Recurance · prevention of future deaths reports
Pre-inquest brief
Absence of mental health liaison during 72‑hour hold and missing discharge note
The earlier warning
Aaron Deeley · 19 Jun 2024 · Sonia Hayes, Essex
“During the waiting period of up to 72 hours, Mental Health Liaison will not attend the acute ward or make assessment of the presenting risks of self-harm”
judiciary.uk/…/aaron-deeley-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Aaron Deeley (19 Jun 2024) · stated timescale: 23rd September 2024
“In order to strengthen collaborative working across the two Trusts, a project group for development of the 'joint protocol' is being put into place. The first meeting with attendees from both Trusts has been arranged for 23rd September 2024”
judiciary.uk/…/2024-0331-Response-from-Essex-Partnership-NHS.pdf
What recurred
- 5 Jun 2025 · Nicholas Gray · Sonia Hayes · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Aaron Deeley · 19 Jun 2024
“During the waiting period of up to 72 hours, Mental Health Liaison will not attend the acute ward or make assessment of the presenting risks of self-harm”
Later · Nicholas Gray · 5 Jun 2025
“There was no record of the mental health liaison nurse review on 24 June 2023 and the discharge of Mr [name redacted] from EPUT.”
What happened next
No web check of the stated actions has been published for this chain.