Morgan-Rose Hart
19 Dec 2023 · Coroner Sonia Hayes · Essex
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. incomplete investigation of patient observations
“The Trust investigation was materially incomplete and there was a lost an opportunity to: a. Understand concerns of the Family b. Acknowledge errors and learn lessons from the circumstances of the death. The Director of Operations and Matron informed the Trust Senior Management that the PSII Report had omissions. The Trust evidence was that it was an early adopter of the new NHS investigation process. The lead investigator did not report on material issues as to how [the deceased] was observed on the”
Linked reports
Closely relatedConfidence 0.85 · high
This report
“The Trust investigation was materially incomplete and there was a lost an opportunity to:”
Later report
“The information used to inform a potential investigation requirement contained significant omissions and was not consistent with the information known to the Trust.”
Responses
2023-0540-Response-from-Bindmans.pdf ↗· Essex County Council
Stated action
“We note that the response state at page 5 that”
2023-0540-Response-from-Essex-County-Council.pdf ↗· Essex County Council
Stated action · later this year or early 2025
“The Council has approval four solo bespoke registered Children Homes to work with Children and Young people with high needs that struggle to live with other people for a variety of reasons. - One is operational and internally delivered in Colchester. - The second also in Colchester and has been tendered to a service provider. The building has been handed over and the provider is awaiting Ofsted registration to be operational. - The third solo is currently in planning permission stages for a full”
2023-0540-Response-from-Essex-Partnership-University-NHS-Foundation-Trust.pdf ↗· Essex Partnership University NHS Foundation Trust
Stated action
“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.”