Elise Sebastian
8 Feb 2026 · Coroner Sonia Hayes · Essex
The coroner's concerns
1. lack of autism training among staff
“[the deceased] was neurodiverse and staff were not trained in Autism”
2. medication chart errors
“[the deceased] asked for changes to her medication and then reported that these changes were not therapeutic”
3. Oxevision rollout failures
“The mental health Trust implemented a system called Oxevision with a Project Board to assist with the planning and roll out of the new system”
4. inadequate supervision during meals
“Detained patients including [the deceased] were not kept under observations by trained staff and mealtimes were chaotic with patients moving between areas without the required supervision”
5. falsified observation records
“The mental health Trust were on notice that staff must have falsified the observation”