Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Timothy Shaw · 15 Feb 2018 · Caroline Beasley-Murray, Essex
“- The standard and accuracy of record keeping by both disciplinary and Healthcare staff needs to be improved.”
judiciary.uk/prevention-of-future-death-reports/timothy-shaw
What was promised
Stated action 1 · response to Danny Anderson (25 Jul 2024) · stated timescale: 26th September 2024
“The Trust have made improvements, at pace in respect of the processes for formulation of risk on discharge with the implementation of discharge steps developed by the Trust Patient Flow Team. There has also been a change in practice to ensure we hold a discharge planning meeting with the Multi-Disciplinary Team (MDT) before discharge from hospital. Clinical service managers and matrons join discharge meetings to ensure a collaborative approach.”
judiciary.uk/…/2024-0405-Response-from-Essex-Partnership-NHS.pdf
Stated action 2 · response to Darren Turner (17 Mar 2025) · stated timescale: none stated
“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.”
judiciary.uk/…/2025-0144-Response-from-Essex-Partnership-Univer…
Stated action 3 · response to Darren Turner (17 Mar 2025) · stated timescale: none stated
“The Trust has initiated a Record Keeping Safety Improvement Programme (SIP). Part of this includes considering how to address issues of copying and pasting.”
judiciary.uk/…/2025-0144-Response-from-Essex-Partnership-Univer…
6 further stated actions are listed on the full chain page.
What recurred
- 25 Jul 2024 · Danny Anderson · Nadia Persaud
- 17 Mar 2025 · Darren Turner · Sean Horstead · Closely related · confidence 0.90 (high)
- 28 May 2025 · Julie Beasley · Sonia Hayes · Identical hazard · confidence 0.90 (high)
- 1 Dec 2025 · Stuart Berry · Sean Horstead · Closely related · confidence 0.90 (high)
- 1 Jun 2026 · Katharine Corrigan · Sonia Hayes · Closely related · confidence 0.92 (high)
The clearest link, quoted from both reports:
Earlier · Darren Turner · 17 Mar 2025
“Failures in Risk Assessments: specifically, failures to appropriately up-date and document matters relating to [the deceased]'s risk assessment consistent with Trust policy.”
Later · Katharine Corrigan · 1 Jun 2026
“Ms [name redacted] risk assessment and care plans had not been appropriately updated in her medical records such that:”
What happened next
No evidence found either way · stated action 1
“The purpose of this study is to describe the development and implementation of a multidisciplinary team intervention to overcome discharge barriers for patients with prolonged hospitalization.”
Multi-Disciplinary Discharge Coordination Team to Overcome Discharge Barriers and Address the Risk of Delayed Discharges · pmc.ncbi.nlm.nih.gov/articles/PMC8819168
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 2
“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 Integrated Care Board - Board Meeting - 15 October 2026 · youtube.com/watch?v=MujXdqQNoCI
“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 HTML report "Effective" for assessment AP20498 - Care Quality Commission · cqc.org.uk/…/effective
“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”
essex-partnership-university-trust-report-and-accounts- ... · eput.nhs.uk/…/essex-partnership-university-trust-report-and-acc…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 3
“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?”
Essex Partnership University NHS Foundation Trust Priorities 2025/26 | What the Board Is Focused On · boardpaperscraper.com/…/priorities
No evidence found does not mean the action did not happen.
No evidence found either way · 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.”
“Join a free 1.5hr information briefing tofind out more about Trauma Informed Practice and how it could work in your setting”
Reflective Supervision · trauma-informed.uk/training/reflective-supervision-workshop
“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.”
University and NHS Trust form new partnership to promote health and wellbeing collaboration - East Suffolk & North Essex NHS Foundation Trust · esneft.nhs.uk/…/university-and-nhs-trust-form-new-partnership-t…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “The Trust is rolling out STORM Training (Skills Training on Risk Management).”
“Presentation: Time to Care and Partnership Working”
BOARD OF DIRECTORS MEETING PART 1 · eput.nhs.uk/…/Board_of_Directors_Meeting_Part_1-April-2026.pdf
No evidence found does not mean the action did not happen.
No evidence found either way · 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.”
“Infrared technology is used in patients' bedrooms and can monitor their breathing and pulse.”
Essex Partnership University NHS Foundation Trust - BBC News · bbc.com/news/topics/cpdkegwjxdkt
“We can provide emotional and wellbeing support for anyone affected by the Lampard Inquiry. [Find support”
Essex Partnership University NHS Foundation Trust · eput.nhs.uk
“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”
England approves first mental health foundation trusts - PMC · pmc.ncbi.nlm.nih.gov/articles/PMC1458549
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “The Trust is continuing focus care planning and will be holding a dedicated Care Unit Local Quality and Safety Group to spotlight”
“[name redacted], interim chief executive Essex Partnership Trust. Good afternoon.”
Essex Integrated Care Board - Board Meeting - 15 October 2026 · youtube.com/watch?v=MujXdqQNoCI
“The trust were asked to address immediate concerns in relation to regulation 12 (safe care and treatment), 13 (safeguarding) and 17 (good governance).”
Essex Partnership University NHS Foundation Trust · cqc.org.uk/provider/R1L/reports
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “The Trust has continued to review our assessment processes to ensure that the appropriate reviews are undertaken in a timely manner and are supported through the MDT approach which then supports a joined up approach to patient assessments. Staff in the Mental Health Crisis team are required to undertake a mental health assessment for all patients, which is monitored and audited via supervision meetings and compliance reviews.”
“Here you will find papers and minutes from our Board of Director meetings.”
Board papers - Essex Partnership University NHS Foundation Trust · eput.nhs.uk/about/board/board-papers
“The Mental Health Urgent Care Department provides care, assessment and support to people with urgent mental health needs and in crisis, providing a calm and therapeutic space with access to mental health specialists.”
Mental Health Urgent Care Department (MHUCD) - Essex Partnership University NHS Foundation Trust · eput.nhs.uk/services/mental-health-urgent-care-department
“The Trust monitors the implementation of and compliance with this procedure i”
CPA PROCEDURE · lampardinquiry.org.uk/…/MK-014-EPUT-CPA-Procedure-2023-FINAL.pdf
No evidence found does not mean the action did not happen.
Evidence found · stated action: “We have now reached a stage where our Lived Experience Ambassadors have worked alongside us throughout this journey and are actively supporting the recommendations for the Complex Needs Pathway within community mental health services-an area that would traditionally have been managed under the CPA framework.”
“The Patient Experience Portfolio offers a range of services that listen, support, and amplify your voice. Whether you're giving feedback, seeking advice, or getting involved directly, your experiences help shape better care for everyone.”
Patient Experience - Essex Partnership University ... · eput.nhs.uk/get-involved/patient-experience
“Today's Health and Social Care Committee report on Community Mental Health Services is an important and timely reminder of what so many of us working in complex care already know: community-based mental health support saves lives, strengthens neighbourhoods, and offers people the dignity and continuity of care they deserve.”
Essex Mental Health Services Prioritize Patient Voice with Lived Experience Ambassadors | Essex Partnership University NHS Foundation Trust posted on the topic | LinkedIn · linkedin.com/…/eputnhs_livedexperience-mentalhealth-essex-activ…