“The evidence identified a risk of patients at high risk of self-harm being able to leave…”
Dated 1 Dec 2025, from the coroner for Essex. Sent to 2 organisations or people.
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 26 Jan 2026.
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 dated1 Dec 2025
- Deadline26 Jan 2026
- Published on judiciary.uk20 Jan 2026
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Mid and South Essex NHS Foundation TrustNamed in the report as “Mid & South Essex NHS Foundation Trust” | Response publishedPublished on judiciary.uk in January 2026. |
| Essex Partnership University NHS Foundation TrustNamed in the report as “Essex Partnership University NHS Trust” | Response publishedPublished on judiciary.uk in January 2026. |
The coroner’s concerns
– (1) The evidence identified a risk of patients at high risk of self-harm being able to leave the acute ward without appropriate risk assessment (2) The evidence identified a risk of patients at high risk of self-harm being able to leave the acute ward without the knowledge of the hospital staff The above shows a lacuna in terms of patients’ safety and safeguarding. (3) The evidence showed that the Mental Health Liaison Service relies on nurses to conduct initial assessments and follow up reviews of patients suffering with mental health issues and the mechanism by which escalation to a Consultants Psychiatric is decided and the factors to be taken into account for escalation are not at all clear. This leads to lack of Consultant’s oversight for these vulnerable patients.
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, 2026-0011
- 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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