Essex
Coroner Area
Reports: 115
Earliest: May 2014
Latest: 18 Mar 2026
73% response rate (above 63% average).
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.
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)
• 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. • 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.
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.
June Parlour
All Responded
2020-0186
28 Sep 2020
East Suffolk and North Essex NHS Founda…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Hospital staff lacked familiarity with morphine guidelines, used outdated policies, received inadequate training, and experienced communication failures preventing a nurse from challenging a dangerous prescription.
Action Taken
(AI summary)
ESNEFT updated the Morphine and Naloxone Administration Guidelines, communicated them to staff, and published them on the Trust intranet and Medusa app. They also developed a new Morphine Prescription sticker and updated the Morphine Administration Competency Framework.
Zak Farmer
All Responded
2020-0196
24 Sep 2020
Essex Partnership University NHS Founda…
Castle Rock Group
Community health care and emergency services related deaths
Mental Health related deaths
Concerns summary (AI summary)
Prison healthcare failed to obtain crucial discharge information from the hospital regarding prescribed medication, diagnoses, and care plans for a released prisoner.
Action Planned
(AI summary)
CRG Medical states a member of the mental health team attends all MHA s117 meetings and they now have a dual system for patient records, audited weekly. They provide advice on registering with a community GP and provide a discharge summary that is now accessible to GPs through NHS Spine. They also employ a social inclusion representative to assist with discharge arrangements. EPUT states that the Clinical Guidelines for Community Mental Health Service Users disengaging or non-concordant with current prescribed treatment plan is currently under review to ensure it is comprehensive and provides clear guidance for staff.
Frederick Terry
All Responded
2020-0173
9 Sep 2020
Mid and South Essex NHS Foundation Trust
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Failures included inadequate risk assessment for delivery, incorrect forceps use due to insufficient training, excessive force, poor locum staff management, communication breakdowns, and unsuitable resuscitation equipment in maternity.
Action Taken
(AI summary)
Mid and South Essex Foundation Trust has strengthened processes, implemented a locum checklist, and added a self-assessment tool for obstetric skills. They employed an additional Obstetric Consultant, implemented a 24-hour bleep for the Senior Nurse in the Neonatal unit, and are driving the 'Below Ten Thousand Feet' initiative for communication in theatres.
Luiz Anjos
All Responded
2020-0259
13 Jul 2020
Highways Agency Essex County Council
Mental Health related deaths
Railway related deaths
Concerns summary (AI summary)
Easy access over the footbridge parapet and sides at the location remains a significant safety concern, despite other identified issues having been remedied.
Action Planned
(AI summary)
Essex Highways has identified three potential options to improve safety at the St Dominic Road Footbridge and prefers installing full-height corrugated steel parapets. A full structural assessment is estimated to be completed by the end of January 2021, with design and refurbishment works to follow, subject to Network Rail approval.
Joseph Gingell
All Responded
2020-0027
17 Feb 2020
NHS England
Alcohol, drug and medication related deaths
Mental Health related deaths
Suicide (from 2015)
Concerns summary (AI summary)
Permitting "self-certification" for medication without checks, allowing abuse by vulnerable individuals, and not involving the GP removes crucial safeguards, contributing to toxic drug interactions.
Noted
(AI summary)
NHS England acknowledges concerns about drug toxicity, self-certification, and not informing GPs but states the death appears to be from services outside the NHS, restating commitment to improving the safety of controlled drugs and online prescribing, highlighting existing guidelines and initiatives.
Terence Pimm
All Responded
2017-0217
14 Aug 2017
Essex Partnership University NHS Founda…
Essex Community Rehabilitation Company
Essex Police
Police related deaths
Concerns summary (AI summary)
Deficiencies in police call handling, record-keeping, and inter-agency information sharing hampered risk assessment for individuals with mental health issues. Insufficient training also affected police in identifying immediate risk and mental health assessors.
Action Taken
(AI summary)
The Trust has directed all health-based place of safety calls through a new call centre where calls are recorded and documented. They have also reinforced to staff the importance of family involvement, reinforced the information-sharing concordat, launched a new street-triage team, and put a new flowchart in place for staff detailing actions to take when people are subject to a warrant, with training underway. Essex Police have instructed switchboard operators to refer public calls not concerning a person in custody to the Force Control Room, and advised custody suite staff on handling detainee-related calls. FCR staff receive training on threat, harm, and risk assessment. The police are implementing a process to notify Essex Police when staff meet with wanted persons and are developing Information Sharing Agreements with health partners.
Melanie Lowe
All Responded
2016-0404
11 Nov 2016
North Essex University NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The Trust's action plan is inadequate, lacking specific detail, supporting evidence, and requiring a far more rigorous approach to prevent future deaths.
Action Taken
(AI summary)
The Trust updated its action plan with supporting evidence and will complete a further audit to ensure that all the actions identified have been embedded into practice.
Keith Harper
All Responded
2016-0151
21 Apr 2016
Highways Agency
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Drivers lacked adequate warning of a pedestrian crossing near a roundabout due to limited visibility and misleading road features. Additionally, carriageway markings were obscured by resurfacing and debris.
Action Taken
(AI summary)
Essex County Council has completed work to refresh the carriageway markings exiting the roundabout, including the segregation line and give-way triangles.
Percy Gurton
All Responded
2014-0546
22 Dec 2014
First Essex Buses
Other related deaths
Concerns summary (AI summary)
The bus design was flawed, lacking a necessary safety barrier in front of the front passenger seat.
Action Planned
(AI summary)
First Essex Buses is investigating with Optare the feasibility of retro-fitting containment measures onto the relevant bus and is engaging with other parties to explore the issue of containment for priority seats with the aim of adopting an industry-wide approach. They note this initiative is ongoing and any unilateral action would have piecemeal effect.
John Leyin
All Responded
2014-0563
16 Dec 2014
Basildon Hospital NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
There was a failure to disseminate trust policy and NPSA guidance, along with weak training systems. Staff training currency was not checked, and knowledge of trained staff numbers for critical procedures was lacking.
Action Taken
(AI summary)
Following the death, Basildon and Thurrock University Hospitals NHS Trust undertook an investigation and developed an action plan. Actions include appointing a Risk and Document Control Manager, overhauling NPSA Alert dissemination, and strengthening nasogastric tube training with designated assessors and monthly compliance reports.
Josephine Foday
All Responded
2014-0301-wp24614
23 May 2014
Chartered Institute of Environmental He…
Other related deaths
Concerns summary (AI summary)
The pool's inherently dangerous profile was not properly risk-assessed. A lack of lifeguards, unmonitored CCTV, unclear signage, and untrained staff in aquatic rescue created significant drowning risks, especially for non-swimmers.
Action Planned
(AI summary)
• IOSH will raise awareness among its 44,000 members by highlighting the facts of this case, the concerns raised, and the Health and Safety Executive guidance on this topic.
• A summary of the key findings will be included in the next available issue (September 2014) of the Institution's official member magazine the Safety and Health Practitioner.
• A news item will be included in the e-bulletin, Connect, on Monday 21 July, which is distributed to all members.