“Re: EPUT A significant number of the causative failings identified in this case have…”

The coroner’s concerns

Re: EPUT A significant number of the causative failings identified in this case have previously informed PFDRs issued to EPUT and have claimed to have been addressed in responses to those PFDRs. In June 2024 a ‘Thematic Analysis’ Review Document prepared by EPUT’s ‘Lessons Team’ identified ‘Triangulated Themes’ from a review of (then) nine PFDRs issued in the Essex Coronial jurisdiction between June 2021 and January 2024. The Review acknowledged six ‘Triangulated Themes’ in respect of which failures causative of deaths had been, and continued to be, identified, including: Communication; Training & Supervision; Record Keeping; Discharge Planning; Care Planning; Risk Assessment. Multiple further PFDRs issued to EPUT in 2024 and through 2025 have raised very similar and related concerns. Of particular concern is the fact that in a response to a previous PFDR issued in 2023, the CEO of EPUT wrote a letter of response to this Coroner dated 21st September 2023 seeking to provide reassurance in regard to a number of features of EPUT performance. However, these same features were identified by the jury in Mr Berry’s case to have been more than minimally causative of his death in early 2024. Specifically, matters identified as having contributed to Mr Berry’s death arose over the period of provision of care that post-dated the CEO’s letter in response the PFDR issued ie September 2023 through to late January 2024. CONCERN: During Mr Berry’s inquest, once again, many of the continuing failings under precisely the themes identified in the 2024 ‘Thematic Review’ and in PFDR responses prior to that review as well as in the period since that Review, have been identified as having informed the causative features contributing to the death of a patient under EPUT’s care. In my opinion, the actions taken by EPUT to date to address the acknowledged failings reflected under the themes and issues referred to above have been, and remain, inadequate and incomplete, specifically: (a) Failures in the performance of the CMHT and the allocated Care Coordinator as required under the Care Programme Approach (CPA) and as mandated by EPUT policy. These failures indicated significant human error not detected by an insufficiently robust system and not therefore corrected prior to the death: 4 (b) Failures in Care Planning: specifically, a failure to appropriately up-date and document matters relating to Mr Berry’s Care Plan consistent with Trust policy. (c) Failures in Risk Assessments: specifically, failures to appropriately update and document matters relating to Mr Berry’s risk assessment consistent with Trust policy. (d) Failures in Documentation: in a number of acknowledged respects the electronic records were inadequate - and inconsistent with EPUT policy. (e) Failure of joint working internally: the CC did not attempt to escalate or consult with EPUT colleagues via the regular weekly MTD meeting or any other type of Professionals’ Meeting. (f) Failure of joint working externally: the CC did not liaise at all with the external specialist substance misuse team, even though the cocaine misuse was a central aspect of his presentation and mental health deterioration. (g) Failures in Communication within and between teams as above but also, crucially, including a failure to appropriately liaise with the deceased’s Family to gather collateral information and to provide a carer’s assessment and/or support to Mr Berry’s family. Re: MOJ: Evidence was given by a senior Prison Officer working for Prison Learning and Development at HMP Chelmsford responsible for providing Prison Officer Entry Level Training (POELT) to new officers at HMP Chelmsford, regarding the training that would have been received by the officers involved in the opening and maintenance of Mr Berry’s ACCT document. She confirmed that ACCT training is provided at HMP Chelmsford under an umbrella heading of Suicide and Self Harm (SASH) training and are covered in induction training. The witness was particularly critical of ACCT training at national level expressing concerns as to whether the said training was ‘fit for purpose’. Evidence indicated that the training was long overdue revision. She confirmed that she had sent some five emails with course improvement proposals to which she had not received a single response. The POELT witness raised a specific concern that the five-minute period allowed for ‘Risk Awareness’ training, as set out in the Safety Support Skills Module 3 Suicide and Self-harm contained in the HMPPS Learning & Development Manual, was wholly inadequate and relayed that she felt obliged to unilaterally extended this critically important aspect of the training to at least one hour. 5 CONCERN: In the context of the finding of the jury of a gross failure to ensure that Mr Berry was, in all the circumstances as known to the prison staff, subject to Constant Supervision, I am concerned that inadequate national training contributed to an over-reliance by prison staff on the subjective perception of an ‘improvement’ in a prisoner’s transient presentation and demeanour over obvious and grave documented risk factors when assessing risk and setting observation levels. The reassurance provided by Mr Berry, (according to the Supervising Officer), appears to have been dangerously misleading and uncritically accepted notwithstanding the clear, high risk of suicide Mr Berry presented. This, in turn, gives rise to my concern (in the light of the evidence provided by the POELT trainer) that the exceptionally short time allocated in national prison officer training to equip officers with the requisite skills to assess, identify and records triggers, risk factors and protective factors is wholly inadequate. CONCERN: A further concern raised by the evidence relates to the lack of any attempt to cost structural cell improvements to mitigate, in at least some cells on each wing, the most obvious of ligature points in the Victorian Prison

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, 2026-0015

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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