Jayden Booroff

Private and Confidential 
Ms Sonia Hayes 
Area Coroner 
Coroner’s Office 
Seax House 
Victoria Road South 
Chelmsford 
CM1 1QH 

Dear Madam, 

Chief Executive Office 
The Lodge 
Lodge Approach 
Wickford  
Essex 
SS11 7XX 

I  am  writing  to  set  out  the  Trust’s  formal  response  to  the  report  made  under  paragraph  7, 
Schedule 5,  of the  Coroners and Justice  Act  2009  and  regulations  28  and  29  of the  Coroners 
(Investigations)  Regulations  2013,  dated  27th  January  2023,  which  was  issued  following  the 
inquest 
in 
acknowledgement of your concerns. 

the  death  of  Jayden  Booroff.  The  Trust  has  provided  a  response 

into 

I  would  like  to  begin  by  extending  my  deepest  condolences  to  the  family  of  Jayden.  This  has 
been an extremely difficult time for them and I hope that my response provides Jayden’s family, 
and  you,  with  assurance  that  the  Trust  takes  their  loss  seriously  and  has  taken  action  to 
address the issue of concern raised in your report. 

1.  Essex  Partnership  NHS  Foundation  Trust  risk  assessments  missed  key  risk 

information that led to a reduction in observations levels on the ward.  

Following  the  incident  on  the  evening  of  Friday  23rd  October  2020,  a  number  of  immediate 
actions  were  taken  related  to  sharing  information  about  patient  risk  and  the  communication  of 
this between professionals: 

  The  Trust  handover  process  was  reviewed.  Following  this  review,  the  electronic 
handover  sheet  was  revised.  The  auditing  of  handovers  was  increased  to  weekly  for 
assurance via Matrons Assurance Tendable audits. 

  The Trust engagement and supportive observation processes were reviewed. Following 
this review, the document in which observations are recorded on was revised to support 
recording  of  actual  time  for  each  observation.  Policy  revisions  related  to  roles  for 
decreasing  observations  and  auditing  of  observations  was  also  added  to  the  Matrons 
Assurance Tendable audits. 

  The  Trust  appointed  a  medical  quality  lead  who  has  taken  the  lead  on  excellence  in 

medical record keeping.  

An  observation  and  engagement  task  and  finish  group  was  established  to  undertake  a  full 
review of processes and implemented a number of improvements including:  

 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
   An  ‘Engagement  and  Observation  Plan’  was  introduced  to  specifically  record  the 
commencement  and  ongoing  review  of  a  prescribed  level  of  observation.  The  plan 
also identifies whether there has been any increase or decrease in observations and 
eventual discontinuation, based on the risk the patient identifies with. 

  Development of new training videos for all staff, including temporary staff members. 

Further learning was identified following the full investigation of the incident and the following 
key actions identified:  

  The  Trust  has  implemented  a  new  electronic  clinical  dashboard,  which  provides  an 
overview of documentation for ward staff. This is used at handover, and allows staff 
to view the three most recent clinical entries for each patient, including up to date risk 
assessments  and  observation  levels.  Record  keeping  audits  also  take  place  to 
support assurance and monitoring processes. 

 

levels; 

  The  expectation  is  that  the  quality  of  risk  assessments  completed  by  our  staff  is 
reviewed during staff monthly 1:1 sessions with line managers to ensure that all staff 
are maintaining good record keeping. Five Deputy Directors of Quality & Safety are in 
post supporting and working with operational managers collaboratively to ensure the 
embedding of this process.  
In  relation  to  the  risk  information  which  led  to  a  reduction  in  the  engagement  and 
supportive  observation 
the  Trustwide  Engagement  and  Supportive 
Observation Procedure was further reviewed in January 2022 and outlines decisions 
about the level of observation should be made by the multi-disciplinary team (MDT). 
The  procedure  also  references  the  requirement  of  considering  a  patient’s  risk 
assessment in the decision discussion of observation levels. In particular, that a risk 
assessment is completed through interview with the patient and carers, careful study 
of the patient history, use of ratified risk assessment tools, and include assessments 
of  other  professionals.  A  patient’s  care  plan  will  contain  the  rationale  for  the 
observation level agreed, details of their risk assessment and how this is managed. 
  The Trust’s Clinical Guideline on the Prevention of Suicide is currently under review 
and  will  incorporate  changes  to  national  guidance.  The  risk  assessment  component 
of  the  Clinical  Guideline  is  written  in  accordance  with  current  national  guidance 
whereby risk formulation is individualised and informative to risk management and not 
a checklist to predict suicidal behaviour. 

  At  present,  risk  assessment  documentation  within  Paris  and  Mobius  are  “trending” 
which means they capture information from the previously typed risk assessment and 
pull  this  automatically  into  a  new  risk  assessment  form.  This  will  ensure  that  risk 
history  is  included  within  one  place,  whilst  new  identified  risk  can  be  included  to 
ensure  the  comprehensive  nature  of  the  assessment.  The  information  can  be 
considered when making clinical decisions with the patient and their family, and can 
be incorporated into their risk management plan.  

The following improvements have been made in the recent months: 

  Behavioural  standards  have  been  discussed  at  handover  meetings,  highlighting 

importance of concentrating during Observation and Engagement.  

  The Trust has re-circulated the observation training video to all staff (including making 

this available to all temporary workers). 

2 

 
  
 
 
 In addition, changes have been undertaken with wards to strengthen Nursing handovers and 
Safety  Huddles.  Nursing  handovers  are  supported  by  safety  huddles  during  the  shift  to 
maintain  a  responsive  cohesive  response  to  changing  needs  of  patients  and  the 
environment. Nursing handovers ensure the transfer of high quality information and to ensure 
the  duty  of  care  is  maintained.  Effective  handover  of  patient  clinical  information  is  a  key 
component of continuity of quality of care and promoting patient safety.  

A Safety Huddle is a short, stand-up meeting – 10 minutes or less to provide teams a way to 
actively  manage  quality  and  safety,  including  reviewing  risks  and  sharing  important 
information. Huddles can be impromptu and requested by any staff member when there is a 
safety and risk concern. They provide a quick process to share important information quickly 
and effectively with the team. Huddles allow the team to review performance and look ahead 
to flag concerns proactively.  

Safety  Huddles  are  to  be  used  as  a quick  and  effective  way  to share  issues  and  concerns 
about  patients  and  the  ward  environment.  They  support  proactive  responsiveness  to 
changing needs and emerging risks supporting patient safety and management of escalating 
situations.  Any  staff  can  request  a  Safety  Huddle,  but  the  nurse  leading  the  shift  is 
responsible  for  chairing  a  safety  huddle  during  the  shift  or  delegating  to  an  appropriate 
member of staff. Bi-weekly Senior huddles take place whereby acuity and observation levels 
are discussed by the senior team.  

The  Trust  continues  with  observation  assurance  monitoring  and  has  strengthened  some  of 
these processes. Key assurance monitoring includes:  

Tendable audit: 

  Ward  Manager  and  Matrons  Assurance  Tendable  reports  are  completed  on 
alternative  weeks  which  provides  the  assurance  on  ‘relevant  risks’  being  recorded 
within the records.  

  Observation and engagement audit tools are in place which looks at whether:  

the patients observation records were recorded  

 
  observations were undertaken in line with their current observation and,  
  whether rational was identified for the increase or decrease to any observation 

level changes.  

The findings are reviewed and discussed weekly within the Inpatient Clinical Support Group. 

Clinical Audits: 
Adult Inpatient Wards Record Keeping Audit continues to be part of the Trust Clinical Audit 
Programme.  Clinical  audit  is  a  proven  method  of  quality  improvement  and  an  important 
mechanism for  providing  assurance  in  relation  to  the  provision  of  safe and effective patient 
care. It gives staff a systematic way of looking at their practice and making improvements.  

The audit focuses on the records within the Electronic Record System to confirm if all service 
users  within  each  service  has  an  up  to  date  risk  assessment  which  includes  a  risk 
management  plan,  and  ensuring  that  the  MDT  have  had  input  into  the  risk  assessment, 
whether observation levels have been care planned and confirmation that the crisis plan been 
discussed / agreed with the service user and/or family. 

3 

 
 
 
 
 
 
 
 2.  There  is  a  lack  of  understanding  at  Essex  Partnership  NHS  Foundation  Trust  level 

about the difference between:  

a. a patient who has been granted section 17 leave under the Mental Health Act 
who does not return from a period of authorised leave, and 
b.  a  patient  who  being  subject  to  detention  under  the  Mental  Health  Act,  who 
has  escaped  from  the  confines  of  the  ward  and  who  has  not  been  granted 
section 17 leave by the Responsible Clinician  

and therefore, there is  a  concern  as  to how this  information  is then  communicated to 
emergency services searching for the patient of the risks of self-harm.  

A  detained  patient  is  someone  who  has  been  placed  under  a  section  of  the  Mental  Health 
Act. An informal patient is one who has agreed to come into hospital for treatment voluntarily 
and has capacity to make this decision. Informal patients are able to leave the ward as they 
please as they are voluntary patients but they would need to confirm this with staff on duty 
who can make sure they know where the patients are but also to assess that they are fit to 
leave and not a risk to themselves or others. For detained patients under the Mental Health 
Act they will need authorisation to leave the hospital grounds which is given under section 17 
of the Mental Health Act. The Trust’s Mental Health Act procedure outlines the differences in 
leave  for  patients  detained  under  the  Mental  Health  Act.  Access  to  the  Dashboard  during 
handover also reinforces the communication of the patient’s status under the Mental Health 
Act and their leave arrangements. 

In light of communication with emergency services, in collaboration with the Trust’s Lessons 
Team,  a  one-page  aide-mémoire  was  created  to  support  staff  to  escalate  concerns  to  the 
police for incidents where a patient does not return from leave or they have absconded from 
the  ward.  This  guidance  provided  information  regarding  the  impact  factors  that  should  be 
verbalised to the police when reporting a person missing. This would then enable the police 
to make an informed decision in relation to their response. This document uses the SBARD 
communication tool  (Situation,  Background,  Assessment,  Recommendation,  Decision). This 
document  was  shared  with  operational  managers  for  cascading  to  front  line  staff  and  calls 
will be audited between EPUT and Essex Police to ascertain the effectiveness of the tool. It 
includes prompts for staff to disclose details of the patient’s Mental Health Act status. 

3.  Miscommunication between:  

a. Essex Partnership NHS Foundation Trust to emergency services  
b. Essex Police to Essex Partnership NHS Foundation Trust  
c. Essex Police to other emergency services  

In  seeking  further  information,  how  a  risk  managed  within  the  confines  of  a  secure 
mental health ward may change for an escaped patient and whether there is real and 
immediate risk of serious or fatal harm to self or others, rather than assumptions that 
language is being used in the same way by different services.  

The  SBARD  document  detailed  above  was  presented  at  the  Essex  Missing  Person  Forum 
and received positive feedback from group members including Essex Police and Social Care. 
It  was  agreed  that  this  document  should  be  shared,  in  order  that  all  partner  agencies 

4 

 
 
 
 
 
 
 
 
 
 
 throughout Essex could use the same product. This would ensure consistency in approach to 
reporting missing incidents and provide the potential for inter-agency training. 

In  December  2022  and  January  2023,  visits  to  wards  at  Chelmsford  and  Basildon  sites 
confirmed that the guidance posters were on the wall in a prominent position in the nurses’ 
offices and there was an awareness of the purpose of the poster. 

In  addition,  an  agreement  has  been  established  with  Essex  Police  whereby  details  of 
incidents when a patient has been reported as missing are shared with them so the call can 
be listened to and further learning can be established and shared where necessary. 

4.  Lack  of  an  Essex  Partnership  NHS  Foundation  Trust  senior  single  point  of  contact 
for  communications  with  emergency  services  who  would  provide  any  further 
information  or  receive  updates  and  how  this  could  be  managed  across  change  of 
shifts.  

Since  the  incident,  the  Trust  has  appointed  a  single  point  of  contact  where  emergency 
services  can  request  to  speak  the  appropriate  senior  manager  managing  the  incident.  The 
Trust, Essex Police, British Transport Police and EEAST Ambulance Leads are continuing to 
build good relationships and communication as described below: 

  The  Trust  have  an  Essex  wide  single  point  of  access  with  a  priority  ‘emergency 
services line’ to the Contact Centre where emergency services can request to be put 
through to senior management of Inpatient Units & Community Services, and On-Call 
Managers  out  of  hours  (after  5pm  and weekends). This  emergency  line  goes to the 
top  of  the  queue,  so  answered  as  a  priority  and  put  through  to  the  appropriate 
manager.  

  The  Trust  have  developed  good  relationships  with  the  police,  who  are  now  able  to 
join  the  Trust  twice  daily  SITREPS  on  Microsoft  Teams  with  service  managers  and 
Matrons to support escalation and communication. This commenced at the beginning 
of February 2023. 

  There  are  police  liaison  officers  linked  to  Inpatient  Units  across  the  Trust  who  are 

active in managing any concerns, working closely with the Matrons. 

  The  Trust  also  have  a  24/7  Crisis  Response  Service  if  emergency  services  need  a 
physical response/support in the community. There is a priority emergency line to this 
service.  

  Senior police officers and Ambulance Leads who have mental health in their portfolio 
also have the mobile numbers of the Trust’s Executive Nurse, Chief Operating Officer 
and Director of Urgent Care & Inpatient Services as an escalation route. 

  The Trust  co-chairs  the Essex  Crisis  Concordat with Essex  Police.  British Transport 
Police  and  EEAST  Ambulance  Leads  also  attend.  The  next  meeting  is  on  4th  April 
2023,  where  learning  from  this  Patient  Safety  Incident  and  Prevention  of  Future 
Deaths report will be shared and communication pathways will be reinforced. 

I hope that I have provided you with robust assurance that the Trust has taken steps to address 
the issues of concern in your report, that we are continuing to take action to strengthen the care 
provided to our patients, and that patient safety is the Trust’s top priority. 

5 

 
 
 
 
 
 
 
 Yours sincerely, 

Chief Executive   
Essex Partnership University NHS Foundation Trust 

6

HM Area Coroner Sonia Hayes 
HM Coroner's Office 
County Hall, A Block 
Victoria Road South, Chelmsford 
Essex 
CM1 1QH 

Essex Police Headquarters, PO Box 
2, 
Springfield, 
Chelmsford  
Essex 
Tel. 01245 452814 
24/03/2023   

Dear Madam 

Inquest in relation to the death of Jayden Booroff 
Response to Prevention of Future Deaths Report 

I write in response to your Regulation 28 Report to Prevent Future Deaths dated 27 
January 2023.  

I was of course saddened by Mr Booroff’s death and I wish to extend my sincere 
condolences to Mr Booroff’s family for their loss. I can confirm that Essex Police is 
continually working with partner agencies to improve our system-wide response and 
we are committed to address any matters of concern. 

In addition to responding to your concerns as detailed at paragraph section 5 (3b) 
and 5 (3c) of your report, in this letter, I will outline a number of measures we have 
taken which have relevance to other areas touched upon during the inquest hearing.  

As detailed by Chief Inspector Scott-Haynes during the inquest, immediate action 
was taken to align our Missing Persons Procedure B1601 with the College of 
Policing guidance.  The Procedure is now clear that contact must be made with the 
British Transport Police (“BTP”) if BTP has placed a suicide risk or related 
information marker on the Police National Computer (“PNC”).  

Protecting and serving Essex 
 
 
 
 
 
 
 
 
 
 
 
 
 
 In relation to partnership working between Essex Police and EPUT, several 
measures to improve and develop working practices between Essex Police and 
EPUT have been initiated since Jayden’s death in October 2020. These measures 
have been put in place to ensure continuous improvements to the single agency and 
joint responses from both organisations, to better safeguard the public.  

These measures are detailed below.   

1.  The Senior Partnership Mental Health Board, chaired by an Essex Police 

Assistant Chief Constable and attended by the CEO of EPUT. This allows for 
the most senior level of discussions, and to discuss system pressures and 
new ideas.  

2.  At a strategic level, a Mental Health Risk Management Board has been 

created.  This board is co-chaired by a Senior Essex Police officer and the 
Director of Adult Social Care in Essex County Council. This strategic forum 
discusses areas concerning mental ill health across Essex, and is attended by 
senior representatives across the health care system, as well as 
representatives from BTP. Examples of areas regularly scrutinised are section 
135 Mental Health Act backlogs, bed availability and firearms backlogs. The 
Board also identifies and tackles the agencies’ demands, blockers and 
enablers. Additionally, a multi-agency policy in relation to sections 135 and 
136 of the Mental Health Act has been drafted by EPUT, supported by Essex 
Police, which enables all agencies to understand their roles when it comes to 
managing these issues, as well as escalation processes that will apply. This 
policy was put in place in December 2022.   

3.  Essex Police’s Strategic Vulnerability Centre is a department that oversees 

and co-ordinates the force’s activity across a number of areas of vulnerability.  
It includes non-operational thematic strands relating to missing persons and 
Mental Health. Through the work of the Strategic Vulnerability Centre: 

a.  the new National Police Chief’s Council ‘Advice to Police Forces on 
Restricted Patients under S37 and S41 Mental Health Act 1983 who 

 
 
 
 
 
 
 Abscond’, received in January 2023, has been shared internally with 
Essex Police and with other relevant agencies/organisations.  

b.  This team are also working towards the implementation of ‘The multi-
agency response for adults missing from health and care settings - A 
national framework for England’. This is collaborative guidance 
produced by the Home Office, NPCC, and the Missing Persons charity. 
The team held a multi-agency collaborative conference in September 
2022 with Essex Local Authorities, local Integrated Care Boards, and 
third sector organisations and achieved buy-in to a Task & Finish group 
looking at how to roll out this framework in Essex.  

4.  Essex Police force growth resulted in the creation of a new dedicated Mental 
Health Team in November 2022. This team is positioned within the Strategic 
Vulnerability Centre. The team has an establishment of an Inspector, a 
Sergeant, a police staff supervisor, 2 Constables and 3 police support staff. 
This team has a holistic overview of mental ill health from a policing 
perspective within Essex and works with EPUT in partnership to improve and 
develop working practices and compliance with service level agreements.  
The intention of the team is to achieve a reduction in existing numbers of 
section 135 MHA warrants, improvements in the multi-agency response to 
section 136 MHA assessments, improved information sharing, reducing 
instances of violence in health care settings, and having multi-agency tactical 
plans in place for individuals at higher risk of causing serious violence.  

5.  This ongoing work is supported and facilitated by regular meetings between 

the Mental Health Team Inspector and EPUT equivalent in which operational 
areas of concern are discussed which allows for closer partnership working 
and early resolution of issues.   

6.  Essex Police representatives also now attend the twice daily bed 

management call to discuss ongoing demands and understand the day’s 
system pressures.  

 
 
 
 
 
 
 
 7.  Additionally, Essex Police assisted EPUT with amendments to the current 

Information Sharing Agreement so that it incorporated more partner agencies 
to cover a broader spectrum. This now includes information-sharing in relation 
to individuals with indicators of serious violence and homicide, as well as 
individuals of concern who are being discharged from health care. This 
enables the identification of risk and for a multi-agency discussion to be held, 
where a tactical plan can be put in place to mitigate the risk of harm to the 
public.  

8.  The Strategic Vulnerability Centre also work with a retired police 

superintendent, who is works at EPUT in a role that includes being tactical 
liaison between both organisations. As part of this role the individual has 
created advice and guidance for EPUT staff particularly when explaining how 
to report a missing person to police and how to articulate their concerns about 
risk in language that is consistent with police terminology and more easily 
understandable. This will do much to address your concern outlined in your 
report about miscommunication and assumptions that language is used the 
same way by different services. 

9.  The Strategic Vulnerability Centre also co-ordinates and encourages internal 
Essex Police communications and messaging in relation to these areas, 
through publishing of relevant guidance and best practice. These internal 
communications include any lessons learnt with a regular focus on Mental 
Health and Missing Persons at least once a month.  

10. At a more local level, Essex Police have embedded dedicated police liaison 

working within the Linden Centre in Chelmsford. This liaison role is resourced 
by a constable, with an Inspector providing a local strategic overview.    

a.  The role of the constable is to  

i.  assist in the early identification of potential operational issues 

and/or individuals of concern,  

ii.  facilitate the completion of enquiries/actions regarding ongoing 

police investigations 

 
 
 
 
 
 
 iii.  improve information-sharing and partnership-working between 

local officers and mental health staff, and  

iv.  support mental health staff from a policing perspective.  

b.  The Inspector role is one undertaken by a current operational officer in 
addition to their established post. This role provides local strategic 
support to the ongoing partnership liaison being conducted by the 
constable and involves  

i.  regular meetings with EPUT equivalents 
ii.  analysis of relevant data around crime and reports of missing 

persons, and  

iii.  ensuring that best practice and relevant joint policies and 

procedures are being complied with.  

11. As detailed in the inquest, the investigation of Ms Booroff’s complaint led to a 
recommendation for additional mental health training within Essex Police.  
Additional training has now been completed with frontline uniformed officers 
receiving specific training on the Mental Capacity Act and police powers, 
diversion through the Mental Health Street Triage team, and how better to 
deal with assaults within healthcare settings, as part of their continuous 
professional development. This training was delivered as part of Essex 
Police’s ongoing training programme. A further continuous professional 
development training session was completed with officers/staff who would not 
have been able to access the training otherwise and this was recorded and 
stored on the force’s relevant internal sharepoint page. Additionally, the force 
learning and development department are reviewing the current training 
package being provided to trainee officers/staff to ensure that it is up to date 
and contains the most recent guidance. 

In light of the measures outlined above – and specifically at number 8 above – I hope 
that your concerns are allayed and that you are reassured that Essex Police have 
taken appropriate actions to ensure that our response is of the highest standard. 

Yours sincerely, 

Chief Constable