Recurance · prevention of future deaths reports
Pre-inquest brief
Delay in prescribing and administering therapeutic medication for first episode
The earlier warning
Bency Joseph · 7 May 2023 · Sonia Hayes, Essex
“[REDACTED] Lorazepam was prescribed and administered on 25 May 2022 at hospital and evidence was that this was sub-therapeutic.”
judiciary.uk/…/bency-joseph-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Bency Joseph (7 May 2023) · stated timescale: end of July 2023
“The Trust is currently considering the need to expand the number and types of medications available for nurses to use via PGD. In order to inform these considerations, the Trust's Director of Pharmacy and Service Managers for urgent care pathways are collaboratively reviewing the medication needs for the services.”
judiciary.uk/…/2023-0148-Response-from-Essex-Partnership-Univer…
What recurred
- 12 Aug 2025 · Resmije Ahmetaj · Sonia Hayes · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Bency Joseph · 7 May 2023
“[REDACTED] Lorazepam was prescribed and administered on 25 May 2022 at hospital and evidence was that this was sub-therapeutic.”
Later · Resmije Ahmetaj · 12 Aug 2025
“(2) There was confusion about the mental health Trust prescribing dose for Ms [name redacted] antidepressant medication and an overreliance on discussions with her rather than checking the prescription dose and communication with the GP was delayed.”
What happened next
No web check of the stated actions has been published for this chain.