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.

Action Taken 71%

Action Planned 18%

Noted 9%

Disputed 2%

Based on 56 classified responses

PFD Reports

30 results

Jayden Booroff

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) 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. 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’.

John Moore

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.

Thomas King

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

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.

Terence Pimm

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.