Sharon Langley

25th April 2023 

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

Dear Ms Hayes, 

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

Tel: 0300 123 0808 

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  February  2023,  which  was  issued  following  the  inquest  into  the 
death  of  Sharon  Langley.  The  Trust  has  provided  a  response  in  acknowledgement  of  your 
concerns. 

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

1.  Essex Partnership NHS Foundation Trust staff immediate emergency response was 

not followed: 

a.  pinpoint alarms were not activated immediately on finding Sharon Langley  

unresponsive 

b.  there was a delay calling the ambulance and basic key information about the 

type of the emergency was not relayed:  

i. 
ii. 

by qualified nurses who made the 999 calls, or  
to paramedics on attendance  

c.  there  was  a  delay  informing  the  site  co-ordinator  of  the  emergency  even 
though she was based on the ward and there was a lack of co-ordination of 
the  emergency  resulting in the  ambulance  being  called  a  second time by 
the site co-ordinator  

d.  staff trained in basic life support did not assist the two nurses who were 

attempting to resuscitate Sharon Langley  

-  EPUT’s Head of Deteriorating Patient Pathways and Resuscitation Training Officer is 
working  closely  with  mental  health  wards  to  facilitate  drop-in  ‘refresher’  life  support 
training for clinical and administrative staff dealing with emergency situations. During 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 the training, the importance of calling for help as soon as possible (i.e. use of pinpoint 
alarm) is highlighted and discussed in detail (1a, 1b, 1c, 1d).  

-  The  issue  of  calling  for  help  as  soon  as  possible  is  also  shared  during  the  weekly 
‘virtual’ drop-in sessions which focus on the deteriorating patient. Head of Deteriorating 
Patient Pathways and Resuscitation Training Officer will continue to work with staff at 
the Derwent Centre to conduct a medical emergency simulation with the team and the 
importance of calling for help at the earliest possible opportunity is relayed during the 
post  simulation  feedback.  In  addition,  the  Trust’s  training  department  have  shared 
details of the learning from this incident and inquest for incorporation and sharing within 
the current training programme (1b, 1c).  

- 

In  September  2022,  EPUT’s  Lessons  Team  shared  a  Safety  Learning  Alert  which 
identified  examples  of  learning  from  good  practice  (e.g.,  requesting  help  in  a  timely 
manner from both internal and external colleagues), whilst identifying further learning 
opportunities. The examples highlighted within the document, were taken from reviews 
of medical emergencies which occurred within the Trust. I have attached a copy of the 
Safety Learning Alert (1b, 1c). 

-  The  Head  of  Deteriorating  Patient  Pathways  and  Resuscitation  Training  Officer, 
operational colleagues and the Lessons Team are formulating a communication tool 
for use when contacting the East of England Ambulance Service. EPUT Subject Matter 
Experts have liaised with external partner colleagues to devise the tool and the specific 
information which our colleagues will require in emergency scenarios. The questions 
the Ambulance control room will ask when reporting an emergency have been used as 
the basis for the communication tool poster. It will include essential information relating 
to  the  patients  presenting  medical  condition,  as  well  as  site  information  including 
address  and  postcode.  This  aide  memoir  poster  will  be  positioned  adjacent  to  the 
Nurses  Station  and  a  laminated  copy  placed  inside  the  grab  bag.  This  is  due  to  be 
completed and launched across all wards in May 2023 (1b).  

-  The importance of informing the Site Coordinator and Doctor, at the time of the medical 
emergency, will be shared and highlighted by our colleagues who currently deliver the 
basic life support and grab bag training. In addition, any learning (examples of good 
practice or areas for improvement) which derives from a medical emergency, can be 
shared as part of the training (1c).  

-  A business case, for the creation of an in-house faculty, to deliver the gold standard 
Resuscitation Council UK ‘Immediate Life Support’ (RCUK ILS) training to EPUT staff 
has recently been presented to the Executive Team for their approval. The business 
case will be reviewed again in June 2023 in order to explore the faculty development 
as part of the system wide consideration. The RCUK ILS training focuses on leadership 
and task allocation during a medical emergency (1b, 1c, 1d). 

-  The  Head  of  Deteriorating  Patient  Pathways  and  Resuscitation  Training  Officer  is 
currently  working  closely  with  Carradale  Futures,  to  develop  a  Standard  Operating 
Procedure (SOP), for use with the deteriorating patent and this will include an A to E 

2 

 
 
 
 
 
 
 
 approach  ‘aide  memoir’  document  to  assist  the  team  during  their  physical  health 
assessment. The SOP will link in with the National Early Warning Score 2 system and 
Situation, Background, Assessment, Recommendation, Decision (SBARD) tool and will 
aid the recognition and handover of the deteriorating patient (1b). 

- 

In  addition,  the  Head  of  Deteriorating  Patient  Pathways  and  Resuscitation  Training 
Officer  is  working  closely  with  the  Head  of  Shared  Learning  to  discuss  and  finalise 
content for  a  live  Learning  Matters:  Your  Monthly  Insight  session, to  be held in May 
2023, which will focus on the identification and management of the deteriorating patient 
(1a, 1b, 1c, 1d). 

-  A Task and Finish Group will be arranged by the Trust’s Head of Deteriorating Patient 
Pathways and Resuscitation Training Officer to explore the use of alternative alert and 
communication systems related to patient incidents. This will require the support and 
expertise  of  external  personnel  and  the  Task  and  Finish  Group  will  assist  with  the 
requirements to changes which may be considered. The Group initially met for scoping 
purposes and plans to meet again on 5th May 2023 to progress discussions and plans 
(1a, 1c). 

2.  There was a difference in the safety measures fitted to the bathroom door on the 
adjoining  Stort Ward that  had a self-closure mechanism  at  the time  of  Sharon’s 
death. This mechanism has now been fitted to Chelmer Ward. There is a concern 
that  safety  information  is  not  shared  across  the  Trust  and  known  risks  are  not 
mitigated appropriately.  

-  Safety Alerts related to risk items, such doors, are distributed to all wards and clinical 
staff via the Datix system. Ward staff would be provided with the details of the risk, and 
actions they are required to take to reduce the risk. This may include for work to be 
completed  by  the  Estates  Team,  which  would  be  communicated  with  Estates  and 
evidence of completion recorded within Datix. New risks are discussed at the Ligature 
Risk Reduction Group where the alert is discussed and recommendations are formed 
for  implementations.  Action  are  monitored  via  the  action  log  and  re-discussed  for 
assurance within each of the meetings. 

- 

In  addition,  The  Trust’s  Lessons  Team  have  worked  with  stakeholders  to  develop  a 
process for communication when there are events where new and significant learning 
has  been  identified.  The  Safety  and  Learning  Command  Call  scheduled  to  bring 
leaders  and  subject  matter  experts  across  the  organisation  together  to  discuss  the 
event which has occurred to ensure this is widely communicated across the leadership 
team. Actions are developed and monitored for completion by the Lessons Team and 
a communication strategy of sharing the key information up, down and across the Trust 
is devised. 

3.  The Trust was on notice of issues on Chelmer ward with doors to high-risk areas 

not closing that included the Staff Room and Patient Storeroom.  

a.  At the time of Sharon’s death, the mitigation on the ward was for staff to 
push  doors  to  see  if  they  were  locked,  this  was  action  even  though 

3 

 
 
 
 
 
 
 
 evidence was heard that these doors had keylocks and staff had keys that 
could have been used.  

b.  The  Patient  Storeroom  contains  items  removed  from  patients  as  they 

pose a significant self-harm risk and/or suicide.  

c.  Staff Room that contains items that pose a risk to patients  

Self-closure  mechanisms  have  not  been  fitted  to  these  doors  in  a  high-risk 
environment  of  a  secure  psychiatric  ward  even  though  the  risk  is  known. 
Evidence was heard from patient safety that it is sufficient to have maintenance 
manually adjust doors if there are closure issues.  

-  Since  the  inquest  hearing  the  death  of  Sharon,  the  bathroom  door  on  Chelmer  and 
Stort Wards have been changed to a key lock and the ACT has been disabled from 
use  on  these  doors;  which  means  the  doors  are  now  only  accessible  via  key.  The 
patient store and staff room have locks fitted to them which are accessible via a key 
which staff would be in possession of. This is to reduce the risk of patients being able 
to access such rooms which contain high risk items within. 

-  Clinical teams and the Estates team work closely together to ensure mitigations are in 
place  to  prevent  harm  to  a  patient,  by  meeting  weekly  to  address.  Any  re-occurring 
issue will be picked up by the help desk/estates engineer and at the weekly huddle any 
issues. The Estates Team will facilitate installation and removal of locks where required 
when instructed to consider, and where it is safe to do so. 

4.  Chelmer Ward staff did not always report door closure issues either on the ward 
to the Nurse in Charge or to maintenance. Following the death of Sharon Langley 
there has been no training on how to report door closure issues reported.  

-  The  introduction  of  daily  safety  huddles  since  Sharon  was  an  inpatient  with  EPUT 
supports  effective  communication  across  the  clinical  team.  This  would  include  any 
concerns they may have with door closures and other environmental issues. Actions 
are taken from the meeting, which would include the reporting of the concern, and a 
plan to mitigate against this until it has been resolved. Where the concern is of a clinical 
nature, the clinicians would be responsible for taking action; and where they are related 
to  Estates  issues,  the  Estates  Team  member  at  the  meeting  would  action  them. 
Huddles involving Estates staff take place weekly. 

-  The process of how to raise issues with Estates is set out within the Trust intranet which 
is available to staff. Although these is no formal recognised training of how to report an 
issue with a door closure, this is one of many issues that may be raised with Estates. 
The  key  point  is  that  staff  are  aware  of  the  process  by  which  to  escalate  matters 
appropriately.  If  staff  require  support  to  utilise  the  portal,  requests  are made  via  the 
Estates  Helpdesk  which  are  responded  to  by  Estates  staff.  The  system  in  use  at 
present  is  3i.  3i  is  an  estates  management  system  which  captures  all  maintenance 
issues  and  requests,  which  enables  the  Estates  Team  to  prioritise  the  tasks.  The 
system is audited for completeness fortnightly by the Trust Chief Engineer. 

4 

 
 
 
 
 
 
 
 
 5.  Evidence was heard that the bath plug was required to be kept in the ward office 
when not in use as the bathroom was a high-risk area. There was no evidence that 
staff had to obtain this from the office on the day Sharon Langley died. There still 
appears to be confusion around the requirement.  

-  Following the evidence provided at Sharon’s inquest, processes for the management 
of the bath plug on Chelmer Ward have been reviewed. Bath plugs are not left within 
the bathroom and a new signing in and out sheet has been implemented across the 
Derwent Centre. The plug will be signed out on the form by the staff member who is 
assisting  the  patient  in  the  bath  and  signed  back  into  the  locked  facility  following 
completion of the bath. This includes the time the plug was removed and put back and 
which patient utilised the bath. The form is also signed by the assisting staff member 
to provide assurance that the bathroom door has been locked following completion of 
the bath. 

-  The bath plug is in a locked cupboard which is not accessible to patients. A signing in 
and out sheet has been implemented; with the expectation that this is locked away with 
the plug and staff are to record the use of the plug on the new form. The document was 
discussed  at  the  Inpatient  Clinical  Support  Group  on  5th  April  2023  and  shared  with 
Trust-wide inpatient Service Managers for use. 

-  General Workplace Risk Assessments for each ward will be used to contain details of 
the risk and mitigations for the use of baths and bath plugs. In addition, on 10th May 
2023 the Ligature Risk Reduction Group will discuss a consideration for amendments 
to be made to the ligature inspection tool related to bath plugs. 

6.  There is concern about the reliability of the Trust investigation and how the Trust 

learns lessons. The investigation report did not:  

a.  scrutinise the movements of staff even though the door logs were available 

or raise any issues for further investigation  

b.  raise any issues around the bath plug or where it should be kept  
c.  investigate concerns raised around the Trust staff emergency response or 

failure to provide basic information on the incident to paramedics  

-  The Lead Investigator and author of the Root Cause Analysis report reviewed the door 
access  control  logs  as  part  of  the  investigation  process.  The  Root  Cause  Analysis 
report was completed under the Serious Incidents Framework (SIF, 2015) whereby the 
expectation at the time was for the report to be completed within 60 days of the date of 
commissioning. The Lead Investigator has stated that the logs were received after the 
chronology had been completed and were not analysed in depth due to the timeline 
above.  

-  With regards to the bath plug, the Lead Investigator’s understanding was that this was 
a supervised bathroom and therefore the type of plug and any related risk would be 
mitigated by staff being present at all times, however he does accept that this could 
have been explored in more detail within the report.  

5 

 
 
 
 
 
 
 
 
 - 

In  relation  to  concerns  raised  around  the  Trust  staff  emergency  response,  East  of 
England  Ambulance  Service  raised  the  potential  learning  opportunities  with  EPUT’s 
investigation team and these were addressed in the Lessons Learned section of the 
investigation report. 

-  The weaknesses of the Serious Incident Framework have been nationally recognised, 
which  has  led  to  the  implementation  of  the  Patient  Safety  Incident  Response 
Framework  (PSIRF,  2022).  EPUT  were  an  early  adopter  of  PSIRF  having  formally 
implemented  on  1st  May  2021,  and  have  helped  shape  the  national  implementation 
expectations.  With  this  in  mind,  under  the  Trust’s  current  Patient  Safety  Incident 
Response Plan (PSIRP), an incident of this nature would have been investigated using 
a revised and recognised methodology and the date in which the investigation would 
have  been  set  would  allow  for  a  longer  period  of  time to  scrutinise the  logs  against 
other information to support with a chronology of events, triangulation of events and 
identification of learning. 

7.  The  Trust  investigation  author  changed  the  conclusion  of  his  report  during  the 
inquest when  he  received  statements  provided  by  staff  that were  not  requested 
and contained timing information that in evidence staff stated they did not know.  

-  During the inquest, the Lead Investigator was provided with additional information in 
the  form  of  staff  statements.  In response,  HM  Coroner  requested  a statement  as to 
whether the review of the ACT logs alter the conclusion of the Root Cause Analysis 
report.  In  his  statement  dated  12th  February  2023,  the  Lead  Investigator  confirmed 
following  review  of  the  ACT  logs,  the  material  findings  of  the  investigation  have  not 
changed. 

8.  Quality of record keeping was not deemed to be appropriate by senior staff during 

evidence:  

a.  Significant  examples  of  cut  and  paste 
information at all grades of ward staff, and  

including  out-of-date  risk 

-  A recent Trust-wide inpatient and urgent care pathway audit for record keeping was 
finalised  in  April  2023.  Questions  related  to  copy  and  pasting  within  records  was 
included in the audit and this was broken down into care groups. Care groups identified 
to  have  an  issue  with  the  copying  and  pasting  in  records  are  in  the  process  of  the 
agreeing next steps. For mental health inpatient areas, they are reviewing assurance 
processes  such  as  Matron’s  Assurance  audit  which  will  feature  some  questions 
regarding copying and pasting. 

- 

In  the  meantime,  local  assurance  to  capture  incidents  of  copying  and  pasting  have 
been  embedded.  The Ward  Manager  and  Matron  completed  spot  checks  of  clinical 
records,  and  discuss  at  the  daily  huddles  involving  Ward  Managers,  Matron  and 
Service Manager will identify incidents of copy and paste within the previous 24 hours 
of  documentation  so  this  can  be  addressed  with  individual  staff  members  where 
required. In addition, clinical documentation is reviewed in individual staff supervision 

6 

 
 
 
 
 
 
 
 to ascertain whether copy and paste has been used within records they have written, 
which will be appropriately addressed as necessary. 

-  Across  the  wider  organisation,  EPUT’s  Lessons  Team  produced  a  short  animated 
video with record keeping tips included, and this was cascaded across the organisation 
on 25th January 2023. On 1st February, the Lessons Team hosted a live learning event 
entitled “Learning Matters: Your Monthly Insight”. The topic of discussion focussed on 
record keeping, themes of good practice and also the legalities around medical records. 

-  On  10th  March  2023,  EPUT’s  Lessons  Team  released  a  Safety  Learning  Alert  which 
focussed on copying and pasting within clinical records. The Alert noted that copying 
and pasting had been evident in records within recent inquests, and provided examples 
of where this had been completed. Learning themes were included within the alert, and 
actions were set for managers to ensure the key learning had been disseminated and 
actions  had  been  taken  to  address  the  concerns  raised.  The  final  action  is  due  for 
completion in May 2023. I have attached a copy of the Safety Learning Alert. 

b.  omissions in multi-disciplinary decision-making and risk of self-harm with 
no rationale for the level of observations set for the patient and a plan for 
how risks should be managed  

- 

In  relation  to  completion  of  engagement  and  supportive  observation  records,  local 
procedure  is  in  place  whereby  the  observation  is  completed  by  the  assigned  staff 
member in full. The Nurse in Charge at the end of the shift will sign the observations 
chart  off.  These  are  checked  by  the  ward  manager  for  assurance  they’ve  been 
completed accurately and in full before being uploaded to the electronic clinical records 
system. EPUT has piloted the use of electronic observations (e-obs) which is now being 
rolled out across the Trust. Observation levels are reviewed regularly by the MDT and 
documented within the care review documentation. 

-  The  Trust  is  currently  undertaking  horizon  scanning  relating  to  MDT  communication 
(including MDT meetings where individual patient risk is discussed and management 
plans  agreed),  which  is  one  of  EPUT’s  nine  medium  to  long  term  continuous 
improvement areas. The horizon scan tool is part of the NHS Patient Safety Incident 
Response  Framework  toolkit  and  supports  health  and  social  care  teams  to  have  a 
forward look at potential, or current, safety themes and issues. The horizon scanning 
tool uses the Systems Engineering Initiative for Patient Safety (SEIPS) framework to 
structure conversations about work as done and emerging patient and staff safety risks. 
The findings will be reviewed and actions taken as required. 

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. 

7 

 
 
 
 
 
 
 
 
 
 Yours sincerely, 

Chief Executive 
Essex Partnership University NHS Foundation Trust 

8