PFD report

Bency Joseph · Prevention of Future Deaths report

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Issued 7 May 2023•Essex

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised4

  1. Failure to involve the deceased patient's family in the Trust investigation
    Part of recurring concern: Failure to acknowledge and act on family and carer safety concerns in patient carePart of recurring concern: Inadequate safety incident investigations
  2. Delays and failures in prescribing and administering therapeutic medication for first-episode psychosis
    Part of recurring concern: Failure to provide required medication promptly when clinically needed
  3. Failure to involve the senior pharmacist in the Trust investigation
    Part of recurring concern: Inadequate safety incident investigations
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 a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. Action

    Share learning about involving pharmacy expertise in clinical review investigations with the Clinical Review Group chair.

    Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 May 2023.
  2. Action

    Review urgent-care medication needs to determine whether to expand nurse-accessible PGD medicines.

    Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 May 2023.
  3. Action

    Develop organisation-wide urgent-care resources reinforcing initial FP10 use for patients requiring urgent symptom-relief medication.

    Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 May 2023.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Failure to acknowledge and act on family and carer safety concerns in patient care; Inadequate safety incident investigations.

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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. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Failure to provide required medication promptly when clinically needed.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Inadequate safety incident investigations.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Failure to acknowledge and act on family and carer safety concerns in patient care; Failure to provide required medication promptly when clinically needed.

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

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
Page 3 · response
Published 17 May 2023

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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
Page 2 · response
Published 17 May 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop 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
Page 2 · response
Published 17 May 2023

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The concern identifies the assessor as a psychiatrist, but the Trust states that a mental health nurse conducted the assessment.

    Stated by Essex Partnership University NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The concern identifies the assessor as a psychiatrist, but the Trust states that a mental health nurse conducted the assessment.

Verbatim wording from the response

“I note the above concern states that Mrs Joseph was assessed by a Psychiatrist. I can also confirm that Mr Joseph was assessed by a Mental Health Nurse in the Mental Health Liaison Team on 24 May 2022.”

Source location

Response from Essex Partnership University NHS Foundation Trust
Page 2 · response
Published 17 May 2023

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026