Lack of discharge plan responsibility and unclear care coordinator allocation
Essex Partnership University NHS Foundation Trust received 2 coroners' reports about this hazard between 25 Feb 2022 and 17 Mar 2025.
They came from 1 coroner. A similar concern was raised again 1 time after the first warning.
No published response from Essex Partnership University NHS Foundation Trust was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“Evidence confirmed a conspicuous lack of clarity as to who, amongst EPUT clinicians/staff, is responsible for ensuring that a clear and comprehensive discharge plan is formulated”
Original on judiciary.uk ↗ No published response from Essex Partnership University NHS Foundation Trust was found for this report.
- 3 years 1 month laterClosely relatedConfidence 0.80 · moderate
“(d) Failure to allocate a Care Coordinator as required under the Care Programme Approach (CPA) and as mandated by EPUT policy.”
Original on judiciary.uk ↗ Essex Partnership University NHS Foundation Trust responded, stating 6 specific actions.Response (PDF) ↗
“We can provide assurance that there is an expectation that care plans are reviewed as a minimum weekly or following any incidents or change. To further support this changes are being made to ensure care plans are discussed at the weekly MDTs.”
Web search (Tavily): No evidence found either way
Essex Integrated Care Board - Board Meeting - 15 October 2026 ↗“The Trust has initiated a Record Keeping Safety Improvement Programme (SIP). Part of this includes considering how to address issues of copying and pasting.”
Web search (Tavily): No evidence found either way
Essex Partnership University NHS Foundation Trust Priorities 2025/26 | What the Board Is Focused On ↗4 more stated actions in the Promises tab.
- All reports to Essex Partnership University NHS Foundation Trust
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2022 → 2025Darren Turner3 years 1 month after Stephanie Moyce · same coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight problems stemming from the absence or unclear responsibility for a Care Coordinator, which undermines effective discharge planning.
Stephanie Moyce · 25 Feb 2022
“Evidence confirmed a conspicuous lack of clarity as to who, amongst EPUT clinicians/staff, is responsible for ensuring that a clear and comprehensive discharge plan is formulated”
Original on judiciary.uk ↗ Darren Turner · 17 Mar 2025
“(d) Failure to allocate a Care Coordinator as required under the Care Programme Approach (CPA) and as mandated by EPUT policy.”
Original on judiciary.uk ↗
No published response from Essex Partnership University NHS Foundation Trust was found for this report.
Stated action
“We can provide assurance that there is an expectation that care plans are reviewed as a minimum weekly or following any incidents or change. To further support this changes are being made to ensure care plans are discussed at the weekly MDTs.”
What happened next: No evidence found either way
The organisation's statement about reviewing care plans weekly or after incidents was not confirmed or denied in the provided sources.
“Welcome to this uh meeting of the Essics Integrated Care Board. Um uh warm [0:21] welcome to the members of the public who've joined us here in Southend. Um and also to those who've joined us [0:29] online, a polite reminder to everyone that this is a meeting which is held”
“Essex Partnership University NHS Foundation Trust This is an organisation that runs the health and social care services we inspect”
“Essex Partnership University NHS Foundation Trust ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST ANNUAL REPORT AND ACCOUNTS 2020-21 | ANNUAL REPORT AND ACCOUNTS 2020-21 2 | ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST (EPUT) ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST (EPUT) | 3 ANNUAL REPORT AND ACCOUNTS 2020-21 | ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST ANNUAL REPORT AND”
No evidence found does not mean the action did not happen.
Stated action
“The Trust has initiated a Record Keeping Safety Improvement Programme (SIP). Part of this includes considering how to address issues of copying and pasting.”
What happened next: No evidence found either way
The Trust's priorities page does not mention a Record Keeping Safety Improvement Programme or any specific initiative addressing copying and pasting.
“What is Essex Partnership University NHS Foundation Trust's digital transformation strategy? What procurement signals are in Essex Partnership University NHS Foundation Trust's board papers? What are Essex Partnership University NHS Foundation Trust's workforce challenges?”
No evidence found does not mean the action did not happen.
Stated action
“A reflective learning supervision session has been held with a member of staff involved in this matter in order to understand the factors in this incident and ensure the staff member understands the importance of communication key information to other clinicians.”
What happened next: No evidence found either way
The organisation's website does not mention any reflective learning supervision session or related staff training.
“Join a free 1.5hr information briefing tofind out more about Trauma Informed Practice and how it could work in your setting”
“The University of Essex and East Suffolk and North Essex NHS Foundation Trust (ESNEFT) have officially joined forces in a new partnership to promote greater collaboration in the areas of health and wellbeing.”
No evidence found does not mean the action did not happen.
Stated action
“The Trust is rolling out STORM Training (Skills Training on Risk Management).”
What happened next: No evidence found either way
The document does not specify a rollout timeline for STORM Training.
“Presentation: Time to Care and Partnership Working”
No evidence found does not mean the action did not happen.
Stated action
“The Trust has initiated a MDT Communication SIP due to the findings from patient safety incident investigations. A working group has been established consisting of senior clinicians and service directors to develop key principles for effective MDT working/communication and documentation.”
What happened next: No evidence found either way
The Trust's website and related news coverage discuss the Lampard Inquiry and mental health services but do not mention any MDT Communication SIP or related working group.
“Infrared technology is used in patients' bedrooms and can monitor their breathing and pulse.”
“We can provide emotional and wellbeing support for anyone affected by the Lampard Inquiry. [Find support”
“The first three mental health foundation trusts have been authorised in England. Monitor, the UK's independent regulator of NHS foundation trusts, has named them as Oxleas NHS Foundation Tru”
No evidence found does not mean the action did not happen.
Stated action
“The Trust is continuing focus care planning and will be holding a dedicated Care Unit Local Quality and Safety Group to spotlight”
What happened next: No evidence found either way
The Trust was asked to address concerns about inpatient deaths and safety standards, but no evidence was found that a dedicated Care Unit Local Quality and Safety Group was held to spotlight care planning.
“[name redacted], interim chief executive Essex Partnership Trust. Good afternoon.”
“The trust were asked to address immediate concerns in relation to regulation 12 (safe care and treatment), 13 (safeguarding) and 17 (good governance).”
No evidence found does not mean the action did not happen.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Essex Partnership University NHS Foundation Trust at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2022 → 2025 | 0.70 | 0.07 | Closely related · 0.80 | same |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for Essex Partnership University NHS Foundation Trust
- Inadequate risk assessment documentation and inaccurate record keeping6 reports · 2018–2026
- Incomplete investigation of patient observations2 reports · 2023–2025
- Absence of mental health liaison during 72‑hour hold and missing discharge note2 reports · 2024–2025
- Inability to access GP medication records across systems3 reports · 2021–2025
This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.