Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Terence Pimm · 14 Aug 2017 · Caroline Beasley-Murray, Essex
“The sufficiency of information sharing and coordination between the police, hospital Trust and probation service.”
judiciary.uk/prevention-of-future-death-reports/terence-pimm
What was promised
Stated action 1 · response to Terence Pimm (14 Aug 2017) · stated timescale: none stated
“All health-based place of safety calls are directed now through the new Trust's call centre. This means that all calls are recorded and documented on a call-log by trained call-handlers.”
judiciary.uk/…/2017-0217-Response-by-Essex-Partnership-Universi…
Stated action 2 · response to Terence Pimm (14 Aug 2017) · stated timescale: none stated
“All patients admitted to health-based places of safety have individual patient records detailing potential risks, assessment of presentation and copies of documentation from other agencies. Further work is continuing on electronic record-keeping processes in regard to this issue.”
judiciary.uk/…/2017-0217-Response-by-Essex-Partnership-Universi…
Stated action 3 · response to Terence Pimm (14 Aug 2017) · stated timescale: none stated
“The information-sharing concordat has been reinforced. Additionally, the new Trust holds localised police liaison emergency care meetings and will ensure that the probation service is invited to improve information sharing in this regard.”
judiciary.uk/…/2017-0217-Response-by-Essex-Partnership-Universi…
4 further stated actions are listed on the full chain page.
What recurred
- 26 Nov 2025 · Aminata Coulibaly · Sonia Hayes · Closely related · confidence 0.85 (high)
The clearest link, quoted from both reports:
Earlier · Terence Pimm · 14 Aug 2017
“The sufficiency of information sharing and coordination between the police, hospital Trust and probation service.”
Later · Aminata Coulibaly · 26 Nov 2025
“Essex Police were aware that [the deceased] was under the care of the crisis mental health team and that the exacerbation of her mental health crisis was linked to a matter that was being investigated as a Hate Crime.”
What happened next
No web check of the stated actions has been published for this chain.