Essex

Coroner Area
Reports: 115 Earliest: May 2014 Latest: 18 Mar 2026

73% response rate (above 63% average).

Response Status
Responded 84 Historic 31
AI Classification
Action Taken 61%
Action Planned 24%
Noted 15%
Disputed 1%
Based on 127 classified responses
Top Categories
Hospital Death (Clinical Procedure… (51) Suicide (from 2015) (26) Mental Health related deaths (23) Alcohol, drug and medication relat… (14) Community health care and emergenc… (9)
Quarterly Trend
Category Breakdown
How does this area compare?
vs East of England average: +44 reports · +5pp response rate
vs national average: +31 reports · +10pp response rate
115 results
Katharine Fox
All Responded
2023-0510 7 Dec 2023
Essex Partnership University Trust
Suicide (from 2015)
Concerns summary (AI summary) A critical disconnection between hospital and community psychology services, compounded by a lack of handover and incompatible computer systems, resulted in substantial wait times and impaired continuity of care.
Action Taken (AI summary) Essex Partnership University NHS Foundation Trust has implemented measures to improve handover of care between inpatient and community psychology services, ensure access to clinical systems and robust information sharing, and provide supervision and training for care coordinators regarding safe patient care.
John Pace
Partially Responded
2023-0447 13 Nov 2023
Castle Rock Group Forward Trust
Alcohol, drug and medication related deaths State Custody related deaths
Concerns summary (AI summary) A new methadone detoxification discharge pathway for prisoners lacks formal documentation, policies, or written procedures. This absence prevents consistent implementation and monitoring, posing a risk to future prisoners' safety.
Action Taken (AI summary) The Forward Trust has drafted and implemented a new protocol on the 'Management of Non-engaging Service Users Protocol'. A dissemination and training programme has been facilitated, and the protocol has been added to Clinical Governance, Managers and Staff meeting agendas.
Frederick Le Grice
All Responded
2023-0358 29 Sep 2023
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Patients and clinicians lack awareness regarding the serious lung damage risk from Nitrofurantoin. Current guidance is insufficient to ensure vigilance for symptoms and regular respiratory monitoring.
Action Taken (AI summary) NHS England worked with the MHRA to update the Summary of Product Characteristics (SmPC) and Patient Information Leaflet (PIL) for Nitrofurantoin to emphasize the risk of respiratory symptoms. This was communicated to healthcare professionals via a MHRA Drug Safety Update and highlighted in an NHS England Patient Safety Case Study. The MHRA updated warnings in the product information for nitrofurantoin for both healthcare professionals and patients, highlighting the risk of pulmonary adverse drug reactions. They also published a Drug Safety Update bulletin to raise further awareness amongst healthcare professionals.
Johanne Blackwood
All Responded
2023-0275 27 Jul 2023
Essex Partnership NHS Trust
Railway related deaths Suicide (from 2015)
Concerns summary (AI summary) A severe lack of clarity in Care Coordinator handovers and absence of formal policy left a vulnerable patient without an allocated CC, and her risk assessment/care plan unupdated, following hospital discharge.
Action Taken (AI summary) The Trust has implemented a formal structured handover template for care coordinators, approved for Trust-wide implementation, to capture vital information about patients' care and risk. All staff who administer medication are now required to complete annual medication competency assessments.
Ronald Ashdown
All Responded
2023-0249 18 Jul 2023
Mid and South Essex NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A hospital's internal investigation into poor patient care was critically flawed and unprofessional, as key photographic evidence was withheld, preventing proper identification of systemic failings.
Action Taken (AI summary) The Trust has updated its action plan and completed several actions to improve personal care, record keeping, and investigation processes including improved management oversight, audits, training, and an updated safeguarding policy with improved governance. They have shared information about the actions taken with the Local Authority.
Christine Cumbers
All Responded
2023-0196 16 Jun 2023
Clacton Community Practices
Other related deaths
Concerns summary (AI summary) The GP practice failed to implement identified learnings from its Significant Event Analysis report, and lacked plans or timescales for addressing recognised shortcomings, risking future reoccurrences.
Action Taken (AI summary) Ranworth Medical Group addressed the consultation concern with the individual clinician and disseminated learning at a practice meeting on 9/8/22 in an anonymous manner. They completed an audit of consultations on 31/7/23 against a known criteria (NHSE audit XL template).
Bency Joseph
All Responded
2023-0148 7 May 2023
Essex Partnership NHS Foundation Trust
Mental Health related deaths
Concerns summary (AI summary) There was a significant delay and inadequacy in prescribing and administering therapeutic medication for psychosis, with family escalations ignored. The subsequent Trust investigation was also deficient, excluding key stakeholders.
Action Taken (AI summary) The Trust has completed a Clinical Review into the death, shared learning with the Chair of the Clinical Review Group, and responded to the family's concerns raised after the inquest. They have also appointed a Family Liaison Officer.
Sharon Langley
All Responded
2023-0075Deceased 27 Feb 2023
Essex Partnership NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths Suicide (from 2015)
Concerns summary (AI summary) The Trust's emergency response was critically flawed, with delays and poor communication during an emergency. Known safety risks, including non-closing doors to high-risk areas, were inadequately mitigated, and the internal investigation was unreliable.
Action Taken (AI summary) The Trust has provided 'refresher' life support training, implemented Safety Huddles, and is rolling out electronic observations. It has a procedure for completing engagement and supportive observation records and has piloted use of electronic observations.
Doris Smith
All Responded
2023-0074Deceased 27 Feb 2023
Essex Partnership NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inadequate falls risk assessments and observations, alongside poor communication, confusing policies, and substandard electronic record-keeping, compromised patient safety.
Action Taken (AI summary) The Trust has implemented practice changes including a 24-hour falls risk assessment, mandatory physiotherapy referrals, and guidelines to address copying and pasting in records. They have also produced a video and hosted a learning event on record keeping.
Molly-Ann Sergeant
All Responded
2023-0078Deceased 19 Feb 2023
Essex Partnership NHS Foundation Trust …
Child Death (from 2015) Suicide (from 2015)
Concerns summary (AI summary) Deficient discharge planning for a child with delayed autism diagnosis and high suicide risk stemmed from insufficient assessment, poor council response to referrals, and a lack of understanding of Mental Health Act rights.
Action Taken (AI summary) Essex County Council has undertaken training and awareness raising with the Children and Families Hub and operational teams regarding referrals to Social Care. They have clarified that every young person in an in-patient unit is a child-in-need and needs to remain open to Social Care, who must be involved in discharge arrangements. There has also been widespread focus and awareness raising in relation to Section 117 and Section 85.
Jayden Booroff
All Responded
2023-0036Deceased 27 Jan 2023
Essex Partnership NHS Foundation Trust Essex Police
Railway related deaths
Concerns summary (AI summary) Inadequate risk assessments at Essex Partnership NHS Foundation Trust led to reduced observations. There was also critical miscommunication and misunderstanding between the Trust and emergency services regarding escaped detained patients.
Action Taken (AI summary) The Trust handover process was reviewed and the electronic handover sheet was revised. The Trust engagement and supportive observation processes were reviewed and the observation recording document was revised. Staff have been provided training on managing patients with challenging behaviour. The Trust have an Essex wide single point of access with a priority ‘emergency services line’. Essex Police has aligned its Missing Persons Procedure with College of Policing guidance. Essex Police has created the Essex Police Mental Health and Missing Person’s Constable post. Frontline uniformed officers have received specific training on the Mental Capacity Act and police powers.
Stephanie Moyce
Historic (No Identified Response)
2022-0059 25 Feb 2022
Essex Partnership University NHS Founda…
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Suicide (from 2015)
Concerns summary (AI summary) Conspicuous lack of clarity regarding responsibility for discharge planning, post-discharge oversight, and safety-netting for psychotherapy patients without a Care Coordinator was identified.
Benjamin Stroud
Historic (No Identified Response)
2022-0039 8 Feb 2022
Essex Partnership University Trust and …
Alcohol, drug and medication related deaths Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Product related deaths
Concerns summary (AI summary) A patient's case was not referred to the Multi-Disciplinary Team, denying essential psychiatric input, as the Care Coordinator made un-documented clinical decisions regarding referrals, posing a significant risk.
John Moore
All Responded
2026-0210 8 Feb 2022
Department of Health and Social Care Essex Partnership NHS Trust Health Education England +1 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) EPUT Care Coordinators receive inadequate formal training for their role, leading to failures in record keeping, care plan updates, communication with other providers, and recognising the clinical significance of patient disengagement.
Noted (AI summary) • The EPUT response has been shared with NHS England and Improvement, and NHS England is assured that the actions will address concerns about the training of current Care Coordinators. • The NHS Long Term Plan sets out investment in community mental health services for adults with severe mental illness. • From April, all areas are receiving additional funding to develop integrated primary and community mental health services. • Since April 2021, all areas are receiving additional funding to develop fully integrated primary and community mental health services. • This investment includes improved access to psychological therapies, improved physical health care, employment support, personalised and trauma informed care, medicines management and support for self-harm and coexisting substance use. • By 2023/24, this investment will amount to almost £1billion extra per year for adults and older adults with severe mental illness.
Maria Howell
Historic (No Identified Response)
2022-0022 27 Jan 2022
Holmes Care Group Limited
Care Home Health related deaths
Concerns summary (AI summary) The care home lacked qualified nursing staff for critical procedures like reinserting a RIG tube and employed staff with inadequate clinical judgment for critically ill residents.
Jan Goodliffe
Historic (No Identified Response)
2022-0009 14 Jan 2022
NHS England and Essex Partnership Unive…
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Other related deaths Suicide (from 2015)
Concerns summary (AI summary) Unqualified social workers conducted home mental health assessments, missing critical opportunities to seek medical expertise regarding medication interactions, which may have contributed to the deceased's death.
Anthony Preston
Historic (No Identified Response)
2021-0319 23 Sep 2021
Essex Police National Police Chiefs’ Council
Mental Health related deaths Police related deaths
Concerns summary (AI summary) The police Missing Person Policy requires review to ensure it is fit for purpose and adequately addresses risks.
Steven Regoli
Historic (No Identified Response)
2021-0273 17 Aug 2021
Essex Partnership University NHS Founda… NHS England
Mental Health related deaths Railway related deaths Suicide (from 2015)
Concerns summary (AI summary) Inadequate systems existed for providing in-depth mental health support to patients with anxiety and non-engagement issues, leaving families as the sole caregivers and preventing necessary intervention.
Fiona Humberstone
Historic (No Identified Response)
2021-0221 28 Jun 2021
Basildon and Brentwood Clinical Commiss… Essex Partnership University NHS Founda…
Alcohol, drug and medication related deaths Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths
Concerns summary (AI summary) A consultant psychiatrist was unaware of a patient's powerful painkiller prescription due to relying solely on self-reporting, impacting risk assessments. Incompatible electronic systems prevent routine access to full medication records between primary and secondary care.
Sharon Kelly
Partially Responded
2020-0250 24 Nov 2020
EFAS Essex Partnership University NHS Founda… Essex Police
Emergency services related deaths (2019 onwards) Mental Health related deaths Suicide (from 2015)
Concerns summary (AI summary) Inadequate training and unclear communication protocols between emergency services led to delays in identifying and responding to mental health crisis risks, including police attendance and urgent mental health assessments.
Action Planned (AI summary) The Trust will ensure referrals for urgent MHA assessments are accompanied by a telephone conversation, risks will be made explicit, and the timing of the MHA assessment will be explored with the referrer to agree/mitigate risk.
Christopher Sparks
Historic (No Identified Response)
2020-0249 24 Nov 2020
PCRSteel Ltd SE Galvanisers
Accident at Work and Health and Safety related deaths
Concerns summary (AI summary) The incident resulted from a lack of safe loading and lifting plans, absence of a banksman, inadequate designated safe zones for drivers, and insufficient equipment for handling large products.
Ann Smith
All Responded
2020-0223 5 Nov 2020
Princess Alexandra Hospital
Hospital Death (Clinical Procedures and medical management) related deaths Other related deaths
Concerns summary (AI summary) There was no local protocol for managing anticoagulated patients over 65 who suffer head trauma, especially when also receiving treatment-dose Clexane.
Action Planned (AI summary) The Trust has established a multi-disciplinary Anticoagulation/Falls Tasking Group to develop an Action Plan addressing the management of anticoagulation in patients over 65 who sustain a head trauma; an update is promised by the end of March 2021. The Trust has completed updates to the Falls Prevention policy, quick reference guides, and Nerve Centre software; mandatory questions have been added to the Datix incident management system, and the action has been formally added to the Trust's Strategic Quality Improvement Programme and Corporate Risk Register.
Clara Moniatis
All Responded
2020-0221 3 Nov 2020
Barts and Whipps Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Concerns included lengthy waiting times between chest x-rays and image review, and the absence of a system ensuring prompt clinical review after a PEWS alert.
Noted (AI summary) The Trust states that early senior review of deteriorating patients is critically important and they have shared learning widely among clinical staff; however, they believe that nothing could have prevented the patient's outcome.
Thomas King
All Responded
2020-0207 15 Oct 2020
Essex Partnership University NHS Founda…
Community health care and emergency services related deaths Mental Health related deaths Suicide (from 2015)
Concerns summary (AI summary) Incompatible software used by the Health and Justice Team prevented crucial mental health information sharing with other teams, risking inaccurate risk assessments and patient harm.
Action Taken (AI summary) The Trust has implemented Tiani Health Information Exchange (HIE), an interoperable application that allows clinicians to view patient data from across systems, including the Health and Justice Service's Exelicare system. All clinical staff in the Trust now have access to the HIE.
Sarah Ferneyhough
Partially Responded
2020-0187 29 Sep 2020
AACE’s National Directors of Operations… Association of Ambulance Chief Executiv… Emergency Call Prioritisation Advisory … +1 more
Alcohol, drug and medication related deaths Emergency services related deaths (2019 onwards)
Concerns summary (AI summary) Ambulance service protocols for 'abandoned calls' and medical condition categorisation are inadequate, leading to potential under-triaging and failure to review full call details.
Action Taken (AI summary) The Trust has revised its EOC Standard Operating Procedure for Mental Health calls, giving guidance to consider Category 2 response if a call is abandoned and information suggests the patient is actively at risk. An ESOP is also in development to address abandoned calls and will include checks by the control room manager.