which is now being rolled out across the Trust. Observation levels are reviewed regularly by the MDT and documented within the care review documentation.” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share emergency-response learning through basic-life-support and grab-bag training, including prompt notification of the Site Coordinator and Doctor.
Verbatim wording from the response “- The importance of informing the Site Coordinator and Doctor, at the time of the medical emergency, will be shared and highlighted by our colleagues who currently deliver the basic life support and grab bag training. In addition, any learning (examples of good practice or areas for improvement) which derives from a medical emergency, can be shared as part of the training (1c).” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate record-keeping guidance through an animated video, live learning event and Safety Learning Alert, with managers completing resulting actions.
Verbatim wording from the response “- Across the wider organisation, EPUT’s Lessons Team produced a short animated video with record keeping tips included, and this was cascaded across the organisation on 25th January 2023. On 1st February, the Lessons Team hosted a live learning event entitled “Learning Matters: Your Monthly Insight”. The topic of discussion focused on record keeping, themes of good practice and also the legalities around medical records.” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver drop-in refresher life-support training for clinical and administrative staff, emphasizing immediate help-seeking and pinpoint-alarm use.
Verbatim wording from the response “- EPUT’s Head of Deteriorating Patient Pathways and Resuscitation Training Officer is working closely with mental health wards to facilitate drop-in ‘refresher’ life support training for clinical and administrative staff dealing with emergency situations. During” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Fit key-operated locks to Chelmer and Stort bathroom doors and to the patient store and staff room to restrict patient access to high-risk areas.
Verbatim wording from the response “- Since the inquest hearing the death of Sharon, the bathroom door on Chelmer and Stort Wards have been changed to a key lock and the ACT has been disabled from use on these doors; which means the doors are now only accessible via key. The patient store and staff room have locks fitted to them which are accessible via a key which staff would be in possession of. This is to reduce the risk of patients being able to access such rooms which contain high risk items within.” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Record bath and bath-plug risks and mitigations in ward workplace risk assessments and consider amending the ligature inspection tool.
Verbatim wording from the response “- General Workplace Risk Assessments for each ward will be used to contain details of the risk and mitigations for the use of baths and bath plugs. In addition, on 10th May 2023 the Ligature Risk Reduction Group will discuss a consideration for amendments to be made to the ligature inspection tool related to bath plugs.” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and launch an emergency communication tool containing essential patient and site information for ambulance calls across all wards.
Verbatim wording from the response “- The Head of Deteriorating Patient Pathways and Resuscitation Training Officer, operational colleagues and the Lessons Team are formulating a communication tool for use when contacting the East of England Ambulance Service. EPUT Subject Matter Experts have liaised with external partner colleagues to devise the tool and the specific information which our colleagues will require in emergency scenarios. The questions the Ambulance control room will ask when reporting an emergency have been used as the basis for the communication tool poster. It will include essential information relating to the patients presenting medical condition, as well as site information including address and postcode. This aide memoir poster will be positioned adjacent to the Nurses Station and a laminated copy placed inside the grab bag. This is due to be completed and launched across all wards in May 2023 (1b).” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the Patient Safety Incident Response Framework and current response plan to investigate incidents with revised methodology and fuller chronology and triangulation.
Verbatim wording from the response “- The weaknesses of the Serious Incident Framework have been nationally recognised, which has led to the implementation of the Patient Safety Incident Response Framework (PSIRF, 2022). EPUT were an early adopter of PSIRF having formally implemented on 1st May 2021, and have helped shape the national implementation expectations. With this in mind, under the Trust’s current Patient Safety Incident Response Plan (PSIRP), an incident of this nature would have been investigated using a revised and recognised methodology and the data in which the investigation would have been set out would allow for a longer period of time to scrutinise the logs against other information to support with a chronology of events, triangulation of events and identification of learning.” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct local clinical-record spot checks and daily-huddle and supervision reviews to identify and address inappropriate copying and pasting.
Verbatim wording from the response “- In the meantime, local assurance to capture incidents of copying and pasting have been embedded. The Ward Manager and Matron completed spot checks of clinical records, and discuss at the daily huddles involving Ward Managers, Matron and Service Manager will identify incidents of copy and paste within the previous 24 hours of documentation so this can be addressed with individual staff members where required. In addition, clinical documentation is reviewed in individual staff supervision” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the business case for creating an in-house faculty to deliver Immediate Life Support training and consider faculty development system-wide.
Verbatim wording from the response “- A business case, for the creation of an in-house faculty, to deliver the gold standard Resuscitation Council UK ‘Immediate Life Support’ (RCUK ILS) training to EPUT staff has recently been presented to the Executive Team for their approval. The business case will be reviewed again in June 2023 in order to explore the faculty development as part of the system wide consideration. The RCUK ILS training focuses on leadership and task allocation during a medical emergency (1b, 1c, 1d).” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake horizon scanning on multidisciplinary-team communication and patient-risk management, then review findings and take required actions.
Verbatim wording from the response “- The Trust is currently undertaking horizon scanning relating to MDT communication (including MDT meetings where individual patient risk is discussed and management plans agreed), which is one of EPUT’s nine medium to long term continuous improvement areas. The horizon scan tool is part of the NHS Patient Safety Incident Response Framework toolkit and supports health and social care teams to have a forward look at potential, or current, safety themes and issues. The horizon scanning tool uses the Systems Engineering Initiative for Patient Safety (SEIPS) framework to structure conversations about work as done and emerging patient and staff safety risks. The findings will be reviewed and actions taken as required.” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Keep bath plugs secured and control their use with Trust-wide signing-in and signing-out records documenting staff, patient and bathroom-locking details.
Verbatim wording from the response “- Following the evidence provided at Sharon’s inquest, processes for the management of the bath plug on Chelmer Ward have been reviewed. Bath plugs are not left within the bathroom and a new signing in and out sheet has been implemented across the Derwent Centre. The plug will be signed out on the form by the staff member who is assisting the patient in the bath and signed back into the locked facility following completion of the bath. This includes the time the plug was removed and put back and which patient utilised the bath. The form is also signed by the assisting staff member to provide assurance that the bathroom door has been locked following completion of the bath.” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a Safety and Learning Command Call and Lessons Team process to communicate significant learning across the Trust and monitor actions to completion.
Verbatim wording from the response “- In addition, The Trust’s Lessons Team have worked with stakeholders to develop a process for communication when there are events where new and significant learning has been identified. The Safety and Learning Command Call scheduled to bring leaders and subject matter experts across the organisation together to discuss the event which has occurred to ensure this is widely communicated across the leadership team. Actions are developed and monitored for completion by the Lessons Team and a communication strategy of sharing the key information up, down and across the Trust is devised.” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Distribute risk-item Safety Alerts through Datix, communicate required mitigations, and monitor resulting actions through the Ligature Risk Reduction Group.
Verbatim wording from the response “- Safety Alerts related to risk items, such doors, are distributed to all wards and clinical staff via the Datix system. Ward staff would be provided with the details of the risk, and actions they are required to take to reduce the risk. This may include for work to be completed by the Estates Team, which would be communicated with Estates and evidence of completion recorded within Datix. New risks are discussed at the Ligature Risk Reduction Group where the alert is discussed and recommendations are formed for implementations. Action are monitored via the action log and re-discussed for assurance within each of the meetings.” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit inpatient and urgent-care record keeping, identify copying-and-pasting issues, and agree follow-up actions for affected care groups.
Verbatim wording from the response “- A recent Trust-wide inpatient and urgent care pathway audit for record keeping was finalised in April 2023. Questions related to copy and pasting within records was included in the audit and this was broken down into care groups. Care groups identified to have an issue with the copying and pasting in records are in the process of the agreeing next steps. For mental health inpatient areas, they are reviewing assurance processes such as Matron’s Assurance audit which will feature some questions regarding copying and pasting.” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use daily safety huddles to identify and escalate door-closure and other environmental concerns, assign mitigation actions, and involve Estates staff weekly.
Verbatim wording from the response “- The introduction of daily safety huddles since Sharon was an inpatient with EPUT supports effective communication across the clinical team. This would include any concerns they may have with door closures and other environmental issues. Actions are taken from the meeting, which would include the reporting of the concern, and a plan to mitigate against this until it has been resolved. Where the concern is of a clinical nature, the clinicians would be responsible for taking action; and where they are related to Estates issues, the Estates Team member at the meeting would action them. Huddles involving Estates staff take place weekly.” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The investigation could not analyse access logs in depth because they arrived after the chronology and the applicable framework required completion within 60 days.
Verbatim wording from the response “- The Lead Investigator and author of the Root Cause Analysis report reviewed the door access control logs as part of the investigation process. The Root Cause Analysis report was completed under the Serious Incidents Framework (SIF, 2015) whereby the expectation at the time was for the report to be completed within 60 days of the date of commissioning. The Lead Investigator has stated that the logs were received after the chronology had been completed and were not analysed in depth due to the timeline above.” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Formal training on reporting door-closure issues is not considered necessary because staff know the existing Estates escalation process.
Verbatim wording from the response “- The process of how to raise issues with Estates is set out within the Trust intranet which is available to staff. Although these is no formal recognised training of how to report an issue with a door closure, this is one of many issues that may be raised with Estates. The key point is that staff are aware of the process by which to escalate matters appropriately. If staff require support to utilise the portal, requests are made via the Estates Helpdesk which are responded to by Estates staff. The system in use at present is 3i. 3i is an estates management system which captures all maintenance issues and requests, which enables the Estates Team to prioritise the tasks. The system is audited for completeness fortnightly by the Trust Chief Engineer.” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
27 Feb 2023 Doris Joyce Smith · Prevention of Future Deaths report Essex
View report summary
Concerns raised 9 Lack of effective communication about required care, treatment and observation levels View source Failure to reconsider observation levels after falls in light of physiotherapist advice View source Failure to implement physiotherapist advice on assisted mobilisation View source Recording of out-of-date information in medical records through cut and paste View source Failure to complete required neurological observations after sustained head injury View source Confusing observation policy failing to address physical healthcare risks View source Delays in completing falls risk assessments View source Inaccurate falls risk assessments and updates View source Difficult-to-use electronic medical record entry interface View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Doris Joyce 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
Doris Joyce Smith fell on Ruby Ward on 9 October 2020, suffered a traumatic subarachnoid haemorrhage, and died on 14 October 2020. The report identifies concerns about delayed and inaccurate falls risk assessments, inadequate neurological and ward observations, failure to implement physiotherapy advice, poor record keeping, and ineffective communication about the care and observation levels required.
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 effective communication about required care, treatment and observation levels
Wider context from the report “(6) Lack of effective communication as to the care and treatment required for Doris Smith between Trust staff and the levels of observations required to keep her safe 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 reconsider observation levels after falls in light of physiotherapist advice
Wider context from the report “(3) Doris Smith had falls on the ward and her level of observations was not reconsidered in light of advice from the physiotherapist after each fall .
” 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 implement physiotherapist advice on assisted mobilisation
Wider context from the report “(1) Essex Partnership NHS Foundation Trust staff:
a. delayed the completion of a falls risk assessment
b. completed the falls risk assessment with inaccurate information to assess Doris Smith’s risk and updates were also inaccurate
c. did not follow the advice of the physiotherapist that would have required Doris Smith to mobilise only with assistance of staff and whether her level of observations should have been changed.
” 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 Recording of out-of-date information in medical records through cut and paste
Wider context from the report “(5) Quality of record keeping:
a. The Trust medical records recording system is electronic and evidence was heard that the window on the screen used for staff to type their records is very small and difficult to use.
b. There were significant examples of cut and paste including out-of-date information recorded in the medical 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 complete required neurological observations after sustained head injury
Wider context from the report “(2) Neurological observations following a sustained head injury were not completed as 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 Confusing observation policy failing to address physical healthcare risks
Wider context from the report “(4) The Trust Observation Policy is used in different therapeutic settings and is confusing as to the Levels of Observation required and the focus is on risk for mental health rather then physical healthcare issues that may arise .
” 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 completing falls risk assessments
Wider context from the report “(1) Essex Partnership NHS Foundation Trust staff:
a. delayed the completion of a falls risk assessment
b. completed the falls risk assessment with inaccurate information to assess Doris Smith’s risk and updates were also inaccurate
c. did not follow the advice of the physiotherapist that would have required Doris Smith to mobilise only with assistance of staff and whether her level of observations should have been changed.
” 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 Inaccurate falls risk assessments and updates
Wider context from the report “(1) Essex Partnership NHS Foundation Trust staff:
a. delayed the completion of a falls risk assessment
b. completed the falls risk assessment with inaccurate information to assess Doris Smith’s risk and updates were also inaccurate
c. did not follow the advice of the physiotherapist that would have required Doris Smith to mobilise only with assistance of staff and whether her level of observations should have been changed.
” 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 Difficult-to-use electronic medical record entry interface
Wider context from the report “(5) Quality of record keeping:
a. The Trust medical records recording system is electronic and evidence was heard that the window on the screen used for staff to type their records is very small and difficult to use .
b. There were significant examples of cut and paste including out-of-date information recorded in the medical records.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include falls-risk assessment training in clinical and temporary-worker induction, with probationary knowledge review for substantive staff.
Verbatim wording from the response “- The falls risk assessment is included in the local induction of all clinical ward staff band 2 to band 7 and for the induction of temporary workers. Knowledge and understanding is also reviewed in the probation period of substantive staff members through discussions, which usually concludes after the first six months of employment. This can be extended if there are further learning requirements or concerns for practice. Furthermore, the admissions checklist (which involves consideration of falls risk) is audited weekly by Ward Managers with action taken to ensure these assessments are completed if they are incomplete.” Source location Response from Essex Partnership University
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 physiotherapy input at daily safety huddles, including communication of observation requirements and risk-mitigation plans.
Verbatim wording from the response “- The unit physiotherapist attends the daily safety huddle to ensure effective communication within and between the clinical team. Where this is not possible, the physiotherapy assistant attends to provide a handover of assessments and plans and to receive updates on any patients requiring physiotherapy input. During these meetings, the physiotherapist or their assistant will contribute to discussion around requirement for observation and other risk mitigating interventions. Any changes to the patient’s care are communicated with the team and are updated within the clinical records, and the mobility poster displayed in their bed area where relevant.” Source location Response from Essex Partnership University
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 Relauch ward Falls Champion Networks to share learning, support revised policy implementation and audit updated falls assessments.
Verbatim wording from the response “- The Falls Champions Networks were re-launched in January 2023 as part of the Trust’s Physical Health Care meeting. Each ward have an identified registered member of staff who attend the meeting and feedback learning, changes in policy and practice developments in their local team. The Champions will also support the implementation of the revised falls policy once approved and will audit clinical records to ensure patient’s falls risk assessments are updated.” Source location Response from Essex Partnership University
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 Issue a safety learning alert on copying and pasting in clinical records and disseminate its learning themes.
Verbatim wording from the response “- On 10ᵗʰ March 2023, EPUT’s Lessons Team released a Safety Learning Alert, which focussed on copying and pasting within clinical records. The Alert noted that copying and pasting had been evident in records within recent inquests, and provided examples of where this had been completed. Learning themes were included within the alert, and actions were set for managers to ensure the key learning had been disseminated and actions had been taken to address the concerns raised. The final action is due for completion in May 2023. I have attached a copy of the Safety Learning Alert.” Source location Response from Essex Partnership University
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 falls-risk assessment completion weekly and monitor outstanding assessments through ward dashboards, handovers and assurance processes.
Verbatim wording from the response “- The falls risk assessment is included in the local induction of all clinical ward staff band 2 to band 7 and for the induction of temporary workers. Knowledge and understanding is also reviewed in the probation period of substantive staff members through discussions, which usually concludes after the first six months of employment. This can be extended if there are further learning requirements or concerns for practice. Furthermore, the admissions checklist (which involves consideration of falls risk) is audited weekly by Ward Managers with action taken to ensure these assessments are completed if they are incomplete.” Source location Response from Essex Partnership University
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 Trust-wide record-keeping audit and use its findings to address copying and pasting in clinical records.
Verbatim wording from the response “- A recent Trust-wide audit on record keeping was completed to review patient records for all clinical teams and the report finalised in April 2023. It was a retrospective audit looking at information recorded for the most recent contact with the patient to obtain assurance the records meet procedure regarding health and social care records. Clinical teams carried out the audit on their own records and submitted the information for analysis by the Clinical Audit Team. One of the findings from the report raised an issue of copying and pasting in records for teams in the Mental Health Inpatient and Urgent Care group. Discussions with the teams are being held to agree next steps to reduce copying and pasting with one suggestion is to use a current assurance process to review some records using the clinical dashboard as part of monitoring.” Source location Response from Essex Partnership University
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete the outstanding manager actions arising from the safety learning alert on copying and pasting in clinical records.
Verbatim wording from the response “- On 10ᵗʰ March 2023, EPUT’s Lessons Team released a Safety Learning Alert, which focussed on copying and pasting within clinical records. The Alert noted that copying and pasting had been evident in records within recent inquests, and provided examples of where this had been completed. Learning themes were included within the alert, and actions were set for managers to ensure the key learning had been disseminated and actions had been taken to address the concerns raised. The final action is due for completion in May 2023. I have attached a copy of the Safety Learning Alert.” Source location Response from Essex Partnership University
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 Recirculate instructions on expanding electronic-record text boxes and enlarging displayed text in the Lessons Identified Newsletter.
Verbatim wording from the response “- Within the clinical records, Paris, there is a function to expand text boxes for clinicians to type information within, and text can be made larger on the screen for this to be readable for the clinician. This technique will be re-circulated to staff in May’s edition of the Lessons Identified Newsletter or 5 Key Messages.” Source location Response from Essex Partnership University
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop two standard operating procedures covering inpatient falls management and post-fall management.
Verbatim wording from the response “In addition to the falls risk assessment and the admission checklist which aid the staff member to introduce falls reduction interventions and strategies for that patient, the Trust is currently engaged with Carradale futures in a project to produce two Standard Operating Procedures (SOP) that relate to the management of inpatient falls. These are management of falls the inpatient setting and the management of a patient following a fall.” Source location Response from Essex Partnership University
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide mandatory neurological-observation training to substantive, bank and non-registered staff using case studies and scenarios.
Verbatim wording from the response “- Training for staff related to the understanding of neurological observations is covered in several mandatory training courses, including; Grab Bag, Preventing Falls in Hospital and Immediate Life Support. This covers theoretical components and the use of case studies and scenario based training to ensure embedding of knowledge in a practical sense. This training is completed by substantive and bank staff and currently includes non-registered staff members.” Source location Response from Essex Partnership University
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 clinical guidance and neurological observation charts to specify post-fall neurological assessment, Glasgow Coma Scale recording and observation frequencies.
Verbatim wording from the response “observations. The ‘Clinical Guideline on the Use of National Early Warning Score System (NEWS2) (CG87) provides staff with a framework for the identification and management of patients who are at risk of physiological deterioration. It has information on when physiological observations must be taken, when to complete a monitoring plan for physiological observations, how to record these observations and what to do if the metrics are abnormal.” Source location Response from Essex Partnership University
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 record-keeping guidance through an animated video and live learning event.
Verbatim wording from the response “- In addition, EPUT’s Lessons Team produced a short animated video with record keeping tips included, and this was cascaded across the organisation on 25ᵗʰ January 2023. The tips included the accuracy and purpose of maintaining adequate records. On 1ˢᵗ February, the Lessons Team hosted a live learning event entitled “Learning Matters: Your Monthly Insight”. The topic of discussion focused on record keeping, themes of good practice and also the legalities around medical records.” Source location Response from Essex Partnership University
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 falls assessments within 24 hours of admission and update them after clinical changes.
Verbatim wording from the response “Since Doris was a patient with EPUT, the Trust have made a number of practice changes to improve the care provided to patients in relation to falls. These are detailed below:” Source location Response from Essex Partnership University
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Display and maintain patient-bedroom mobility-assistance posters, updating and communicating them when mobility needs change.
Verbatim wording from the response “- Posters are displayed in patient bedrooms to clearly inform the patient and supporting staff of the mobility assistance they require, and includes details of aids they may require for the hearing and visual needs. The posters are initiated by physiotherapy staff and updated by them or the occupational therapy staff. When an update is completed, this is emailed to the team, updated within the clinical records, discussed at the safety huddle and handover. This ensures prompt and thorough communication sharing. This was in place at the time Doris was an inpatient and remains current practice.” Source location Response from Essex Partnership University
Open published response
19 Feb 2023 Molly Ann Sergeant · Prevention of Future Deaths report Essex
View report summary
Concerns raised 13 Lack of escalation when assessment and discharge planning requests are not answered View source Lack of assessment of section 117 needs for discharge View source Delayed appointment of a social worker View source Failure to act on appropriate social care referrals View source Lack of understanding of section 117 Mental Health Act rights and entitlements View source Discharge planning that compels a choice between family members and changes homelessness status View source Lack of understanding of changing child-in-need assessment rights during detention View source Failure to conduct required assessments during detention View source Lack of appreciation of autism diagnosis and suicide risk in decision-making capacity View source Insufficient assessment of the impact of autism diagnosis in discharge planning View source Delayed diagnosis of autism View source Excessive key worker or care co-ordinator workload View source Insufficient consideration of autism diagnosis in relation to suicide risk during discharge planning View source See 10 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Molly Ann Sergeant · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Molly Ann Sergeant, aged 17, was found deceased on 16 October 2020 after hanging, having left a note. The report identifies concerns about delayed autism diagnosis, insufficient assessment and discharge planning, failures in social-care assessments and coordination, and a lack of understanding of her aftercare rights and chronic suicide risk.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of escalation when assessment and discharge planning requests are not answered
Wider context from the report “(4) Lack of escalation to Essex County Council when there was a failure to respond to requests for assessment and attendance at discharge planning meetings and the key worker/care co-ordinator carrying too heavy a workload as a consequence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of assessment of section 117 needs for discharge
Wider context from the report “(6) A lack of understanding of section 117 Mental Health Act rights and potential for consideration for entitlements to meet Molly’s needs related to her mental health disorder, by Essex County Council:
a. compelling Molly to choose between family members as part of her discharge planning and then as a consequence changing Molly’s status during her detention from homeless.
b. Lack of assessment for any s117 needs to facilitate discharge
c. Lack of appreciation of the impact of Molly’s autism diagnosis in a background of chronic suicide risk on decision-making and Molly’s potential to understand the decisions being made.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delayed appointment of a social worker
Wider context from the report “(5) Essex County Council did not:
a. act on appropriate referrals to social care by Essex Partnership NHS Trust
b. conduct required assessments of Molly during her detention
c. did not appoint a social worker until after Molly was discharged
There was a lack of understanding of the impact of Molly’s detention on her right to assessment as a child in need and how this changed during her detention under the Mental Health Act.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to act on appropriate social care referrals
Wider context from the report “(5) Essex County Council did not:
a. act on appropriate referrals to social care by Essex Partnership NHS Trust
b. conduct required assessments of Molly during her detention
c. did not appoint a social worker until after Molly was discharged
There was a lack of understanding of the impact of Molly’s detention on her right to assessment as a child in need and how this changed during her detention under the Mental Health Act.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of section 117 Mental Health Act rights and entitlements
Wider context from the report “(6) A lack of understanding of section 117 Mental Health Act rights and potential for consideration for entitlements to meet Molly’s needs related to her mental health disorder , by Essex County Council:
a. compelling Molly to choose between family members as part of her discharge planning and then as a consequence changing Molly’s status during her detention from homeless.
b. Lack of assessment for any s117 needs to facilitate discharge
c. Lack of appreciation of the impact of Molly’s autism diagnosis in a background of chronic suicide risk on decision-making and Molly’s potential to understand the decisions being made.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Discharge planning that compels a choice between family members and changes homelessness status
Wider context from the report “(6) A lack of understanding of section 117 Mental Health Act rights and potential for consideration for entitlements to meet Molly’s needs related to her mental health disorder, by Essex County Council:
a. compelling Molly to choose between family members as part of her discharge planning and then as a consequence changing Molly’s status during her detention from homeless .
b. Lack of assessment for any s117 needs to facilitate discharge
c. Lack of appreciation of the impact of Molly’s autism diagnosis in a background of chronic suicide risk on decision-making and Molly’s potential to understand the decisions being made.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of changing child-in-need assessment rights during detention
Wider context from the report “(5) Essex County Council did not:
a. act on appropriate referrals to social care by Essex Partnership NHS Trust
b. conduct required assessments of Molly during her detention
c. did not appoint a social worker until after Molly was discharged
There was a lack of understanding of the impact of Molly’s detention on her right to assessment as a child in need and how this changed during her detention under the Mental Health Act.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct required assessments during detention
Wider context from the report “(5) Essex County Council did not:
a. act on appropriate referrals to social care by Essex Partnership NHS Trust
b. conduct required assessments of Molly during her detention
c. did not appoint a social worker until after Molly was discharged
There was a lack of understanding of the impact of Molly’s detention on her right to assessment as a child in need and how this changed during her detention under the Mental Health Act.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of appreciation of autism diagnosis and suicide risk in decision-making capacity
Wider context from the report “(6) A lack of understanding of section 117 Mental Health Act rights and potential for consideration for entitlements to meet Molly’s needs related to her mental health disorder, by Essex County Council:
a. compelling Molly to choose between family members as part of her discharge planning and then as a consequence changing Molly’s status during her detention from homeless.
b. Lack of assessment for any s117 needs to facilitate discharge
c. Lack of appreciation of the impact of Molly’s autism diagnosis in a background of chronic suicide risk on decision-making and Molly’s potential to understand the decisions being made.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient assessment of the impact of autism diagnosis in discharge planning
Wider context from the report “(2) There was insufficient assessment for discharge planning purposes of the impact of Molly’s recent diagnosis of Autism by Essex Partnership NHS Foundation Trust
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delayed diagnosis of autism
Wider context from the report “(1) Molly had a delayed diagnosis of Autism . Molly was diagnosed during her detention at the St. Aubyn Centre when she experienced a mental health crisis and detained under the Mental Health Act.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Excessive key worker or care co-ordinator workload
Wider context from the report “(4) Lack of escalation to Essex County Council when there was a failure to respond to requests for assessment and attendance at discharge planning meetings and the key worker/care co-ordinator carrying too heavy a workload as a consequence .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient consideration of autism diagnosis in relation to suicide risk during discharge planning
Wider context from the report “(3) There was insufficient consideration given to the impact of Molly’s delayed diagnosis of Autism on her chronic high risk of suicide in her discharge and discharge planning in a background of Molly not accepting her diagnosis.
” Open source report
27 Jan 2023 Jayden Andrew Booroff · Prevention of Future Deaths report Essex
View report summary
Concerns raised 6 Lack of a senior single point of contact for ongoing communications with emergency services across shift changes View source Failure of risk assessments to capture key risk information before ward observation levels are reduced View source Failure to communicate self-harm risks to emergency services searching for an absent patient View source Miscommunication between mental health, police and other emergency services View source Lack of understanding of the distinction between an unauthorised absence after section 17 leave and an escape from a detained ward patient View source Failure to establish the changed risk and immediacy of serious or fatal harm when a patient escapes from a secure mental health ward View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 12
Action
Implement an electronic clinical dashboard showing recent clinical entries, current risk assessments and observation levels at handover.
Stated completedThe respondent said that this action was complete when they made their response on 3 February 2023. View source
Action
Enable Essex Police to join twice-daily Trust SITREPs with service managers and Matrons to support escalation and communication.
Stated completedThe respondent said that this action was complete when they made their response on 3 February 2023. View source
Action
Configure risk-assessment documentation in Paris and Mobius to carry forward risk history while capturing newly identified risks.
Stated completedThe respondent said that this action was complete when they made their response on 3 February 2023. View source
Action
Create and disseminate an SBARD aide-mémoire guiding staff escalation to police for patients absent from authorised leave or absconded, including Mental Health Act status and risk information.
Stated completedThe respondent said that this action was complete when they made their response on 3 February 2023. View source
Action
Review the Trustwide Engagement and Supportive Observation Procedure to require MDT decisions informed by comprehensive risk assessment and documented care-plan rationale.
Stated completedThe respondent said that this action was complete when they made their response on 3 February 2023. View source
Action
Audit missing-person calls with Essex Police to assess the aide-mémoire’s effectiveness and establish and share further learning.
Stated in progressThe respondent said that this action was in progress when they made their response on 3 February 2023. View source
Action
Continue observation assurance monitoring through Tendable and observation-engagement audits, with weekly review of findings by the Inpatient Clinical Support Group.
Stated in progressThe respondent said that this action was in progress when they made their response on 3 February 2023. View source
Action
Revise observation recording documentation and add observation-level decision and audit requirements to assurance audits.
Stated completedThe respondent said that this action was complete when they made their response on 3 February 2023. View source
Action
Introduce an Engagement and Observation Plan recording observation commencement, review, changes and discontinuation against patient risk.
Stated completedThe respondent said that this action was complete when they made their response on 3 February 2023. View source
Action
Share learning from the patient-safety incident and Prevention of Future Deaths report at the Essex Crisis Concordat and reinforce communication pathways.
Stated plannedThe respondent said that this action was planned when they made their response on 3 February 2023. View source
Action
Continue the adult inpatient record-keeping clinical audit covering current risk assessments, risk-management plans, MDT input, observation care plans and crisis plans.
Stated in progressThe respondent said that this action was in progress when they made their response on 3 February 2023. View source
Action
Appoint a senior single point of contact and provide a prioritised emergency-services line to appropriate senior and out-of-hours managers.
Stated completedThe respondent said that this action was complete when they made their response on 3 February 2023. View source See 9 more actions
×
AI-generated summary
Jayden Andrew Booroff · 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
Jayden Andrew Booroff died after absconding from The Linden Centre and being struck by a train on 23 October 2020. The report identified concerns about risk assessments, observation levels, ward security, absconsion procedures, record keeping, medication, and communication between healthcare professionals and emergency 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 Lack of a senior single point of contact for ongoing communications with emergency services across shift changes
Wider context from the report “(4) Lack of an Essex Partnership NHS Foundation Trust senior single point of contact for communications with emergency services who would provide any further information or receive updates and how this could be managed across change of shifts .
” 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 risk assessments to capture key risk information before ward observation levels are reduced
Wider context from the report “(1) Essex Partnership NHS Foundation Trust risk assessments missed key risk information that led to a reduction in observations levels 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 communicate self-harm risks to emergency services searching for an absent patient
Wider context from the report “(2) There is a lack of understanding at Essex Partnership NHS Foundation Trust level about the difference between:
a. a patient who has been granted section 17 leave under the Mental Health Act who does not return from a period of authorised leave, and
b. a patient who being subject to detention under the Mental Health Act, who has escaped from the confines of the ward and who has not been granted section 17 leave by the Responsible Clinician
and therefore, there is a concern as to how this information is then communicated to emergency services searching for the patient of the risks of self-harm .
” 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 Miscommunication between mental health, police and other emergency services
Wider context from the report “(3) Miscommunication between:
a. Essex Partnership NHS Foundation Trust to emergency services
b. Essex Police to Essex Partnership NHS Foundation Trust
c. Essex Police to other emergency services
In seeking further information, how a risk managed within the confines of a secure mental health ward may change for an escaped patient and whether there is real and immediate risk of serious or fatal harm to self or others, rather than assumptions that language is being used in the same way by different services.
” 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 the distinction between an unauthorised absence after section 17 leave and an escape from a detained ward patient
Wider context from the report “(2) There is a lack of understanding at Essex Partnership NHS Foundation Trust level about the difference between :
a. a patient who has been granted section 17 leave under the Mental Health Act who does not return from a period of authorised leave , and
b. a patient who being subject to detention under the Mental Health Act, who has escaped from the confines of the ward and who has not been granted section 17 leave by the Responsible Clinician
and therefore, there is a concern as to how this information is then communicated to emergency services searching for the patient of the risks of self-harm.
” 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 establish the changed risk and immediacy of serious or fatal harm when a patient escapes from a secure mental health ward
Wider context from the report “(3) Miscommunication between:
a. Essex Partnership NHS Foundation Trust to emergency services
b. Essex Police to Essex Partnership NHS Foundation Trust
c. Essex Police to other emergency services
In seeking further information, how a risk managed within the confines of a secure mental health ward may change for an escaped patient and whether there is real and immediate risk of serious or fatal harm to self or others , rather than assumptions that language is being used in the same way by different services .
” 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 an electronic clinical dashboard showing recent clinical entries, current risk assessments and observation levels at handover.
Verbatim wording from the response “• The Trust has implemented a new electronic clinical dashboard, which provides an overview of documentation for ward staff. This is used at handover, and allows staff to view the three most recent clinical entries for each patient, including up to date risk assessments and observation levels. Record keeping audits also take place to support assurance and monitoring processes.” Source location Response from Essex Partnership University
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 Essex Police to join twice-daily Trust SITREPs with service managers and Matrons to support escalation and communication.
Verbatim wording from the response “• The Trust have developed good relationships with the police, who are now able to join the Trust twice daily SITREPS on Microsoft Teams with service managers and Matrons to support escalation and communication. This commenced at the beginning of February 2023.” Source location Response from Essex Partnership University
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 risk-assessment documentation in Paris and Mobius to carry forward risk history while capturing newly identified risks.
Verbatim wording from the response “• At present, risk assessment documentation within Paris and Mobius are “trending” which means they capture information from the previously typed risk assessment and pull this automatically into a new risk assessment form. This will ensure that risk history is included within one place, whilst new identified risk can be included to ensure the comprehensive nature of the assessment. The information can be considered when making clinical decisions with the patient and their family, and can be incorporated into their risk management plan.” Source location Response from Essex Partnership University
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 Create and disseminate an SBARD aide-mémoire guiding staff escalation to police for patients absent from authorised leave or absconded, including Mental Health Act status and risk information.
Verbatim wording from the response “In light of communication with emergency services, in collaboration with the Trust’s Lessons Team, a one-page aide-mémoire was created to support staff to escalate concerns to the police for incidents where a patient does not return from leave or they have absconded from the ward. This guidance provided information regarding the impact factors that should be verbalised to the police when reporting a person missing. This would then enable the police to make an informed decision in relation to their response. This document uses the SBARD communication tool (Situation, Background, Assessment, Recommendation, Decision). This document was shared with operational managers for cascading to front line staff and calls will be audited between EPUT and Essex Police to ascertain the effectiveness of the tool.” Source location Response from Essex Partnership University
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 Trustwide Engagement and Supportive Observation Procedure to require MDT decisions informed by comprehensive risk assessment and documented care-plan rationale.
Verbatim wording from the response “• In relation to the risk information which led to a reduction in the engagement and supportive observation levels; the Trustwide Engagement and Supportive Observation Procedure was further reviewed in January 2022 and outlines decisions about the level of observation should be made by the multi-disciplinary team (MDT). The procedure also references the requirement of considering a patient’s risk assessment in the decision discussion of observation levels. In particular, that a risk assessment is completed through interview with the patient and carers, careful study of the patient history, use of ratified risk assessment tools, and include assessments of other professionals. A patient’s care plan will contain the rationale for the observation level agreed, details of their risk assessment and how this is managed.” Source location Response from Essex Partnership University
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 missing-person calls with Essex Police to assess the aide-mémoire’s effectiveness and establish and share further learning.
Verbatim wording from the response “In light of communication with emergency services, in collaboration with the Trust’s Lessons Team, a one-page aide-mémoire was created to support staff to escalate concerns to the police for incidents where a patient does not return from leave or they have absconded from the ward. This guidance provided information regarding the impact factors that should be verbalised to the police when reporting a person missing. This would then enable the police to make an informed decision in relation to their response. This document uses the SBARD communication tool (Situation, Background, Assessment, Recommendation, Decision). This document was shared with operational managers for cascading to front line staff and calls will be audited between EPUT and Essex Police to ascertain the effectiveness of the tool.” Source location Response from Essex Partnership University
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 observation assurance monitoring through Tendable and observation-engagement audits, with weekly review of findings by the Inpatient Clinical Support Group.
Verbatim wording from the response “The Trust continues with observation assurance monitoring and has strengthened some of these processes. Key assurance monitoring includes:” Source location Response from Essex Partnership University
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 observation recording documentation and add observation-level decision and audit requirements to assurance audits.
Verbatim wording from the response “• The Trust engagement and supportive observation processes were reviewed. Following this review, the document in which observations are recorded on was revised to support recording of actual time for each observation. Policy revisions related to roles for decreasing observations and auditing of observations was also added to the Matrons Assurance Tendable audits.” Source location Response from Essex Partnership University
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 an Engagement and Observation Plan recording observation commencement, review, changes and discontinuation against patient risk.
Verbatim wording from the response “An observation and engagement task and finish group was established to undertake a full review of processes and implemented a number of improvements including:” Source location Response from Essex Partnership University
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 learning from the patient-safety incident and Prevention of Future Deaths report at the Essex Crisis Concordat and reinforce communication pathways.
Verbatim wording from the response “• The Trust co-chairs the Essex Crisis Concordat with Essex Police. British Transport Police and EEAST Ambulance Leads also attend. The next meeting is on 4th April 2023, where learning from this Patient Safety Incident and prevention of Future Deaths report will be shared and communication pathways will be reinforced.” Source location Response from Essex Partnership University
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 adult inpatient record-keeping clinical audit covering current risk assessments, risk-management plans, MDT input, observation care plans and crisis plans.
Verbatim wording from the response “Clinical Audits:
Adult Inpatient Wards Record Keeping Audit continues to be part of the Trust Clinical Audit Programme. Clinical audit is a proven method of quality improvement and an important mechanism for providing assurance in relation to the provision of safe and effective patient care. It gives staff a systematic way of looking at their practice and making improvements.” Source location Response from Essex Partnership University
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 Appoint a senior single point of contact and provide a prioritised emergency-services line to appropriate senior and out-of-hours managers.
Verbatim wording from the response “Since the incident, the Trust has appointed a single point of contact where emergency services can request to speak the appropriate senior manager managing the incident. The Trust, Essex Police, British Transport Police and EEAST Ambulance Leads are continuing to build good relationships and communication as described below:” Source location Response from Essex Partnership University
Open published response
25 Feb 2022 Stephanie Moyce · Prevention of Future Deaths report Essex
View report summary
Concerns raised 6 Failure to routinely discuss psychotherapy patients in locality multidisciplinary team meetings before discharge to share progress, vulnerability and relapse-risk information View source Lack of clarity about responsibility for formulating clear and comprehensive psychotherapy discharge plans View source Failure to involve patients’ carers as equal partners in the development and review of Section 117 after-care plans View source Lack of clarity about responsibility for oversight of patient care following discharge View source Lack of clarity about responsibility for post-discharge relapse safety-netting View source Failure to use pre-discharge multidisciplinary team meetings to organise and follow up overall discharge planning for psychotherapy patients View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Stephanie Moyce · 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
Stephanie Moyce, who had a history of mental health issues and repeated suicide attempts, took her own life on 30 July 2021 and was discovered by her partner. The report identified concerns about unclear responsibility for care and oversight after psychotherapy discharge, inadequate discharge planning and safety-netting, the lack of routine multidisciplinary discussion, and insufficient involvement of her carer in Section 117 after-care reviews.
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 routinely discuss psychotherapy patients in locality multidisciplinary team meetings before discharge to share progress, vulnerability and relapse-risk information
Wider context from the report “3. Evidence confirmed that patients under psychotherapy are not presently routinely discussed in the locality multi-disciplinary team meetings prior to their discharge leading to a missed opportunity: (a) to share information about the specific progress, vulnerabilities and risks of relapse of the patient (and measures to mitigate or deal with the same) ; as well as (b) to organise and follow up the overall discharge planning.
” 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 formulating clear and comprehensive psychotherapy discharge plans
Wider context from the report “1. Evidence confirmed a conspicuous lack of clarity as to who, amongst EPUT clinicians/staff, is responsible for ensuring that a clear and comprehensive discharge plan is formulated for those coming to the end of a course of psychotherapy where a Care Coordinator is no longer in place/has not been replaced;
” 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 patients’ carers as equal partners in the development and review of Section 117 after-care plans
Wider context from the report “4. The evidence in this case indicated that, contrary to EPUT’s own established Protocol, a patient’s carer (in this case her long-term partner who no confidentiality issue were identified) are not in practice always “seen as equal partners in the development and review of Section 117 after-care plans” and involved directly in such reviews .
” 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 “2. 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;
” 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 post-discharge relapse safety-netting
Wider context from the report “2. 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;
” 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 pre-discharge multidisciplinary team meetings to organise and follow up overall discharge planning for psychotherapy patients
Wider context from the report “3. Evidence confirmed that patients under psychotherapy are not presently routinely discussed in the locality multi-disciplinary team meetings prior to their discharge leading to a missed opportunity: (a) to share information about the specific progress, vulnerabilities and risks of relapse of the patient (and measures to mitigate or deal with the same); as well as (b) to organise and follow up the overall discharge planning .
” Open source report
8 Feb 2022 Benjamin Lee Stroud · Prevention of Future Deaths report Essex
View report summary
Concerns raised 3 Reliance on a Care Coordinator to make clinical decisions about MDT referral View source Failure to document the rationale for non-referral to the MDT View source Failure to ensure all cases go before the MDT View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Benjamin Lee Stroud · 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
Benjamin Lee Stroud died at his home on 19 March 2021 after an overdose involving multiple drugs, including tramadol and alprazolam, with empty medication blister packets and insulin pens found around him. The report raised concerns that his case was not referred to the multidisciplinary team despite escalating psychosis, that the Care Coordinator made the referral decision without a recorded rationale, and that this practice posed a risk of future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Reliance on a Care Coordinator to make clinical decisions about MDT referral
Wider context from the report “That in all cases must go before the MDT, the evidence in this inquest, made it clear that had Mr Stroud’s case had been discussed at an MDT then more help would have been made available to him, that he would have been seen by a psychiatrist and may have prevented his death.
On the evidence from EPUT and the PSIIR it was clear that the Care Coordinator makes the decisions as to whether to refer a case to the MDT , in this case, no entries were made around the rationale for none referral and no explanation was provided at the inquest. This is not the first time this issue has arisen at an Inquest and the reliance on a Care Coordinator to make a clinical decision and no written explanation provided on any clinical notes documented appears to be a way of working. If these practices continue there is a real risk of future deaths occurring.
” 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 the rationale for non-referral to the MDT
Wider context from the report “That in all cases must go before the MDT, the evidence in this inquest, made it clear that had Mr Stroud’s case had been discussed at an MDT then more help would have been made available to him, that he would have been seen by a psychiatrist and may have prevented his death.
On the evidence from EPUT and the PSIIR it was clear that the Care Coordinator makes the decisions as to whether to refer a case to the MDT, in this case, no entries were made around the rationale for none referral and no explanation was provided at the inquest. This is not the first time this issue has arisen at an Inquest and the reliance on a Care Coordinator to make a clinical decision and no written explanation provided on any clinical notes documented appears to be a way of working. If these practices continue there is a real risk of future deaths occurring.
” 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 all cases go before the MDT
Wider context from the report “That in all cases must go before the MDT , the evidence in this inquest, made it clear that had Mr Stroud’s case had been discussed at an MDT then more help would have been made available to him, that he would have been seen by a psychiatrist and may have prevented his death .
On the evidence from EPUT and the PSIIR it was clear that the Care Coordinator makes the decisions as to whether to refer a case to the MDT, in this case, no entries were made around the rationale for none referral and no explanation was provided at the inquest. This is not the first time this issue has arisen at an Inquest and the reliance on a Care Coordinator to make a clinical decision and no written explanation provided on any clinical notes documented appears to be a way of working. If these practices continue there is a real risk of future deaths occurring.
” Open source report
8 Feb 2022 John David Moore · Prevention of Future Deaths report Essex
View report summary
Concerns raised 8 Inadequate communication with primary and secondary care providers View source Failure to formally update Care Plans and Risk Assessments thoroughly and timely View source Failure to recognise the need to escalate patient issues to multidisciplinary meetings or experienced supervisors View source Failure to maintain basic care records, including contacts and failed contacts View source Incomplete and inadequate recording of Care Coordinator supervision sessions View source Insufficient attention to the clinical significance of patient disengagement from services View source Inadequate formal training for Care Coordinators View source Lack of records of the nature, extent and duration of on-the-job or shadowing training View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
John David Moore · 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
John David Moore had a history of homelessness, mental health issues, substance misuse and previous suicide or serious self-harm incidents. He died by suicide on 10 June 2021 while homeless, after no recorded intervention from primary or secondary care since 2020. The report identified concerns about inadequate training and supervision of EPUT Care Coordinators, including shortcomings in record keeping, care planning, communication, recognition of disengagement and escalation of 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 Inadequate communication with primary and secondary care providers
Wider context from the report “(2) The evidence in this case, and in other recent inquests heard by me and fellow coroners in this jurisdiction, establishes the following common themes in respect to the inadequate performance of several EPUT Care Coordinators. In my settled view, these themes are (at least to a significant degree) a consequence of inadequate training for the role:
(i) failure to maintain basic record keeping generally and, particularly, with respect to the recording of contacts or, potentially importantly, failed contacts with the deceased in the weeks and months prior to a self-inflicted death;
(ii) a failure to formally up-date Care Plans and Risk Assessments in a thorough and/or timely fashion, or at all;
(iii) inadequate communication with other primary and secondary care providers ;
(iv) consistently, insufficient attention to the potential clinical significance of ‘disengagement’ with services by patients;
(v) failure to recognise the need to raise issues relating to a patient with the Multi-Disciplinary Team Meetings or in supervision with experienced supervisors.
” 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 formally update Care Plans and Risk Assessments thoroughly and timely
Wider context from the report “(2) The evidence in this case, and in other recent inquests heard by me and fellow coroners in this jurisdiction, establishes the following common themes in respect to the inadequate performance of several EPUT Care Coordinators. In my settled view, these themes are (at least to a significant degree) a consequence of inadequate training for the role:
(i) failure to maintain basic record keeping generally and, particularly, with respect to the recording of contacts or, potentially importantly, failed contacts with the deceased in the weeks and months prior to a self-inflicted death;
(ii) a failure to formally up-date Care Plans and Risk Assessments in a thorough and/or timely fashion, or at all ;
(iii) inadequate communication with other primary and secondary care providers;
(iv) consistently, insufficient attention to the potential clinical significance of ‘disengagement’ with services by patients;
(v) failure to recognise the need to raise issues relating to a patient with the Multi-Disciplinary Team Meetings or in supervision with experienced supervisors.
” 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 recognise the need to escalate patient issues to multidisciplinary meetings or experienced supervisors
Wider context from the report “(2) The evidence in this case, and in other recent inquests heard by me and fellow coroners in this jurisdiction, establishes the following common themes in respect to the inadequate performance of several EPUT Care Coordinators. In my settled view, these themes are (at least to a significant degree) a consequence of inadequate training for the role:
(i) failure to maintain basic record keeping generally and, particularly, with respect to the recording of contacts or, potentially importantly, failed contacts with the deceased in the weeks and months prior to a self-inflicted death;
(ii) a failure to formally up-date Care Plans and Risk Assessments in a thorough and/or timely fashion, or at all;
(iii) inadequate communication with other primary and secondary care providers;
(iv) consistently, insufficient attention to the potential clinical significance of ‘disengagement’ with services by patients;
(v) failure to recognise the need to raise issues relating to a patient with the Multi-Disciplinary Team Meetings or in supervision with experienced supervisors .
” 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 basic care records, including contacts and failed contacts
Wider context from the report “(2) The evidence in this case, and in other recent inquests heard by me and fellow coroners in this jurisdiction, establishes the following common themes in respect to the inadequate performance of several EPUT Care Coordinators. In my settled view, these themes are (at least to a significant degree) a consequence of inadequate training for the role:
(i) failure to maintain basic record keeping generally and, particularly, with respect to the recording of contacts or, potentially importantly, failed contacts with the deceased in the weeks and months prior to a self-inflicted death;
(ii) a failure to formally up-date Care Plans and Risk Assessments in a thorough and/or timely fashion, or at all;
(iii) inadequate communication with other primary and secondary care providers;
(iv) consistently, insufficient attention to the potential clinical significance of ‘disengagement’ with services by patients;
(v) failure to recognise the need to raise issues relating to a patient with the Multi-Disciplinary Team Meetings or in supervision with experienced supervisors.
” 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 and inadequate recording of Care Coordinator supervision sessions
Wider context from the report “(3) The evidence received in the course of Mr Moore's inquest disclosed that the record keeping of supervision sessions , where a Care Coordinator might seek or be provided with further advice and support from a senior colleague, was incomplete and 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 Insufficient attention to the clinical significance of patient disengagement from services
Wider context from the report “(2) The evidence in this case, and in other recent inquests heard by me and fellow coroners in this jurisdiction, establishes the following common themes in respect to the inadequate performance of several EPUT Care Coordinators. In my settled view, these themes are (at least to a significant degree) a consequence of inadequate training for the role:
(i) failure to maintain basic record keeping generally and, particularly, with respect to the recording of contacts or, potentially importantly, failed contacts with the deceased in the weeks and months prior to a self-inflicted death;
(ii) a failure to formally up-date Care Plans and Risk Assessments in a thorough and/or timely fashion, or at all;
(iii) inadequate communication with other primary and secondary care providers;
(iv) consistently, insufficient attention to the potential clinical significance of ‘disengagement’ with services by patients ;
(v) failure to recognise the need to raise issues relating to a patient with the Multi-Disciplinary Team Meetings or in supervision with experienced supervisors.
” 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 formal training for Care Coordinators
Wider context from the report “(1) EPUT Care Coordinators receive inadequate training for the role . Care Coordinators carry significant responsibilities to coordinate the care provided to an often extremely vulnerable cohort of patients. This responsibility was significantly heightened in the context of the Covid-19 pandemic, and the accompanying periods of ‘lockdown’, when vulnerable and often isolated sufferers of mental health illness and disorders, including those with substance misuse issues, became increasingly isolated and thus increasingly vulnerable. Notwithstanding the imposition of this additional responsibility, the evidence in this and similar coronial investigations has established that Care Coordinators receive no formal training for the role and, at best, are introduced to it via the ‘shadowing’ of colleagues ‘on the job’ . At inquest evidence was provided by an experienced (Band 8a) EPUT Clinical Manager that the lack of formal training for the pivotal role of Care Coordinator within EPUT is one that reflects the same practice in NHS Trusts across the country.
” 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 records of the nature, extent and duration of on-the-job or shadowing training
Wider context from the report “(4) A lack of formal (or even informal) records of the nature, extent or duration of ad hoc ‘on the job’/shadowing’ training , apparently provided to new Care Coordinators.
” 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 the MaST caseload-management tool through agreed pilot sites to support risk, disengagement, caseload, and record-keeping oversight.
Verbatim wording from the response “The Trust is in the process of gathering data in order to implement the Management and Supervision Tool (MaST) caseload management tool, which will help the care coordinator to” Source location Response from Essex Partnership NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor documentation timeliness and completeness through recording targets, supervised caseload reviews, and monthly performance reporting.
Verbatim wording from the response “The Trust accepts that it needs to improve record keeping and there are a number of methods in place to monitor and review the completion of timely and accurate documentation, which include:” Source location Response from Essex Partnership NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update the Disengagement Guideline to add Purple RAG identification and regular multidisciplinary discussion of disengaging patients.
Verbatim wording from the response “(iv) consistently, insufficient attention to the potential clinical significance of ‘disengagement’ with services by patients;” Source location Response from Essex Partnership NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver enhanced care-coordination training to all community mental-health staff and maintain it pending the new Community Framework.
Verbatim wording from the response “Current systems relating to CPA will remain in place until implementation of the new framework is agreed. In light of this, the Trust are delivering an enhanced care coordination training package as we recognise from recent incidents that whilst a person’s professional training and preceptorship equips them with the skills for care coordination, there is clearly a need for further support for staff in this area.” Source location Response from Essex Partnership NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide all care coordinators with additional guidance on undertaking and recording supervision.
Verbatim wording from the response “3. The evidence received in the course of Mr Moore’s inquest disclosed that the record keeping of supervision sessions, where a Care Coordinator might seek or be provided with further advice and support from a senior colleague, was incomplete and inadequate.” Source location Response from Essex Partnership NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deploy mental-health clinicians within Essex Primary Care Networks to improve communication between primary and secondary care providers.
Verbatim wording from the response “The Trust has identified mental health clinicians working within the Primary Care Networks across Essex which will increase the efficacy of communication between primary and secondary care providers. In addition to this, we have ensured that the importance of communication with other services and organisations forms a key part of the enhanced care coordinator training.” Source location Response from Essex Partnership NHS Trust
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 Not all patients require weekly MDT discussion; professional judgment, dynamic risk assessment and other discussion routes are considered sufficient.
Verbatim wording from the response “It is within a professional’s role to determine whether a patient’s care would need to be presented to the MDT meeting and this is based on clinical judgement. A care coordinator is a registered professional who would work within their code of conduct, which provides a clear framework for accountability and responsibility, and the Trust values. Care coordinators would have undertaken Trust induction and training in order to support their role and would be deemed to be equipped to independently make clinical decisions around presentation to MDT. Their decision would be based upon dynamic risk assessment of the patient, the therapeutic relationship they have with the patient and their family, and their identified needs. Not all patients on caseloads would require discussion at the weekly MDT meeting as there are other means of formulating discussions to meet the needs of the patient.” Source location Response from Essex Partnership NHS Trust
Open published response
14 Jan 2022 Jan Goodliffe · Prevention of Future Deaths report Essex
View report summary
Concerns raised 2 Failure to use medically qualified clinicians in home assessments View source Failure to seek qualified medical advice on medication interactions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Jan Goodliffe · 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
Jan Goodliffe died on 15 June 2021 several days after taking his own life, following a recent suicide attempt and a history of mental health problems. The report raises concerns that social workers, rather than medically qualified clinicians, assessed him despite information about his suicide risk and recent restart of medication, and that opportunities to obtain qualified medical advice may have been missed.
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 medically qualified clinicians in home assessments
Wider context from the report “That the Clinicians who attended to assess Mr Goodliffe where not medically qualified, they were social workers . They were presented with evidence around a serious attempt by Mr Goodliffe to take his own life that he had been doing by a family member. ████████ gave all this information at the assessment along with the recent reintroduction of the Bi Polar medication, and the facts of the previous reintroduction when starting this medication and the time taken for this medication to start to work. As they were unqualified medical practitioners, there were missed opportunities to seek qualified medical advice around the interactions of the medication and whether as a result of this contributed to his death.
I am concerned that suitably medically qualified clinicians are not being used in the home assessments and decisions are being made around issues that require medical expertise.
” 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 qualified medical advice on medication interactions
Wider context from the report “That the Clinicians who attended to assess Mr Goodliffe where not medically qualified, they were social workers. They were presented with evidence around a serious attempt by Mr Goodliffe to take his own life that he had been doing by a family member. ████████ gave all this information at the assessment along with the recent reintroduction of the Bi Polar medication, and the facts of the previous reintroduction when starting this medication and the time taken for this medication to start to work. As they were unqualified medical practitioners, there were missed opportunities to seek qualified medical advice around the interactions of the medication and whether as a result of this contributed to his death.
I am concerned that suitably medically qualified clinicians are not being used in the home assessments and decisions are being made around issues that require medical expertise .
” Open source report
17 Aug 2021 Steven Antonio Regoli · Prevention of Future Deaths report Essex
View report summary
Concerns raised 2 Failure to provide needed pathways and help to people who do not engage View source Lack of systems to prevent people who do not engage being left solely in family care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Steven Antonio Regoli · 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
Steven Antonio Regoli died on 26 June 2020 at a Lineside location adjacent to Gipsy Lane following a collision with a train. The report identifies concerns that opportunities for more appropriate help, including inpatient care, were not acted upon, and that there were no systems to support people who did not engage with services, leaving families to provide care alone.
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 provide needed pathways and help to people who do not engage
Wider context from the report “During the inquest, there were clear signs that Steven needed more in depth help as did his family, but due to him not engaging, which was a major part of his symptoms he was never given the pathway or help he needed and there were no systems in place for this to happen . There needs to be systems in place where people who do not engage are not left with family only to care 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 systems to prevent people who do not engage being left solely in family care
Wider context from the report “During the inquest, there were clear signs that Steven needed more in depth help as did his family, but due to him not engaging, which was a major part of his symptoms he was never given the pathway or help he needed and there were no systems in place for this to happen. There needs to be systems in place where people who do not engage are not left with family only to care for them .
” Open source report
28 Jun 2021 Fiona May Humberstone · Prevention of Future Deaths report Essex
View report summary
Concerns raised 3 Failure of primary and secondary care systems to provide timely access to definitive medication and concordance records View source Insufficient time for responsible clinicians to consider medical records before mental health reviews View source Reliance on patients’ accounts of current medication without routine verification View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Fiona May Humberstone · 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
Fiona May Humberstone, who had longstanding mental health conditions, alcohol misuse and chronic pain, died at home from an inadvertent overdose of prescribed Oromorph taken with other medication. The concerns included mental health clinicians relying solely on patients’ accounts of their medication and inadequate access to accurate, up-to-date prescribing information between primary and secondary care.
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 primary and secondary care systems to provide timely access to definitive medication and concordance records
Wider context from the report “(2) Further, oral evidence from a senior EPUT witness confirmed that the Trust could not, as electronic systems were presently configured, readily access information held by GP practices regarding individual patients (and vice versa) . It appeared that this evidence was provided by way of an explanation as to why accurate and up to date medication/prescribing information was not routinely obtained by clinicians in advance of reviews of patients. Absent any other system for ensuring swift and accurate information transfer between primary and secondary care providers , then the continuation of a state of affairs where a consultant psychiatrist is undertaking a review of a mental health patient but does not have access to a definitive record of the medication presently being taken by that patient (and/or their concordance with prescribed medication) gives rise to a conspicuous risk of future deaths. The EPUT witness suggested that this was a matter for the Clinical Commissioning Group (CCG) to address.
” 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 time for responsible clinicians to consider medical records before mental health reviews
Wider context from the report “(3) Issues regarding the necessity for access to (and adequate time for the consideration of) medical records including prescriptions and concordance with medication in advance of mental health reviews undertaken by responsible clinicians has been raised in relation to mental health related death in Essex previously. I am concerned that the evidence from FH’s inquest indicates that such matters remain unresolved .
” 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 patients’ accounts of current medication without routine verification
Wider context from the report “(1) In her statement provided for the purposes of the inquest, FH’s consultant psychiatrist listed the medications prescribed to FH at the time of her death but made no reference to the Oromorph. During the course of her oral evidence she confirmed that, at the time of her last review of FH in April 2020, she was entirely unaware that she had been prescribed this powerful morphine-based pain killer for a number of months. She also confirmed that had she known of the prescription for that medication it would have affected her risk assessment, given LH’s continuing misuse of alcohol. She told the court that it was (and remains) her usual practice to rely entirely on the information regarding medication (including dosage and frequency) provided by the patient, even in telephone only consultations. She stated that she would only rarely (and certainly not routinely) check the accuracy of the account provided by obtaining a list of medication from the GP or other clinical records.
Although not causative in respect of FH’s death, I am concerned that the practice of relying entirely on a patient’s account of current medication , in circumstances where significant mental health issues are often involved (including where there is chronic substance and/or alcohol misuse) gives rise to a serious risk of future deaths. As was accepted by the witness, any risk assessments, care plan reviews or further prescribing of (or alteration to) a medication regimen may in such circumstances be predicated upon incomplete, inaccurate and potentially dangerously misleading information . In my view the risk of future deaths is clear.
” Open source report
24 Nov 2020 Sharon Louise Kelly · Prevention of Future Deaths report Essex
View report summary
Concerns raised 5 Insufficiently clear communication lines and operating arrangements between EEAS and Essex Police for potential joint attendance at a risk-marked property View source Lack of sufficiently clear EEAS training on communicating relevant recorded information to ambulance crews for dynamic risk assessments View source Lack of sufficiently clear EEAS training on identifying relevant flag markers for appropriate police attendance at a property View source Lack of sufficiently clear Essex Police Comms Officer training on when a blue lights response should be mandated View source Failure to maintain adequate arrangements for convening an urgent MHS assessment with social services View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sharon Louise Kelly · 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
Sharon Louise Kelly, who had a long history of mental health and alcohol problems and frequent suicide attempts, informed a family member that she would kill herself on the anniversary of her baby son’s death. On 27 June 2019, an ambulance attended her property but did not enter while awaiting delayed police attendance; when services eventually entered, Ms Kelly was deceased. The concerns included delays and communication between ambulance and police services, risk assessment and police response procedures, and arrangements for urgent mental health assessments.
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 Insufficiently clear communication lines and operating arrangements between EEAS and Essex Police for potential joint attendance at a risk-marked property
Wider context from the report “Whether lines of communication and the modus operandi between EEAS and Essex Police are sufficiently clear in relation to a potential joint attendance at a property where there is a risk marker (given the delays on 27 June 2019)
” 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 sufficiently clear EEAS training on communicating relevant recorded information to ambulance crews for dynamic risk assessments
Wider context from the report “Whether there is sufficiently clear training at EEAS in relation to (1) identifying relevant flag markers to ensure police attendance at a property where appropriate and 2) communicating relevant information from relevant records to ambulance crews to ensure that dynamic risk assessments take place on the basis of all relevant information (in light of decision making and delays on 27 June 2019)
” 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 sufficiently clear EEAS training on identifying relevant flag markers for appropriate police attendance at a property
Wider context from the report “Whether there is sufficiently clear training at EEAS in relation to (1) identifying relevant flag markers to ensure police attendance at a property where appropriate and 2) communicating relevant information from relevant records to ambulance crews to ensure that dynamic risk assessments take place on the basis of all relevant information (in light of decision making and delays on 27 June 2019)
” 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 sufficiently clear Essex Police Comms Officer training on when a blue lights response should be mandated
Wider context from the report “Whether there is sufficient clarity in the training for Essex Police Comms Officers as to the circumstances in which a blue lights response should be mandated (in light of the evidence of Insp ████████ as to the response on 27 June 2019)
” 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 adequate arrangements for convening an urgent MHS assessment with social services
Wider context from the report “Whether EPUT can review its arrangements for convening an urgent MHS assessment, in conjunction with social services . (in light of the jury’s findings with regard to the MHA assessment in June 2019)
” 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 Require referrers to state identified risks explicitly in urgent Mental Health Act assessment referrals and accompanying telephone discussions.
Verbatim wording from the response “In response to your concern, the Trust’s Associate Director for Social Care and the ECC Service Manager for Mental Health have jointly reviewed the current processes and have identified the following actions to be implemented by the Trust:” Source location 2020-0250-Response-from-EPUT_Redacted.pdf
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 urgent Mental Health Act assessment referrals to include a telephone discussion between the referrer and the relevant out-of-hours service or AMHP hub.
Verbatim wording from the response “In response to your concern, the Trust’s Associate Director for Social Care and the ECC Service Manager for Mental Health have jointly reviewed the current processes and have identified the following actions to be implemented by the Trust:” Source location 2020-0250-Response-from-EPUT_Redacted.pdf
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 assessment timing with referrers and explicitly identify related risk or system issues to agree and mitigate risk management.
Verbatim wording from the response “In response to your concern, the Trust’s Associate Director for Social Care and the ECC Service Manager for Mental Health have jointly reviewed the current processes and have identified the following actions to be implemented by the Trust:” Source location 2020-0250-Response-from-EPUT_Redacted.pdf
Open published response
15 Oct 2020 THOMAS JEFFERY KING · Prevention of Future Deaths report Essex
View report summary
Concerns raised 1 Failure to enable relevant mental health teams to access and share important information View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
THOMAS JEFFERY KING · 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
Thomas Jeffery King was found hanging at his home on 28 April 2020, and his death was confirmed at the scene. The inquest concluded that he had intentionally ended his own life while experiencing very low mood and a history of poor mental health. The principal concern was that the Health and Justice Team used software that could not be accessed by other relevant mental health teams, meaning important information about crises and risks could be unavailable when assessing and managing a person.
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 enable relevant mental health teams to access and share important information
Wider context from the report “(1) It was the evidence of the author of the EPUT Root Cause Analysis Investigation Report, ████████, that whilst all the other EPUT teams that came into contact with Mr King, such as the Mental Health Liaison Team and the Street Triage Team, used the same software called Mobius with which to record, access and share important information and developments regarding Mr King, one Team, namely the Health and Justice Team did not use this software and instead used software that was incapable of being accessed by the other teams . A consequence of this was that the other teams were wholly unaware of crises and other important information regarding Mr King’s mental health that were known to the Health and Justice Team .
(2) Whilst it was the view of the RCA author that in Mr King’s case such an obstacle to the sharing / accessing of important information did not have a direct bearing on the outcome for Mr King, she did expressly state, and I share this concern, that there is the potential for the wellbeing and lives of other individuals to be jeopardised where important information and / or crises are known to and recorded by the Health and Justice Team but unknown to all the other relevant Teams. There is the potential for the risk of harm to self and others, including death, to be inaccurately assessed and managed where the assessor does not have access to the full picture.
(3) The RCA author was not aware as to why the Health and Justice Team had different software to Mobius or why it was not capable of integration with Mobius, but she felt, and I agree, that action should be taken, if it has not already happened, to explore this issue and to implement a solution.
” 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 Use the health information exchange to share information across organisations through the shared care record for Essex STPs.
Verbatim wording from the response “The Trust has been working on its strategy to ensure that patient data is accessible by clinicians no matter what system the data is collected on. To ensure this type of incident does not happen again, the Trust has implemented an interoperable application called Tiani Health Information Exchange (HIE) which ensures that a central data repository can be accessed by clinicians to view patient data from across systems. The HIE holds data for patients accessing EPUT services and will also be the tool used to share information across organisations as part of the shared care record for the three STP’s across Essex. All clinical staff in the Trust now have access to the HIE.” Source location 2020-0207-Response-from-EPUT_Redacted.pdf
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 interoperable health information exchange providing clinicians access to patient data across recording systems.
Verbatim wording from the response “The Trust has been working on its strategy to ensure that patient data is accessible by clinicians no matter what system the data is collected on. To ensure this type of incident does not happen again, the Trust has implemented an interoperable application called Tiani Health Information Exchange (HIE) which ensures that a central data repository can be accessed by clinicians to view patient data from across systems. The HIE holds data for patients accessing EPUT services and will also be the tool used to share information across organisations as part of the shared care record for the three STP’s across Essex. All clinical staff in the Trust now have access to the HIE.” Source location 2020-0207-Response-from-EPUT_Redacted.pdf
Open published response
24 Sep 2020 Zak Miles Joe Walter Paul Farmer · Prevention of Future Deaths report Essex
View report summary
Concerns raised 3 Lack of defined steps when a patient cannot be contacted View source Lack of clarity about the meaning of “urgent” referrals to the Access and Assessment Team View source Inadequacy of clinical guidelines for community mental health service users disengaging or non concordant with prescribed treatment plans View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Zak Miles Joe Walter Paul Farmer · 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
Zak Miles Joe Walter Paul Farmer, a 23-year-old man, died on 21 July 2019 after being found hanging. Concerns included a lack of clarity about the meaning of “urgent” referrals to the Access and Assessment Team and shortcomings in guidance for community mental health service users disengaging from prescribed treatment plans.
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 defined steps when a patient cannot be contacted
Wider context from the report “1. There appeared to be a lack of clarity over the meaning of the word “urgent” when a referral is made to the Access and Assessment Team and what steps will be taken if a patient cannot be contacted .
” 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 the meaning of “urgent” referrals to the Access and Assessment Team
Wider context from the report “1. There appeared to be a lack of clarity over the meaning of the word “urgent” when a referral is made to the Access and Assessment Team and what steps will be taken if a patient cannot be contacted.
” 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 clinical guidelines for community mental health service users disengaging or non concordant with prescribed treatment plans
Wider context from the report “2. The trust document Clinical Guidelines for Community Mental Health Service Users disengaging or non concordant with current prescribed treatment plans was found lacking and requires perfecting.
” 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 strengthen the Community Mental Health Service disengagement guideline to provide comprehensive, clear staff guidance.
Verbatim wording from the response “In response to the matter of concern regarding the EPUT Clinical Guidelines for Community Mental Health Service Users disengaging or non-concordant with current prescribed treatment” Source location 2020-0196-Response-from-EPUT_Redacted.pdf
Open published response
9 Aug 2018 Kelly Marie Campbell · Prevention of Future Deaths report Essex
View report summary
Concerns raised 2 Lack of stimulating and suitable physical surroundings in patient rooms View source Lack of rigorous policies governing clinical decisions to return patients’ shoe laces View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Kelly Marie Campbell · 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
Kelly Marie Campbell was a 17-year-old girl detained under section 3 of the Mental Health Act at Rochford Hospital. She was found hanging by a ligature made from shoe laces attached to a bathroom light fitting, and the inquest concluded that she killed herself. Concerns included the return of her shoe laces, the need for rigorous policies governing such decisions, and dreary physical surroundings that may have contributed to boredom during the night.
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 stimulating and suitable physical surroundings in patient rooms
Wider context from the report “(2) Kelly’s mother lamented the fact that the physical surroundings in the rooms were so dreary – she cited magnolia paint everywhere, no colourful pictures to brighten up the environment etc. She observed that the lack of mobiles, a clock etc. in the rooms led to boredom in the long night hours .
” 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 rigorous policies governing clinical decisions to return patients’ shoe laces
Wider context from the report “(1) The evidence revealed that some time previously Kelly’s shoe laces had been returned to her. The court accepts that this sort of decision is a clinical decision but wants to be assured that there are rigorous trust policies surrounding such decisions .
” Open source report
15 Feb 2018 Timothy John Shaw · Prevention of Future Deaths report Essex
View report summary
Concerns raised 7 Inadequate standard and accuracy of record keeping by disciplinary and healthcare staff View source Inadequate communication between healthcare and disciplinary staff about the purpose of Intelligence Reports View source Inadequate processes and systems for reducing access to illegal substances View source Lack of an appropriate audit system View source Lack of criteria and a system for Intelligence Reports View source Inadequate referral processes to psychosocial services View source Failure of healthcare staff to complete Intelligence Reports correctly View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Timothy John Shaw · 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
Timothy John Shaw, aged 34, was found collapsed in his prison cell on 28 February 2017 after apparent substance use and died in hospital on 2 March 2017. The report identified concerns about communication, intelligence reporting, access to illegal substances, referrals to psychosocial services, and record keeping.
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 standard and accuracy of record keeping by disciplinary and healthcare staff
Wider context from the report “The standard and accuracy of record keeping by both disciplinary and Healthcare staff needs to be improved.
” 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 communication between healthcare and disciplinary staff about the purpose of Intelligence Reports
Wider context from the report “Healthcare staff seemed unclear as to how to fill in an Intelligence Report. There needs to be better communication between Healthcare staff and disciplinary staff as to the purpose of an Intelligence Report. Some criteria need to be developed and a system in place. An appropriate audit system needs to be 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 Inadequate processes and systems for reducing access to illegal substances
Wider context from the report “The processes and systems for reducing access to illegal substances need to be improved and tightened up
” 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 an appropriate audit system
Wider context from the report “Healthcare staff seemed unclear as to how to fill in an Intelligence Report. There needs to be better communication between Healthcare staff and disciplinary staff as to the purpose of an Intelligence Report. Some criteria need to be developed and a system in place. An appropriate audit system needs to be 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 Lack of criteria and a system for Intelligence Reports
Wider context from the report “Healthcare staff seemed unclear as to how to fill in an Intelligence Report. There needs to be better communication between Healthcare staff and disciplinary staff as to the purpose of an Intelligence Report. Some criteria need to be developed and a system in place. An appropriate audit system needs to be 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 Inadequate referral processes to psychosocial services
Wider context from the report “The processes for referrals by both prisoners and staff to psychosocial services needs to be tightened up and improved.
” 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 healthcare staff to complete Intelligence Reports correctly
Wider context from the report “Healthcare staff seemed unclear as to how to fill in an Intelligence Report. There needs to be better communication between Healthcare staff and disciplinary staff as to the purpose of an Intelligence Report. Some criteria need to be developed and a system in place. An appropriate audit system needs to be in place.
” Open source report
20 Dec 2017 Craig David Royce · Prevention of Future Deaths report Essex
View report summary
Concerns raised 1 Lack of a reliable documentary system for communicating mental health referral information View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Craig David Royce · 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
Craig Royce, who had a history of mental health problems and epilepsy, was found hanging in his prison cell on 24 December 2016. The report identified concerns that a referral to mental health services following an incident of self-harm was not made and that there was no robust documentary system for communicating such referrals. The inquest jury also considered that his risk of self-harm or suicide was not properly reviewed with appropriate precautions taken.
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 reliable documentary system for communicating mental health referral information
Wider context from the report “There is no form/template to deal with the situation of a prisoner who needs to be referred to the mental health service. Reliance upon the transfer of this vital information to Healthcare by means of a telephone conversation could be unreliable. A robust, simple documentary system is required for the communication of such important information , namely that a prisoner needs to be referred to mental health services for an assessment to be carried out by mental health services. This would be distinct from the TAG system which caters for a brief assessment to be relayed across.
” 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 a prison-wide written mental-health referral system, requiring written follow-up after emergency telephone referrals and providing forms electronically and on all prison wings.
Verbatim wording from the response “In response to the matter of concern relating to the former provider of the prison healthcare service; I can confirm that since EPUT took over the service in 2017 a robust documentary system for referral of prisoners to mental health care has been put in place across the prison.” Source location 2017-0379-Response-Essex-Partnership-NHS-Trust
Open published response
14 Aug 2017 Terence Joseph Pimm · Prevention of Future Deaths report Essex
View report summary
Concerns raised 11 Insufficient guidance View source Insufficient coordination between the police, hospital Trust and probation service View source Failure of call handling at The Lakes View source Insufficient training View source Failure of mental health assessors to seek family input in appropriate circumstances View source Failure of police call handlers to assess whether an individual is objectively at immediate risk View source Failure of record-keeping at the police custody suite View source Failure of call handling at the police custody suite View source Failure of record-keeping at The Lakes View source Failure of mental health clinicians to understand the effect of warrants on their ability to assess and treat View source Insufficient information sharing between the police, hospital Trust and probation service View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Terence Joseph Pimm · 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
Terence Joseph Pimm died after leaping from the seventh floor of a car park on 26 August 2016, following recent threats to jump and contact with police, hospital and probation services. The substantive concerns included call handling and record-keeping, guidance and training, assessment of immediate risk, involvement of family members in mental health assessments, information sharing and coordination, and clinicians’ understanding of warrants.
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 guidance
Wider context from the report “3). The sufficiency of guidance and training.
” 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 coordination between the police, hospital Trust and probation service
Wider context from the report “6). The sufficiency of information sharing and coordination between the police, hospital Trust and probation service .
” 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 call handling at The Lakes
Wider context from the report “1). Call handling and record-keeping at The Lakes
” 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 training
Wider context from the report “3). The sufficiency of guidance and training.
” 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 assessors to seek family input in appropriate circumstances
Wider context from the report “5). To mental health assessors as to the circumstances in which the input of family Members should be sought .
” 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 police call handlers to assess whether an individual is objectively at immediate risk
Wider context from the report “4). To police call handlers as to whether an individual is, objectively, at an “immediate” risk .
” 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 record-keeping at the police custody suite
Wider context from the report “2). Call handling and record-keeping at the police custody suite
” 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 call handling at the police custody suite
Wider context from the report “2). Call handling and record-keeping at the police custody suite
” 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 record-keeping at The Lakes
Wider context from the report “1). Call handling and record-keeping at The Lakes
” 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 clinicians to understand the effect of warrants on their ability to assess and treat
Wider context from the report “7). Training/guidance for mental health clinicians in relation to persons who are subject to a warrant . The evidence pointed to a lack of understanding as to the effect of a warrant upon the clinician’s ability to assess and treat .
” 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 information sharing between the police, hospital Trust and probation service
Wider context from the report “6). The sufficiency of information sharing and coordination between the police, hospital Trust and probation service.
” 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 Operate a street-triage team pairing mental health practitioners with dedicated police officers.
Verbatim wording from the response “The new Trust has launched a new street-triage team in which mental health practitioners work together with dedicated police officers. We anticipate that this initiative will also help significantly to improve information-sharing and coordination between our services.” Source location 2017-0217-Response-by-Essex-Partnership-University-NHS-Trust_Redacted
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 training on the warrant-related flowchart to mental health accident and emergency and criminal justice teams.
Verbatim wording from the response “A new flowchart is in place now for staff, which details clearly which actions to take in situations where people are subject to a warrant. Training on this is underway for all our staff working in mental health accident and emergency teams and mental health criminal justice teams.” Source location 2017-0217-Response-by-Essex-Partnership-University-NHS-Trust_Redacted
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 electronic record-keeping processes for health-based place-of-safety information.
Verbatim wording from the response “All patients admitted to health-based places of safety have individual patient records detailing potential risks, assessment of presentation and copies of documentation from other agencies. Further work is continuing on electronic record-keeping processes in regard to this issue.” Source location 2017-0217-Response-by-Essex-Partnership-University-NHS-Trust_Redacted
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 family involvement and communications through the staff supervision process.
Verbatim wording from the response “The new Trust has taken steps to reinforce to staff the importance of family involvement and ongoing communications. A detailed debrief in this respect was undertaken with the staff involved in Mr Pimm’s care. Additionally, audits on this issue are being undertaken via the new Trust’s staff supervision process.” Source location 2017-0217-Response-by-Essex-Partnership-University-NHS-Trust_Redacted
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 to staff the importance of family involvement and ongoing communications.
Verbatim wording from the response “The new Trust has taken steps to reinforce to staff the importance of family involvement and ongoing communications. A detailed debrief in this respect was undertaken with the staff involved in Mr Pimm’s care. Additionally, audits on this issue are being undertaken via the new Trust’s staff supervision process.” Source location 2017-0217-Response-by-Essex-Partnership-University-NHS-Trust_Redacted
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 the probation service is invited to local police liaison emergency care meetings to improve information sharing.
Verbatim wording from the response “The information-sharing concordat has been reinforced. Additionally, the new Trust holds localised police liaison emergency care meetings and will ensure that the probation service is invited to improve information sharing in this regard.” Source location 2017-0217-Response-by-Essex-Partnership-University-NHS-Trust_Redacted
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 staff with a flowchart specifying actions for situations involving people subject to a warrant.
Verbatim wording from the response “A new flowchart is in place now for staff, which details clearly which actions to take in situations where people are subject to a warrant. Training on this is underway for all our staff working in mental health accident and emergency teams and mental health criminal justice teams.” Source location 2017-0217-Response-by-Essex-Partnership-University-NHS-Trust_Redacted
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 the information-sharing concordat between police, hospital and probation services.
Verbatim wording from the response “The information-sharing concordat has been reinforced. Additionally, the new Trust holds localised police liaison emergency care meetings and will ensure that the probation service is invited to improve information sharing in this regard.” Source location 2017-0217-Response-by-Essex-Partnership-University-NHS-Trust_Redacted
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 all health-based place-of-safety calls through the Trust call centre for recording and call-log documentation by trained handlers.
Verbatim wording from the response “All health-based place of safety calls are directed now through the new Trust’s call centre. This means that all calls are recorded and documented on a call-log by trained call-handlers.” Source location 2017-0217-Response-by-Essex-Partnership-University-NHS-Trust_Redacted
Open published response
Concerns raised 8 Failure to provide timely assessment and treatment when transfer between teams is necessary View source Delays in granting urgent psychiatric assessments View source Inadequate assessment of patients’ risk of suicide View source Failure to assign clear responsibility for coordinating and delivering care before discharge View source Failure to put care plans in place before discharge View source Prescription recommendations without psychiatrist assessment of the patient View source Failure to manage identified suicide risk View source Failure to provide means of monitoring psychiatric medication effectiveness View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Charlotte Anne Agnew · 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
Charlotte Anne Agnew became psychiatrically unwell and expressed suicidal ideation. After referrals to psychiatric services, her care was not effectively transferred, her suicide risk was not sufficiently assessed or managed, and no care plan was put in place; she died on 25 March 2016 after ingesting high levels of alcohol and medication and jumping in front of a London Underground train. The report identified an ongoing risk that similar failures in timely assessment, treatment, care transfer and suicide-risk management could recur.
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 provide timely assessment and treatment when transfer between teams is necessary
Wider context from the report “It was apparent from the evidence that there were five principal failures by the Trust in relation to the treatment and care provided to the Deceased. These were:
(1) The Deceased was first assessed by the Trust’s Early Intervention and Assertive Psychosis Team who recognised that she was in need of psychiatric treatment and care by another team but, despite referring her on to other psychiatric teams within the Trust, made no effective transfer of her care before discharging her back to her General Practitioner and closing her case . A significant number of clinical and managerial staff were involved in this process and none of them prevented the Deceased’s premature discharge.
(2) Prior to the Deceased’s discharge no sufficient assessment was made of her risk of suicide. Despite at least two clinical staff being involved, there was insufficient evidence gathering, including from the Deceased’s family, and a wholly inadequate assessment was made despite the use of the Trust’s electronic assessment tool (which was not properly completed). Further, no plan was put in place to manage the Deceased’s recognised risk of suicide.
(3) Prior to the Deceased’s discharge no care plan was put in place and no single person had responsibility for ensuring care was properly assessed, co-ordinated and delivered prior to discharge.
(4) The Deceased was discharged back to the care of her General Practitioner with a recommendation for the prescription of psychiatric medication without her having been seen or assessed by the psychiatrist who made the recommendation and with no means of monitoring its subsequent effectiveness.
(5) Despite the matters set out in (1) to (4), the General Practitioner’s request, made on 15 March 2016, for an urgent assessment was not granted and the Trust’s Access and Assessment Team provided an appointment for a date five weeks later on 20 April 2016.
I was told by witnesses from the Trust (and in submissions made on behalf of the Trust) that the Trust had adequate relevant policies and procedures in place at the time and that the failings set out above occurred because all the staff involved failed to follow those policies and procedures. It was said that there had been no subsequent amendment of the policies and procedures but, in summary, that staff have been reminded of them and what ought to happen (by email) and there is now an increased level of monitoring of compliance.
Whilst the staff directly involved, who gave oral evidence at the inquest, told me that they now understand that the above failings ought not to have happened and would not occur now, I remain concerned that one or more of the above failings could recur in the future. Although the Trust has taken steps to inform current staff of what went wrong in the Deceased’s case, it has not taken steps to ensure that the above failings could not occur again (whether by amendment or clarification of its policies and/or procedures or sufficient training of staff or otherwise).
Most particularly, the evidence provided to me did not satisfy me that the Trust’s policies and procedures, and the training given upon them, now ensure that every patient who is referred to the Trust will be assessed and treated in a timely manner, even if transfer between teams is necessary . Nor did it satisfy me that every patient’s risk of suicide is now properly assessed and managed so as to ensure the risk is minimised.
In all the circumstances I consider that there is an ongoing risk that any one or more of the above failings could recur. If that risk is permitted to continue, it could have an adverse impact on the assessment, treatment and care of current and future patients and upon the protection of their lives.
” 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 granting urgent psychiatric assessments
Wider context from the report “It was apparent from the evidence that there were five principal failures by the Trust in relation to the treatment and care provided to the Deceased. These were:
(1) The Deceased was first assessed by the Trust’s Early Intervention and Assertive Psychosis Team who recognised that she was in need of psychiatric treatment and care by another team but, despite referring her on to other psychiatric teams within the Trust, made no effective transfer of her care before discharging her back to her General Practitioner and closing her case. A significant number of clinical and managerial staff were involved in this process and none of them prevented the Deceased’s premature discharge.
(2) Prior to the Deceased’s discharge no sufficient assessment was made of her risk of suicide. Despite at least two clinical staff being involved, there was insufficient evidence gathering, including from the Deceased’s family, and a wholly inadequate assessment was made despite the use of the Trust’s electronic assessment tool (which was not properly completed). Further, no plan was put in place to manage the Deceased’s recognised risk of suicide.
(3) Prior to the Deceased’s discharge no care plan was put in place and no single person had responsibility for ensuring care was properly assessed, co-ordinated and delivered prior to discharge.
(4) The Deceased was discharged back to the care of her General Practitioner with a recommendation for the prescription of psychiatric medication without her having been seen or assessed by the psychiatrist who made the recommendation and with no means of monitoring its subsequent effectiveness.
(5) Despite the matters set out in (1) to (4), the General Practitioner’s request, made on 15 March 2016, for an urgent assessment was not granted and the Trust’s Access and Assessment Team provided an appointment for a date five weeks later on 20 April 2016.
I was told by witnesses from the Trust (and in submissions made on behalf of the Trust) that the Trust had adequate relevant policies and procedures in place at the time and that the failings set out above occurred because all the staff involved failed to follow those policies and procedures. It was said that there had been no subsequent amendment of the policies and procedures but, in summary, that staff have been reminded of them and what ought to happen (by email) and there is now an increased level of monitoring of compliance.
Whilst the staff directly involved, who gave oral evidence at the inquest, told me that they now understand that the above failings ought not to have happened and would not occur now, I remain concerned that one or more of the above failings could recur in the future. Although the Trust has taken steps to inform current staff of what went wrong in the Deceased’s case, it has not taken steps to ensure that the above failings could not occur again (whether by amendment or clarification of its policies and/or procedures or sufficient training of staff or otherwise).
Most particularly, the evidence provided to me did not satisfy me that the Trust’s policies and procedures, and the training given upon them, now ensure that every patient who is referred to the Trust will be assessed and treated in a timely manner, even if transfer between teams is necessary. Nor did it satisfy me that every patient’s risk of suicide is now properly assessed and managed so as to ensure the risk is minimised.
In all the circumstances I consider that there is an ongoing risk that any one or more of the above failings could recur. If that risk is permitted to continue, it could have an adverse impact on the assessment, treatment and care of current and future patients and upon the protection of their lives.
” 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 assessment of patients’ risk of suicide
Wider context from the report “It was apparent from the evidence that there were five principal failures by the Trust in relation to the treatment and care provided to the Deceased. These were:
(1) The Deceased was first assessed by the Trust’s Early Intervention and Assertive Psychosis Team who recognised that she was in need of psychiatric treatment and care by another team but, despite referring her on to other psychiatric teams within the Trust, made no effective transfer of her care before discharging her back to her General Practitioner and closing her case. A significant number of clinical and managerial staff were involved in this process and none of them prevented the Deceased’s premature discharge.
(2) Prior to the Deceased’s discharge no sufficient assessment was made of her risk of suicide . Despite at least two clinical staff being involved, there was insufficient evidence gathering, including from the Deceased’s family, and a wholly inadequate assessment was made despite the use of the Trust’s electronic assessment tool (which was not properly completed). Further, no plan was put in place to manage the Deceased’s recognised risk of suicide.
(3) Prior to the Deceased’s discharge no care plan was put in place and no single person had responsibility for ensuring care was properly assessed, co-ordinated and delivered prior to discharge.
(4) The Deceased was discharged back to the care of her General Practitioner with a recommendation for the prescription of psychiatric medication without her having been seen or assessed by the psychiatrist who made the recommendation and with no means of monitoring its subsequent effectiveness.
(5) Despite the matters set out in (1) to (4), the General Practitioner’s request, made on 15 March 2016, for an urgent assessment was not granted and the Trust’s Access and Assessment Team provided an appointment for a date five weeks later on 20 April 2016.
I was told by witnesses from the Trust (and in submissions made on behalf of the Trust) that the Trust had adequate relevant policies and procedures in place at the time and that the failings set out above occurred because all the staff involved failed to follow those policies and procedures. It was said that there had been no subsequent amendment of the policies and procedures but, in summary, that staff have been reminded of them and what ought to happen (by email) and there is now an increased level of monitoring of compliance.
Whilst the staff directly involved, who gave oral evidence at the inquest, told me that they now understand that the above failings ought not to have happened and would not occur now, I remain concerned that one or more of the above failings could recur in the future. Although the Trust has taken steps to inform current staff of what went wrong in the Deceased’s case, it has not taken steps to ensure that the above failings could not occur again (whether by amendment or clarification of its policies and/or procedures or sufficient training of staff or otherwise).
Most particularly, the evidence provided to me did not satisfy me that the Trust’s policies and procedures, and the training given upon them, now ensure that every patient who is referred to the Trust will be assessed and treated in a timely manner, even if transfer between teams is necessary. Nor did it satisfy me that every patient’s risk of suicide is now properly assessed and managed so as to ensure the risk is minimised.
In all the circumstances I consider that there is an ongoing risk that any one or more of the above failings could recur. If that risk is permitted to continue, it could have an adverse impact on the assessment, treatment and care of current and future patients and upon the protection of their lives.
” 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 assign clear responsibility for coordinating and delivering care before discharge
Wider context from the report “It was apparent from the evidence that there were five principal failures by the Trust in relation to the treatment and care provided to the Deceased. These were:
(1) The Deceased was first assessed by the Trust’s Early Intervention and Assertive Psychosis Team who recognised that she was in need of psychiatric treatment and care by another team but, despite referring her on to other psychiatric teams within the Trust, made no effective transfer of her care before discharging her back to her General Practitioner and closing her case. A significant number of clinical and managerial staff were involved in this process and none of them prevented the Deceased’s premature discharge.
(2) Prior to the Deceased’s discharge no sufficient assessment was made of her risk of suicide. Despite at least two clinical staff being involved, there was insufficient evidence gathering, including from the Deceased’s family, and a wholly inadequate assessment was made despite the use of the Trust’s electronic assessment tool (which was not properly completed). Further, no plan was put in place to manage the Deceased’s recognised risk of suicide.
(3) Prior to the Deceased’s discharge no care plan was put in place and no single person had responsibility for ensuring care was properly assessed, co-ordinated and delivered prior to discharge .
(4) The Deceased was discharged back to the care of her General Practitioner with a recommendation for the prescription of psychiatric medication without her having been seen or assessed by the psychiatrist who made the recommendation and with no means of monitoring its subsequent effectiveness.
(5) Despite the matters set out in (1) to (4), the General Practitioner’s request, made on 15 March 2016, for an urgent assessment was not granted and the Trust’s Access and Assessment Team provided an appointment for a date five weeks later on 20 April 2016.
I was told by witnesses from the Trust (and in submissions made on behalf of the Trust) that the Trust had adequate relevant policies and procedures in place at the time and that the failings set out above occurred because all the staff involved failed to follow those policies and procedures. It was said that there had been no subsequent amendment of the policies and procedures but, in summary, that staff have been reminded of them and what ought to happen (by email) and there is now an increased level of monitoring of compliance.
Whilst the staff directly involved, who gave oral evidence at the inquest, told me that they now understand that the above failings ought not to have happened and would not occur now, I remain concerned that one or more of the above failings could recur in the future. Although the Trust has taken steps to inform current staff of what went wrong in the Deceased’s case, it has not taken steps to ensure that the above failings could not occur again (whether by amendment or clarification of its policies and/or procedures or sufficient training of staff or otherwise).
Most particularly, the evidence provided to me did not satisfy me that the Trust’s policies and procedures, and the training given upon them, now ensure that every patient who is referred to the Trust will be assessed and treated in a timely manner, even if transfer between teams is necessary. Nor did it satisfy me that every patient’s risk of suicide is now properly assessed and managed so as to ensure the risk is minimised.
In all the circumstances I consider that there is an ongoing risk that any one or more of the above failings could recur. If that risk is permitted to continue, it could have an adverse impact on the assessment, treatment and care of current and future patients and upon the protection of their lives.
” 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 put care plans in place before discharge
Wider context from the report “It was apparent from the evidence that there were five principal failures by the Trust in relation to the treatment and care provided to the Deceased. These were:
(1) The Deceased was first assessed by the Trust’s Early Intervention and Assertive Psychosis Team who recognised that she was in need of psychiatric treatment and care by another team but, despite referring her on to other psychiatric teams within the Trust, made no effective transfer of her care before discharging her back to her General Practitioner and closing her case. A significant number of clinical and managerial staff were involved in this process and none of them prevented the Deceased’s premature discharge.
(2) Prior to the Deceased’s discharge no sufficient assessment was made of her risk of suicide. Despite at least two clinical staff being involved, there was insufficient evidence gathering, including from the Deceased’s family, and a wholly inadequate assessment was made despite the use of the Trust’s electronic assessment tool (which was not properly completed). Further, no plan was put in place to manage the Deceased’s recognised risk of suicide.
(3) Prior to the Deceased’s discharge no care plan was put in place and no single person had responsibility for ensuring care was properly assessed, co-ordinated and delivered prior to discharge.
(4) The Deceased was discharged back to the care of her General Practitioner with a recommendation for the prescription of psychiatric medication without her having been seen or assessed by the psychiatrist who made the recommendation and with no means of monitoring its subsequent effectiveness.
(5) Despite the matters set out in (1) to (4), the General Practitioner’s request, made on 15 March 2016, for an urgent assessment was not granted and the Trust’s Access and Assessment Team provided an appointment for a date five weeks later on 20 April 2016.
I was told by witnesses from the Trust (and in submissions made on behalf of the Trust) that the Trust had adequate relevant policies and procedures in place at the time and that the failings set out above occurred because all the staff involved failed to follow those policies and procedures. It was said that there had been no subsequent amendment of the policies and procedures but, in summary, that staff have been reminded of them and what ought to happen (by email) and there is now an increased level of monitoring of compliance.
Whilst the staff directly involved, who gave oral evidence at the inquest, told me that they now understand that the above failings ought not to have happened and would not occur now, I remain concerned that one or more of the above failings could recur in the future. Although the Trust has taken steps to inform current staff of what went wrong in the Deceased’s case, it has not taken steps to ensure that the above failings could not occur again (whether by amendment or clarification of its policies and/or procedures or sufficient training of staff or otherwise).
Most particularly, the evidence provided to me did not satisfy me that the Trust’s policies and procedures, and the training given upon them, now ensure that every patient who is referred to the Trust will be assessed and treated in a timely manner, even if transfer between teams is necessary. Nor did it satisfy me that every patient’s risk of suicide is now properly assessed and managed so as to ensure the risk is minimised.
In all the circumstances I consider that there is an ongoing risk that any one or more of the above failings could recur. If that risk is permitted to continue, it could have an adverse impact on the assessment, treatment and care of current and future patients and upon the protection of their lives.
” 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 Prescription recommendations without psychiatrist assessment of the patient
Wider context from the report “It was apparent from the evidence that there were five principal failures by the Trust in relation to the treatment and care provided to the Deceased. These were:
(1) The Deceased was first assessed by the Trust’s Early Intervention and Assertive Psychosis Team who recognised that she was in need of psychiatric treatment and care by another team but, despite referring her on to other psychiatric teams within the Trust, made no effective transfer of her care before discharging her back to her General Practitioner and closing her case. A significant number of clinical and managerial staff were involved in this process and none of them prevented the Deceased’s premature discharge.
(2) Prior to the Deceased’s discharge no sufficient assessment was made of her risk of suicide. Despite at least two clinical staff being involved, there was insufficient evidence gathering, including from the Deceased’s family, and a wholly inadequate assessment was made despite the use of the Trust’s electronic assessment tool (which was not properly completed). Further, no plan was put in place to manage the Deceased’s recognised risk of suicide.
(3) Prior to the Deceased’s discharge no care plan was put in place and no single person had responsibility for ensuring care was properly assessed, co-ordinated and delivered prior to discharge.
(4) The Deceased was discharged back to the care of her General Practitioner with a recommendation for the prescription of psychiatric medication without her having been seen or assessed by the psychiatrist who made the recommendation and with no means of monitoring its subsequent effectiveness.
(5) Despite the matters set out in (1) to (4), the General Practitioner’s request, made on 15 March 2016, for an urgent assessment was not granted and the Trust’s Access and Assessment Team provided an appointment for a date five weeks later on 20 April 2016.
I was told by witnesses from the Trust (and in submissions made on behalf of the Trust) that the Trust had adequate relevant policies and procedures in place at the time and that the failings set out above occurred because all the staff involved failed to follow those policies and procedures. It was said that there had been no subsequent amendment of the policies and procedures but, in summary, that staff have been reminded of them and what ought to happen (by email) and there is now an increased level of monitoring of compliance.
Whilst the staff directly involved, who gave oral evidence at the inquest, told me that they now understand that the above failings ought not to have happened and would not occur now, I remain concerned that one or more of the above failings could recur in the future. Although the Trust has taken steps to inform current staff of what went wrong in the Deceased’s case, it has not taken steps to ensure that the above failings could not occur again (whether by amendment or clarification of its policies and/or procedures or sufficient training of staff or otherwise).
Most particularly, the evidence provided to me did not satisfy me that the Trust’s policies and procedures, and the training given upon them, now ensure that every patient who is referred to the Trust will be assessed and treated in a timely manner, even if transfer between teams is necessary. Nor did it satisfy me that every patient’s risk of suicide is now properly assessed and managed so as to ensure the risk is minimised.
In all the circumstances I consider that there is an ongoing risk that any one or more of the above failings could recur. If that risk is permitted to continue, it could have an adverse impact on the assessment, treatment and care of current and future patients and upon the protection of their lives.
” 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 manage identified suicide risk
Wider context from the report “It was apparent from the evidence that there were five principal failures by the Trust in relation to the treatment and care provided to the Deceased. These were:
(1) The Deceased was first assessed by the Trust’s Early Intervention and Assertive Psychosis Team who recognised that she was in need of psychiatric treatment and care by another team but, despite referring her on to other psychiatric teams within the Trust, made no effective transfer of her care before discharging her back to her General Practitioner and closing her case. A significant number of clinical and managerial staff were involved in this process and none of them prevented the Deceased’s premature discharge.
(2) Prior to the Deceased’s discharge no sufficient assessment was made of her risk of suicide. Despite at least two clinical staff being involved, there was insufficient evidence gathering, including from the Deceased’s family, and a wholly inadequate assessment was made despite the use of the Trust’s electronic assessment tool (which was not properly completed). Further, no plan was put in place to manage the Deceased’s recognised risk of suicide .
(3) Prior to the Deceased’s discharge no care plan was put in place and no single person had responsibility for ensuring care was properly assessed, co-ordinated and delivered prior to discharge.
(4) The Deceased was discharged back to the care of her General Practitioner with a recommendation for the prescription of psychiatric medication without her having been seen or assessed by the psychiatrist who made the recommendation and with no means of monitoring its subsequent effectiveness.
(5) Despite the matters set out in (1) to (4), the General Practitioner’s request, made on 15 March 2016, for an urgent assessment was not granted and the Trust’s Access and Assessment Team provided an appointment for a date five weeks later on 20 April 2016.
I was told by witnesses from the Trust (and in submissions made on behalf of the Trust) that the Trust had adequate relevant policies and procedures in place at the time and that the failings set out above occurred because all the staff involved failed to follow those policies and procedures. It was said that there had been no subsequent amendment of the policies and procedures but, in summary, that staff have been reminded of them and what ought to happen (by email) and there is now an increased level of monitoring of compliance.
Whilst the staff directly involved, who gave oral evidence at the inquest, told me that they now understand that the above failings ought not to have happened and would not occur now, I remain concerned that one or more of the above failings could recur in the future. Although the Trust has taken steps to inform current staff of what went wrong in the Deceased’s case, it has not taken steps to ensure that the above failings could not occur again (whether by amendment or clarification of its policies and/or procedures or sufficient training of staff or otherwise).
Most particularly, the evidence provided to me did not satisfy me that the Trust’s policies and procedures, and the training given upon them, now ensure that every patient who is referred to the Trust will be assessed and treated in a timely manner, even if transfer between teams is necessary. Nor did it satisfy me that every patient’s risk of suicide is now properly assessed and managed so as to ensure the risk is minimised .
In all the circumstances I consider that there is an ongoing risk that any one or more of the above failings could recur. If that risk is permitted to continue, it could have an adverse impact on the assessment, treatment and care of current and future patients and upon the protection of their lives.
” 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 means of monitoring psychiatric medication effectiveness
Wider context from the report “It was apparent from the evidence that there were five principal failures by the Trust in relation to the treatment and care provided to the Deceased. These were:
(1) The Deceased was first assessed by the Trust’s Early Intervention and Assertive Psychosis Team who recognised that she was in need of psychiatric treatment and care by another team but, despite referring her on to other psychiatric teams within the Trust, made no effective transfer of her care before discharging her back to her General Practitioner and closing her case. A significant number of clinical and managerial staff were involved in this process and none of them prevented the Deceased’s premature discharge.
(2) Prior to the Deceased’s discharge no sufficient assessment was made of her risk of suicide. Despite at least two clinical staff being involved, there was insufficient evidence gathering, including from the Deceased’s family, and a wholly inadequate assessment was made despite the use of the Trust’s electronic assessment tool (which was not properly completed). Further, no plan was put in place to manage the Deceased’s recognised risk of suicide.
(3) Prior to the Deceased’s discharge no care plan was put in place and no single person had responsibility for ensuring care was properly assessed, co-ordinated and delivered prior to discharge.
(4) The Deceased was discharged back to the care of her General Practitioner with a recommendation for the prescription of psychiatric medication without her having been seen or assessed by the psychiatrist who made the recommendation and with no means of monitoring its subsequent effectiveness .
(5) Despite the matters set out in (1) to (4), the General Practitioner’s request, made on 15 March 2016, for an urgent assessment was not granted and the Trust’s Access and Assessment Team provided an appointment for a date five weeks later on 20 April 2016.
I was told by witnesses from the Trust (and in submissions made on behalf of the Trust) that the Trust had adequate relevant policies and procedures in place at the time and that the failings set out above occurred because all the staff involved failed to follow those policies and procedures. It was said that there had been no subsequent amendment of the policies and procedures but, in summary, that staff have been reminded of them and what ought to happen (by email) and there is now an increased level of monitoring of compliance.
Whilst the staff directly involved, who gave oral evidence at the inquest, told me that they now understand that the above failings ought not to have happened and would not occur now, I remain concerned that one or more of the above failings could recur in the future. Although the Trust has taken steps to inform current staff of what went wrong in the Deceased’s case, it has not taken steps to ensure that the above failings could not occur again (whether by amendment or clarification of its policies and/or procedures or sufficient training of staff or otherwise).
Most particularly, the evidence provided to me did not satisfy me that the Trust’s policies and procedures, and the training given upon them, now ensure that every patient who is referred to the Trust will be assessed and treated in a timely manner, even if transfer between teams is necessary. Nor did it satisfy me that every patient’s risk of suicide is now properly assessed and managed so as to ensure the risk is minimised.
In all the circumstances I consider that there is an ongoing risk that any one or more of the above failings could recur. If that risk is permitted to continue, it could have an adverse impact on the assessment, treatment and care of current and future patients and upon the protection of their lives.
” Open source report
Concerns raised 8 Failure of the admissions protocol to allow transfer of mentally disordered people from police custody View source Failure to meaningfully involve families in the ACCT process View source Insufficient resilience of psychiatric cover at Chelmsford prison View source Failure to provide effective ACCT process training View source Lack of a written record of the forensic pathway View source Failure to formally record concerns raised by a prisoner’s family View source Failure to communicate concerns raised by a prisoner’s family View source Lack of clarity in the hospital transfer process View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Dean Gary Saunders · 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
Dean Gary Saunders was found unresponsive in his cell at HM Prison Chelmsford on 4 January 2016, and his death was confirmed as electrocution. The inquest identified serious failings in mental health assessment and care, the prison transfer pathway, ACCT assessments and observations, record-keeping and communication, clinical leadership, and family involvement.
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 admissions protocol to allow transfer of mentally disordered people from police custody
Wider context from the report “1. FOR SEPT:- The admitted lacuna in the SEPT admissions protocol governing the transfer of mentally disordered people from police custody . The current admissions protocol does not allow for the transfer of any individual from police custody , irrespective of the criminal charges the individual is facing.
” 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 meaningfully involve families in the ACCT process
Wider context from the report “6. FOR NOMS:- The meaningful involvement of families in the ACCT process , including by ensuring the formal recording, and communication of concerns raised by a prisoner’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 Insufficient resilience of psychiatric cover at Chelmsford prison
Wider context from the report “5. FOR NHS ENGLAND:- The resilience of psychiatric cover at Chelmsford prison , which would need to be raised with NHS England who commission such services and decide on the budget.
” 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 effective ACCT process training
Wider context from the report “4. FOR NOMS:- Training regarding the ACCT process . In previous prison deaths and in response to previous PPO reports, promises have been made about training having been provided to staff yet the same mistakes are being repeated . Meaningful action in required in this regard.
” 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 written record of the forensic pathway
Wider context from the report “2. FOR SEPT AND NHS ENGLAND:- The absence of a written record of the “best practice” forensic pathway referred to by ████████ in his evidence, and consideration of whether the transfer of individuals such as Dean to prison is indeed “best practice”, taking into account the consequent delay in transfer and the suitability of the prison environment for mentally disordered individuals.
” 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 formally record concerns raised by a prisoner’s family
Wider context from the report “6. FOR NOMS:- The meaningful involvement of families in the ACCT process, including by ensuring the formal recording , and communication of concerns raised by a prisoner’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 concerns raised by a prisoner’s family
Wider context from the report “6. FOR NOMS:- The meaningful involvement of families in the ACCT process, including by ensuring the formal recording, and communication of concerns raised by a prisoner’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 Lack of clarity in the hospital transfer process
Wider context from the report “3. FOR CARE UK, NOMS, SEPT:- The lack of clarity regarding the hospital transfer process . The evidence at the inquest demonstrated that this is currently shrouded in confusion and contradiction (if the PSI and the NHS England “good practice” is compared). Given that rationalisation of the process is still a “work in progress”, the family consider that it should be given urgent consideration.
” 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 Submit the admissions protocol for regional review.
Verbatim wording from the response “Although the admissions protocol used by the Trust is an all-inclusive one and does not exclude any scenario (provided that the individual has been detained under the Mental Health Act 1983) the Trust has submitted the protocol for regional review by the Secure Services Catchment Group for East of England and will ensure you are informed of the outcome.” Source location 2017-0056-Response-by-Essex-Partnership-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss hospital transfer arrangements with NHS England.
Verbatim wording from the response “The Trust has been in discussion with NHS England, as the commissioners of the service, on the hospital transfer issue and understands that the commissioners are taking this forward with Care UK as the providers of the healthcare service and with NOMS.” Source location 2017-0056-Response-by-Essex-Partnership-NHS-Trust
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 existing admissions protocol covers all scenarios involving individuals detained under the Mental Health Act 1983.
Verbatim wording from the response “Although the admissions protocol used by the Trust is an all-inclusive one and does not exclude any scenario (provided that the individual has been detained under the Mental Health Act 1983) the Trust has submitted the protocol for regional review by the Secure Services Catchment Group for East of England and will ensure you are informed of the outcome.” Source location 2017-0056-Response-by-Essex-Partnership-NHS-Trust
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 commissioners are taking forward the hospital transfer issue with Care UK and NOMS.
Verbatim wording from the response “The Trust has been in discussion with NHS England, as the commissioners of the service, on the hospital transfer issue and understands that the commissioners are taking this forward with Care UK as the providers of the healthcare service and with NOMS.” Source location 2017-0056-Response-by-Essex-Partnership-NHS-Trust
Open published response
Concerns raised 2 Failure to appropriately treat pressure ulcers in elderly people in the community View source Insufficient Tissue Viability Nurse staffing in community and hospital settings View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Jean Marjorie McHALE · 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
Jean Marjorie McHALE was admitted to hospital in July 2016 with confusion, fever, poor general health and two Grade 4 pressure sores. The inquest concluded that she died from sepsis from infected pressure ulcers. Concerns included inadequate treatment of pressure ulcers, insufficient Tissue Viability Nurse provision, and the need for an urgent review.
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 appropriately treat pressure ulcers in elderly people in the community
Wider context from the report “(1) That if pressure ulcers are not treated appropriately to the elderly in the community will suffer, develop Osteomyelitis leading to Sepsis and 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 Insufficient Tissue Viability Nurse staffing in community and hospital settings
Wider context from the report “(2) That there are not enough Tissue Viability Nurses working in the community or in the hospital to meet the needs of the patients
” Open source report
Concerns raised 1 Lack of sufficiently detailed, complete and evidence-supported action planning View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Melanie Ellen Lowe · 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
Melanie Ellen Lowe, who had been sectioned under the Mental Health Act, was found unresponsive in her room on 2 March and later died in hospital after tissues were found obstructing her airway. The inquest concluded that she killed herself and found that her risk of self-harm or suicide had not been properly assessed or reviewed and that adequate precautions had not been taken. The report also raised concern that the trust’s action plan was too basic and lacked detail and supporting evidence.
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 sufficiently detailed, complete and evidence-supported action planning
Wider context from the report “(1) The trust's action plan is very basic, lacking specific detail. Some elements are blank and there is an absence of supporting evidence . A far more rigorous action plan is required in an effort to prevent future deaths such as Melanie's.
” 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 Update the previous action plan with supporting evidence showing that identified actions have been taken forward.
Verbatim wording from the response “I can confirm that the previous action plan has been updated with supporting evidence to provide assurance that actions have been taken forward. Please find enclosed a copy of the Action Plan, which I hope addresses all of your concerns. I can also confirm that the Trust will complete a further audit to ensure that all the actions identified have been embedded into practice.” Source location 2016-0404-Response
Open published response
Concerns raised 1 Lack of a robust, comprehensive action plan with timescales View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Margaret Ann Richardson · 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
Margaret Ann Richardson suffered at least five falls while a patient in Kitwood Ward at St Margaret’s Hospital Epping and died in Princess Alexandra Hospital Harlow after the last fall. The inquest identified failings in implementing the Trust’s falls policy, and the report raised concern about putting in place a robust, comprehensive action plan with timescales.
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 robust, comprehensive action plan with timescales
Wider context from the report “(1) a robust, comprehensive Action Plan with timescales’ needs to be put in place , following the findings of the Serious Incident Investigation and the evidence heard during the inquest.
” Open source report
Concerns raised 2 Failure to sign off review meeting outcomes in writing View source Failure to clearly communicate review meeting outcomes to the affected person View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Dorota Agnieszka Kijowska · 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
Dorota Agnieszka Kijowska was found hanging at Gosfield ward on 23 March 2015 after returning from weekend leave and expressing threats to harm herself. The report identified concerns that the review outcome was not documented or clearly communicated to her, alongside a jury finding of failures to provide a safe environment and ineffective communication.
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 sign off review meeting outcomes in writing
Wider context from the report “The outcome of the review meeting was not signed off in writing by those in attendance (Consultant psychiatrist, middle grade doctor, review nurse) and clearly communicated to Dorota
” 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 clearly communicate review meeting outcomes to the affected person
Wider context from the report “The outcome of the review meeting was not signed off in writing by those in attendance (Consultant psychiatrist, middle grade doctor, review nurse) and clearly communicated to Dorota
” Open source report
Concerns raised 3 Failure to allocate a named nurse View source Failure to carry out the named nurse role View source Failure to carry out appropriate assessments and reviews View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
David John Pooley · 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 John Pooley, aged 66, was admitted to hospital after attempting to hang himself and was later found hanging in a ward toilet; his death was confirmed on 20 May 2015. Concerns included the absence of a named nurse until the day before his death and the resulting failure to carry out appropriate risk assessments, care planning and reviews.
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 allocate a named nurse
Wider context from the report “1. Contrary to the trust’s policy, there was no named nurse allocated until the day before Mr Pooley’s death . The role of the named nurse had not therefore been carried out – this entails the devising of a risk assessment, care plans, one to ones, contact with the patient’s family etc.
2. The appropriate assessments and reviews were therefore not carried out.
” 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 carry out the named nurse role
Wider context from the report “1. Contrary to the trust’s policy, there was no named nurse allocated until the day before Mr Pooley’s death. The role of the named nurse had not therefore been carried out – this entails the devising of a risk assessment, care plans, one to ones, contact with the patient’s family etc.
2. The appropriate assessments and reviews were therefore not carried out.
” 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 carry out appropriate assessments and reviews
Wider context from the report “1. Contrary to the trust’s policy, there was no named nurse allocated until the day before Mr Pooley’s death. The role of the named nurse had not therefore been carried out – this entails the devising of a risk assessment, care plans, one to ones, contact with the patient’s family etc.
2. The appropriate assessments and reviews were therefore not carried out .
” Open source report
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Request correction
Addressed to North Essex Partnership University NHS Foundation Trust, now represented here by Essex Partnership University NHS Foundation Trust.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations