Essex Partnership University NHS Foundation Trust

PFD Addressee
Reports: 40 Earliest: Mar 2016 Latest: 8 Feb 2026

94% 2-year response rate (above 83% average). 71% of classified responses show concrete action taken.

Response Status (last 2 years, 16 reports)
Responded 15
AI Classification
Action Taken 71%
Action Planned 18%
Noted 9%
Disputed 2%
Based on 56 classified responses
PFD Reports Received by Quarter
PFD Reports
40 results
Doris Smith
All Responded
2023-0074Deceased 27 Feb 2023 Essex
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
Child Death Suicide
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
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
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Suicide
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.
John Moore
All Responded
2026-0210 8 Feb 2022 Essex
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.
Steven Regoli
Historic (No Identified Response)
2021-0273 17 Aug 2021 Essex
Mental Health related deaths Railway related deaths Suicide
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 Essex
Alcohol, drug and medication related deaths Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) 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 Essex
Emergency services related deaths Mental Health related deaths Suicide
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.
Thomas King
All Responded
2020-0207 15 Oct 2020 Essex
Community health care and emergency services related deaths Mental Health related deaths Suicide
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.
Zak Farmer
All Responded
2020-0196 24 Sep 2020 Essex
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.
Kelly Campbell
Historic (No Identified Response)
2018-0271 9 Aug 2018 Essex
Mental Health related deaths
Concerns summary (AI summary) Concerns exist regarding the lack of rigorous trust policies for returning items like shoelaces and the dreary, unstimulating physical environment in patient rooms, which contributes to boredom.
Timothy Shaw
Partially Responded
2018-0047 15 Feb 2018 Essex
State Custody related deaths
Concerns summary (AI summary) Healthcare staff showed confusion regarding intelligence reports, communication between departments was poor, and systems for reducing illegal substances and managing referrals needed improvement. Record-keeping was also substandard.
Noted (AI summary) Care UK acknowledges receipt of the report but states they ceased providing healthcare at HMP Chelmsford on 26 May 2017 and therefore will not be filing a substantive response.
Craig Royce
Partially Responded
2017-0379 20 Dec 2017 Essex
Hospital Death (Clinical Procedures and medical management) related deaths State Custody related deaths
Concerns summary (AI summary) A lack of a formal, robust documentary system for referring prisoners to mental health services meant reliance on unreliable telephone conversations, risking delays in crucial assessments.
Action Taken (AI summary) Since taking over prison healthcare services in 2017, Essex Partnership University NHS Foundation Trust has implemented a robust documentary system for referral of prisoners to mental health care, including widening the availability of a referral form to all prison staff.
Terence Pimm
All Responded
2017-0217 14 Aug 2017 Essex
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.
Dorota Kijowska
Historic (No Identified Response)
2016-0121 29 Mar 2016 Essex
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The outcome of a critical review meeting was not formally signed off by attendees nor clearly communicated to the patient, leading to a lack of clarity.