“There is no system that prevents staff that are non- compliant with mandatory training…”
Dated 12 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 7 Aug 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 dated12 Jun 2025
- Deadline7 Aug 2025
- Published on judiciary.uk19 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) There is no system that prevents staff that are non- compliant with mandatory training, including basic life support training, from being able to work on EPUT in- patient wards. (2) This is a particular concern generally, but especially in hospitals such as St Margaret’s where at least some of the wards specialise in treating elderly patients who are likely to be at greater risk of medical collapse than the general population.
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, 2025-0294
- 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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