PFD report

KATHARINE ANNE FOX · Prevention of Future Deaths report

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Issued 7 Dec 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.

View original report
Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
9

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 raised3

  1. Delays in the provision of psychology sessions
    Part of recurring concern: Failure to provide indicated psychological interventions in mental health care
  2. Failure to provide continuity and handover between hospital and community psychology services
    Part of recurring concern: Failure to communicate clinically important information reliably between care servicesPart of recurring concern: Failure to integrate mental health services across care settingsPart of recurring concern: Failure to provide continuity of patient carePart of recurring concern: Unreliable handover of care information and responsibility
  3. Failure to provide psychology clinicians with access to clinical notes across hospitals and county locations
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care recordsPart of recurring concern: Unreliable consolidation and access to patients’ cross-service clinical risk information
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.9

  1. Action

    Embed a clinical information-sharing mechanism through a joint forum incorporating formal handover of required inpatient and community information.

    Stated by Essex Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 December 2023.
  2. Action

    Undertake regular telephone contact with people waiting for psychological assessment or treatment.

    Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
  3. Action

    Commission a unified electronic medical records system.

    Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 12 December 2023.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Relevant clinical records are accessible to inpatient and community psychological staff through existing electronic systems and the Health Information Exchange.

    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 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 in the provision of psychology sessions

Wider context from the report

“(1) I am concerned that the disconnection between the provision of psychology services to patients in hospital and the provision of similar psychology services to patients in the community, including the fact that the community psychology service does not receive any form of handover and that there is a substantial wait for the provision of psychology sessions which may well require continuity to be delivered effectively. ”

Is this part of a recurring concern?

Yes — Failure to provide indicated psychological interventions in mental health care.

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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

Failure to provide continuity and handover between hospital and community psychology services

Wider context from the report

“(1) I am concerned that the disconnection between the provision of psychology services to patients in hospital and the provision of similar psychology services to patients in the community, including the fact that the community psychology service does not receive any form of handover and that there is a substantial wait for the provision of psychology sessions which may well require continuity to be delivered effectively. ”

Is this part of a recurring concern?

Yes — Failure to communicate clinically important information reliably between care services; Failure to integrate mental health services across care settings; Failure to provide continuity of patient care; Unreliable handover of care information and responsibility.

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 provide psychology clinicians with access to clinical notes across hospitals and county locations

Wider context from the report

“(2) I am concerned about the fact, if that is indeed right, that some clinicians in the psychology service may not be able to access notes made by clinicians in either other hospitals or other parts of the county. I was told that the deceased actually managed to procure psychology sessions that the new psychologist may not have been able to read the notes of their predecessor if they were on a different computer system. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records; Unreliable consolidation and access to patients’ cross-service clinical risk information.

Open source report

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Embed a clinical information-sharing mechanism through a joint forum incorporating formal handover of required inpatient and community information.

Verbatim wording from the response

“Further, the Court is advised that it is commissioning a unified Electronic Medical Records System, in the interim Psychological Services will now have access to all of the required clinical systems and will also embed a new mechanism to ensure robust clinical information sharing between inpatient and community clinicians. This will be achieved through the aforementioned joint forum which will incorporate a formal handover of all required information. Should access to more detailed clinical information be required, this can be requested.”

Source location

Response from Essex Partnership University NHS Foundation Trust
Page 3 · response
Published 12 December 2023

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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 regular telephone contact with people waiting for psychological assessment or treatment.

Verbatim wording from the response

“With regards to community wait times, the current demand for psychological treatments exceeds capacity, which is unfortunately not unusual within the NHS at this time. However, going forward the system of clinical prioritisation following case-specific discussion/handover will determine if urgency of need and risk warrants prioritisation. In relation to this, the Court is advised that in order to mitigate against any risk for those waiting for treatment in the community, the Psychological Services team implemented a new clinical process in 2023 which involves undertaking regular telephone contact with those waiting for psychological assessment and/or treatment.”

Source location

Response from Essex Partnership University NHS Foundation Trust
Page 2 · response
Published 12 December 2023

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Commission a unified electronic medical records system.

Verbatim wording from the response

“Further, the Court is advised that it is commissioning a unified Electronic Medical Records System, in the interim Psychological Services will now have access to all of the required clinical systems and will also embed a new mechanism to ensure robust clinical information sharing between inpatient and community clinicians. This will be achieved through the aforementioned joint forum which will incorporate a formal handover of all required information. Should access to more detailed clinical information be required, this can be requested.”

Source location

Response from Essex Partnership University NHS Foundation Trust
Page 3 · response
Published 12 December 2023

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Embed clinical prioritisation for community psychological treatment, record prioritisation decisions electronically, and monitor waiting-time data.

Verbatim wording from the response

“Whilst it is noted that patients do not always require immediate on-going psychological therapy upon discharge from hospital, Psychological Services will, going forward, embed a mechanism for clinical prioritisation in order to ensure that the most urgent cases are appropriately identified and prioritised in the community, ensuring continuity of psychological treatment and minimising waiting times as much as is practicably possible. This will be monitored through the waiting time data that is collected by each service team, and which is reported through our Trust Accountability Framework process.”

Source location

Response from Essex Partnership University NHS Foundation Trust
Page 2 · response
Published 12 December 2023

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Provide formal handovers from inpatient psychologists to community psychological practitioners and coordinate follow-on care with community mental health teams.

Verbatim wording from the response

“Every patient who is receiving psychological intervention on an inpatient unit and is in need of continued psychological intervention post discharge, will have a handover of care from the inpatient psychologist (verbal/in writing) to the Community Team psychological practitioner. The Community Team psychological practitioner will discuss the care and treatment with the community mental health team to ensure the patient receives appropriate care and support in the community. The care in the community can be provided by the psychological practitioner or other appropriate team member under the supervision of a qualified registered psychological practitioner.”

Source location

Response from Essex Partnership University NHS Foundation Trust
Page 1 · response
Published 12 December 2023

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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

Introduce locality-based joint inpatient-community consultations, formal pre-discharge handovers, and electronic recording of handover information.

Verbatim wording from the response

“The new process will include a joint consultation between the inpatient and community psychological services in order to aid care planning and formal handover of appropriate inpatient cases prior to discharge across each locality in Essex. Handover will be recorded on the patient’s electronic notes.”

Source location

Response from Essex Partnership University NHS Foundation Trust
Page 2 · response
Published 12 December 2023

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Regularly audit handovers to verify safe transfer of psychological care to community teams.

Verbatim wording from the response

“The process of handover will be regularly audited to ensure that the care is safely transferred to the Community Team.”

Source location

Response from Essex Partnership University NHS Foundation Trust
Page 2 · response
Published 12 December 2023

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Review the operational model for transitions and handovers between inpatient and community psychological services.

Verbatim wording from the response

“Further, the Unit is currently reviewing the operational model to improve the transition and handover of care between inpatient and community psychological services, with the aim of streamlining this provision.”

Source location

Response from Essex Partnership University NHS Foundation Trust
Page 2 · response
Published 12 December 2023

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Enable Adult Community Psychological Services clinicians to access PARIS, MOBIUS, and Health Information Exchange records.

Verbatim wording from the response

“The Court is respectfully advised that EPUT (like a number of NHS Trusts) uses multiple Electronic Medical Records Systems, which includes PARIS and MOBIUS. Staff within the Inpatient Psychological Services team have access to both systems, as well as Health Information Exchange (HIE) and can therefore access all records/reports. Our IT department has recently confirmed that all clinical staff in Adult Community Psychological Services can also access both systems.”

Source location

Response from Essex Partnership University NHS Foundation Trust
Page 2 · response
Published 12 December 2023

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

Relevant clinical records are accessible to inpatient and community psychological staff through existing electronic systems and the Health Information Exchange.

Verbatim wording from the response

“The Court is respectfully advised that EPUT (like a number of NHS Trusts) uses multiple Electronic Medical Records Systems, which includes PARIS and MOBIUS. Staff within the Inpatient Psychological Services team have access to both systems, as well as Health Information Exchange (HIE) and can therefore access all records/reports. Our IT department has recently confirmed that all clinical staff in Adult Community Psychological Services can also access both systems.”

Source location

Response from Essex Partnership University NHS Foundation Trust
Page 2 · response
Published 12 December 2023

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

Patients do not always require immediate ongoing psychological therapy after discharge; treatment urgency should be determined by clinical need.

Verbatim wording from the response

“Whilst it is noted that patients do not always require immediate on-going psychological therapy upon discharge from hospital, Psychological Services will, going forward, embed a mechanism for clinical prioritisation in order to ensure that the most urgent cases are appropriately identified and prioritised in the community, ensuring continuity of psychological treatment and minimising waiting times as much as is practicably possible. This will be monitored through the waiting time data that is collected by each service team, and which is reported through our Trust Accountability Framework process.”

Source location

Response from Essex Partnership University NHS Foundation Trust
Page 2 · response
Published 12 December 2023

Open published response
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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