Recipient

Essex Partnership University NHS Foundation Trust

First report 25 Jun 2014•Latest report 1 Jun 2026

Recipient record

Reports, concerns and published responses

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

Reports: 53
Published responses: 66%
Concerns addressed: 217
Stated actions: 421

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

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

66%published responses found

421stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

15 Jul2015
City of London
Concerns raised2
1. Lack of a clear clinical basis for overriding a GP request for patient assessment
2. Failure to undertake adequate clinical inquiry and mental health assessment before making a clinical determination
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

Karen O’Brien · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

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

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Lack of a clear clinical basis for overriding a GP request for patient assessment
Wider context from the report
“It is difficult to understand how there can be a clinical determination by SEPT without more inquiry and, preferably, some face-to-face assessment of the patient by a mental health professional. The NICE guidance is stated to be a recommendation. It must therefore be presumed not to be applied slavishly without careful assessment. The patient’s GP had asked for her to be seen. On what basis did SEPT decide to override the GP’s request? ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to undertake adequate clinical inquiry and mental health assessment before making a clinical determination
Wider context from the report
“It is difficult to understand how there can be a clinical determination by SEPT without more inquiry and, preferably, some face-to-face assessment of the patient by a mental health professional. The NICE guidance is stated to be a recommendation. It must therefore be presumed not to be applied slavishly without careful assessment. The patient’s GP had asked for her to be seen. On what basis did SEPT decide to override the GP’s request? ”
Open source report
19 Jan2015
Bedfordshire and Luton
Concerns raised4
1. Discharge of patients despite ongoing assessed need for support
2. Failure to conduct a formal Serious Incident Investigation
3. Failure to provide a formal handover at discharge
1. Failure to record the reason for discharge
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

Simon Robert ALLISTON · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

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

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Discharge of patients despite ongoing assessed need for support
Wider context from the report
“(2) That he was discharged when the Community Team still considered that he needed support. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to conduct a formal Serious Incident Investigation
Wider context from the report
“(4) That following the death of Simon Alliston there was no formal Serious Incident Investigation ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide a formal handover at discharge
Wider context from the report
“(1) That a patient with a long mental health history was discharged without a formal hand over. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to record the reason for discharge
Wider context from the report
“(3) That the reason for discharge was never recorded. ”
Open source report
25 Jun2014
Essex
Concerns raised1
1. Failure to ensure messages for mental health staff are read promptly
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

Marion Joanne Turner · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

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

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Essex Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure messages for mental health staff are read promptly
Wider context from the report
“(1) Evidence was given that the day before Ms Turner’s death, her solicitor, as a result of concerns about her mental health, had telephoned into the mental health trust office and left a message for Ms Turner’s CPN. This message remained on a slip of paper, unread, in a pigeon hole until sometime the next day. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised2

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

Failure to undertake adequate clinical inquiry and mental health assessment before making a clinical determination

Concerns raised4

Discharge of patients despite ongoing assessed need for support

Failure to conduct a formal Serious Incident Investigation

Failure to provide a formal handover at discharge

Failure to record the reason for discharge

Concerns raised1

Failure to ensure messages for mental health staff are read promptly