Recurance · prevention of future deaths reports
Pre-inquest brief
Incomplete investigation of patient observations
The earlier warning
Morgan-Rose Hart · 19 Dec 2023 · Sonia Hayes, Essex
“The Trust investigation was materially incomplete and there was a lost an opportunity to:”
judiciary.uk/…/morgan-rose-hart-prevention-of-future-deaths-rep…
What was promised
Stated action 1 · response to Morgan-Rose Hart (19 Dec 2023) · stated timescale: none stated
“The Trust has now convened a PSIRF Improvement Oversight Project Board which is chaired by the Executive Nurse and will report into the Safety of Care Committee which is chaired by the Chief Executive Officer.”
judiciary.uk/…/2023-0540-Response-from-Essex-Partnership-Univer…
Stated action 2 · response to Morgan-Rose Hart (19 Dec 2023) · stated timescale: none stated
“We note that the response state at page 5 that”
What recurred
- 5 Jun 2025 · Nicholas Gray · Sonia Hayes · Closely related · confidence 0.85 (high)
The clearest link, quoted from both reports:
Earlier · Morgan-Rose Hart · 19 Dec 2023
“The Trust investigation was materially incomplete and there was a lost an opportunity to:”
Later · Nicholas Gray · 5 Jun 2025
“The information used to inform a potential investigation requirement contained significant omissions and was not consistent with the information known to the Trust.”
What happened next
No web check of the stated actions has been published for this chain.