“There was a lack of information sharing between professionals involved in the care and…”

The coroner’s concerns

– (1) There was a lack of information sharing between professionals involved in the care and treatment of Jillian Steedman who was a complex mental health patient with a long history of treatment resistant mental disorder. (2) Mrs Steedman’s consultant responsible for ongoing Electroconvulsive Therapy (ECT) was not informed of her mental health deterioration. Previous adjustments to the frequency of ECT had proved beneficial. Essex Partnership NHS Foundation Trust (3) There was a dispute in evidence between the mental health Trust care co-ordinator and other witnesses that this was a complex case with a complex discharge. Mrs Steedman had experienced a failed and several delayed discharges due to the complexity of her case. (4) The mental health Trust staff involved in the discharge and community care of Mrs Steedman were put on notice by a clinical lead on 16 March 2023 that the care plans, risk assessment and procedures relevant to the discharge had not been completed and were required in addition to the integrated plan that was attached to the email. These were never completed. (5) Mrs Steedman was discharged to the care home on 11 April 2023 from mental health hospital following an admission of over 12 months and previously failed discharges. Evidence was heard Mrs Steedman was not 2 appropriately placed in the Care Home based on her needs and the local authority were on notice that another care home had refused to admit Mrs Steedman due to her mental health. There was no review and the s117 care plan had not been updated since 13 September 2022. (6) The mental health Trust staff and the local authority social worker were visiting Mrs Steedman. The integrated plan required significant visits for Mrs Steedman initially every day with out of hours support available with a slow taper off over weeks. None of the visiting professionals asked to review the care plans or risk assessments and any such scrutiny would have revealed these necessary documents had not been completed. (7) Visiting Professionals did not complete the required reviews necessary when Mrs Steedman was distressed and experiencing crises. (8) The appropriateness of the placement was not reviewed following a crisis on 15 April 2023 just a few days after admission. (9) Mental health resource ‘Sanctuary’ became involved in supporting Mrs Steedman as a consequence of the handling of the call to the crisis team, this was not part of the Integrated Plan and should have raised concerns when entries appeared in the mental health records that this crisis had not been actioned with the appointed support teams involved. (10) The Trust investigation following Mrs Steedman’s death did not: a. Refer to any delay in the Trust completing the risk assessment or the omission of the agreed risk management for Mrs Steedman following the professionals meeting on 27th April 2023. The Care Home raised concerns with the Trust that Mrs Steedman had ongoing expressed suicidal risk and that she was travelling unaccompanied and may divert the taxi. Mrs Steedman had gone for a home visit that morning and due to the risk, the Care Home Management had directed Mrs Steedman be accompanied by a member of care home staff. The Care Home Management were directed by the mental health Trust team that they must not interfere with the Integrated plan and that Mrs Steedman must not be accompanied. It was agreed that a risk assessment and risk management plan would be completed by the mental health Trust and provided to the Care Home. This had not been received by 5 May 2023 and the Care Home drafted its own risk assessment. b. Note significant deficiencies in the mental health Trust risk 3 assessment completed and sent to the Care Home later on 5 May 2023 that made no reference to: i. ii. iii. iv. contact with the Trust Crisis Team on 15 April 2023 where Mrs Steedman was expressing suicidal thoughts and that she would throw herself in front of a train. concerns raised by the care home that Mrs Steedman was expressing ongoing suicidal thoughts and may divert the taxi to the train station assessment of the current risk Mrs Steedman would harm herself by throwing herself in front of a train, the likelihood of the risk occurring and that the outcome would be fatal assessment of the specific risk of Mrs Steedman taking a taxi home and may divert the taxi to the train station raised by the Care Home Management. c. The absence of a Trust risk management plan to manage Mrs Steedman going home alone in a taxi and there was a lack of understanding that Mrs Steedman was paying the taxi driver in cash. d. Delay in the attendance of the mental health Trust team following concerns raised by a Trust health care assessment that Mrs Steedman was experiencing a crisis, was expressing suicidal thoughts and was so distressed she could not stand up on 10 May 2023. The FIRST team had seen Mrs Steedman that morning as part of a planned visit to support out of hours and had made entries in the medical records with no significant concerns at that time. Evidence was that the FIRST team were not informed of the crisis, should have been and were available and would have attended the same day. This was part of the integrated plan and this was not actioned. Instead, a decision was made for attendance of the community older adults’ team the next day leaving Mrs Steedman in distress. e. Mrs Steedman was in significant distress on the visit on 11 May 2023 and the mental health nurse was unable to complete an assessment, did not alert the FIRST team for assistance and left Mrs Steedman in f. the care home in the care of staff with no mental health expertise. Note that a risk assessment following the visit on 11 May 2023 was entered into the medical records on 12 May 2023 after Mrs Steedman had died. This was not entered into the record as a 4 retrospective entry and the medical record was accessed after Mrs Steed

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, 2025-0506

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8 Oct 2026

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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