“The Trust PSIRF Decision Monitoring Tool completed after Mr Gray died contained…”
Dated 5 Jun 2025, from the coroner for Essex. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 31 Jul 2025.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated5 Jun 2025
- Deadline31 Jul 2025
- Published on judiciary.uk17 Jun 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Essex Partnership University NHS Foundation TrustNamed in the report as “Essex Partnership University NHS Trust” | Response publishedPublished on judiciary.uk in June 2025. |
The coroner’s concerns
– (1) The Trust PSIRF Decision Monitoring Tool completed after Mr Gray died contained inaccurate information, the dates of EPUT contact and the substance of the interactions were inaccurate: a. Self-harm was noted as “none known or recorded” b. There was no record of the mental health liaison nurse review on 24 June 2023 and the discharge of Mr Gray from EPUT. The information used to inform a potential investigation requirement contained significant omissions and was not consistent with the information known to the Trust.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2025-0283
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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