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recurance

Phephisa Mabusa

15 Jul 2024 · Coroner Patricia Harding · Central and South East Kent

The coroner's concerns

  1. 1. delayed response to category D mental health crises

    “The Trust has departed from the national guidance for category D presentations such that the local guidance has been amended to reflect a 7 day response when the national guidance states 72 hours”
  2. 2. incorrect triage code documentation in operational policy

    “Essex Partnership University NHS Foundation Trust's existing standard operational policy document for the Crisis Response Service incorrectly states triage codes D and E on the appendix as 'within 24 hours- same day response and do not reflect the scale on the 111 Triage form or the national guidance”

Responses

2024-0487-Response-from-Essex-Partnership-NHS.pdf ↗· Essex Partnership University NHS Foundation Trust

Stated action

“The Standard Operational Policy has been reviewed and the identified errors rectified. A memo has been sent to all clinicians within the service reminding them of the use of the UK Mental Health Triage Scale in informing their clinical judgment in the decision making process. This has also been shared with the leads covering the other CRS teams.”
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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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