“The accepted absence of effective formal, compulsory training for clinicians regarding…”
Dated 29 Oct 2024, 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 24 Dec 2024.
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 dated29 Oct 2024
- Deadline24 Dec 2024
- Published on judiciary.uk7 Nov 2024
- 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 NHS Foundation Trust” | Response publishedPublished on judiciary.uk in November 2024. |
The coroner’s concerns
– (a) The accepted absence of effective formal, compulsory training for clinicians regarding the Dual Diagnosis (DD) pathway and what it does and does not provide, how to access it and the potential benefits of it. The evidence confirmed that practitioners outside of the DD 3 workers/pathway were unaware how they could contact them, including directly. (b) In addition to weak record keeping and poor communication with patients and their families, the evidence revealed the lack of a robust and reliable system to ensure that the FRT deals with its caseload efficiently and effectively and particularly how it flags and then follows up referrals to and queries from other services/clinicians contributing, in turn and on the facts of this case, to the significant failure to hold an MDT. The FRT did not follow up (as it was accepted it should have) the referral (via a self-referral) to Open Road or the referrals for a medication review. Had there been such follow up, EPUT evidence confirmed that there would likely have been a discussion of Jamie’s case at a full MDT with the likely allocation of a Care Coordinator, the likely involvement of the Dual Diagnosis pathway and the likely use of the RAG rating system to ensure on-going risk assessment. In my opinion these features give rise to a clear risk of future deaths and must be addressed.
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, 2024-0610
- Added to Minute Book
- 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
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