Bency Joseph

7 July 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 

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 7 May 2023, which was issued following the inquest into the death of 
Mrs Bency Joseph. The Trust has provided a response in acknowledgement of your concerns. 

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

1.  Essex Partnership NHS Foundation Trust Mental Health Liaison Psychiatrist assessed Bency 
Joseph as suffering from a first episode psychosis when she attended hospital on 23 May as 
an emergency and there was a delay in prescribing and administering therapeutic medication 
required for a first episode of psychosis with delusions. 

a. 

 Lorazepam was prescribed and administered on 25 May 2022 at hospital 
and  evidence  was  that  this  was  sub-therapeutic.  One  dose  of  medication  was 
administered  and  Bency  Joseph  was  discharged  under  the  care  of  the  Home 
Treatment Team. 

b.  On  26  May  the  Home  Treatment  Team  found  that  Bency  Joseph  did  not  have 
capacity, had deteriorated and prescribed urgent medication to be provided on the 
same day. The medication was not provided. 

c. 

It is unclear if the urgent prescription was received and processed. 

d.  The family’s concerns and attempts to escalate the failure to provide the medication 
were not actioned by the Trust and the death occurred in the early morning of 27 
May  as  the  family  were  making  arrangements  to  take  Bency  Joseph  back  to 
accident  and  emergency  due  to  the  omission  to  provide  medication  and  further 
deterioration. 

 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 I note the above concern states that Mrs Joseph was assessed by a Psychiatrist. I can also 
confirm that Mrs Joseph was assessed by a Mental Health Nurse in the Mental Health Liaison 
Team on 24 May 2022. 

In relation to access to medications, staff within the Home Treatment Teams (HTT) and Mental 
Health  Liaison  Teams  (MHLT),  have  access  to  Patient  Group  Direction  (PGD)  medications 
which they can provide to patients on assessment, if required. The current PGDs available to 
staff for supply/administration are: 

  Lorazepam 
hours 
  Zopiclone 
  Promethazine 

anxiety 

 when needed for anxiety, every four to six 

 at night when needed for sleep 
 when required for 

Nurses  are  required  to  undertake  training  for  working  with  PGDs  generally  available  as  e-
learning  via  the  Trust  online  training  portal  addressing  legal  and  accountability  issues. 
Competencies are assessed by team managers during supervision, medicines management 
face-to-face and online training. Authorisation to work within a PGD has to be renewed every 
two years or if the document is updated ahead of this timeframe. 

As patients are often referred to MHLT and HTT with varying symptoms. The Trust is currently 
considering the need to expand the number and types of medications available for nurses to 
use via PGD.  In order to inform these considerations, the Trust’s  Director of Pharmacy and 
Service Managers for urgent care pathways are collaboratively reviewing the medication needs 
for the services. 

Within  urgent  care  services  where  patients  may  access  the  services  out  of  hours,  quick 
initiation of medication is sometimes required. In Mrs Joseph’s case, the medication had been 
requested  by  the  Psychiatrist  in  the  HTT  on  26  May  to  the  Trust’s  pharmacy  team  at 
15:30hours when he reviewed the patient. The Trust’s pharmacy team operates 09:00hours to 
17:30hours and it may take several hours for a request to be processed, which then requires 
delivery from the central pharmacy department to the requesting site. 

Doctors and Nurse Prescribers are aware of the need to utilise FP10 prescriptions and signpost 
patients and relatives to their local pharmacy to obtain medications without delay if it’s safe to 
do so. 

As part of care provided by the HTT, there are occasions where medication may need to be 
supplied by the Trust’s pharmacy department; an example being on occasions where the HTT 
are  administering  and  monitoring  the  medications  in  the  home  environment  to  support 
concordance  or  where  the  medicines  involved  are  “hospital  only”.  In  these  circumstances 
robust planning takes place to ensure that a timely supply is possible. 

Resources are being developed for urgent care services across the organisation to re-enforce 
the  expectation  that  an  FP10  should  be  used  initially  for  patients  who  require  urgent 
medications to manage their symptoms. We aim to have the resources available by the end of 
July 2023. Supply via PGD would be used where there is an urgent need and no access to a 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
  
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Doctor or Nurse Prescriber to complete an FP10, and where the medication is available by this 
route with a competent Nurse to supply. 

2.  The Trust investigation did not: 

a.  Inform or involve the Trust Senior Pharmacist who was unaware of the death and 

had no opportunity to be involved in the internal investigation. 

b.  Involve the Family of the deceased 

c.  Lost  an  opportunity  to  understand  concerns  that  the  Family  had  been  trying  to 
access additional urgent medication prescribed on 26 May 2022 without success 
and had been telephoning the Trust to raise an alert. 

Following  notification  of  Mrs  Joseph’s  death,  the  Trust’s  Clinical  Review  Group  reviewed 
details of the incident on 14 June 2022 and requested that a Clinical Review be completed. 
The Group directed that the scope of the review should be from Mrs Joseph’s first contact with 
the Trust until her death and that any questions from the family should also be answered. At 
that point in time, it was  not  evident that involvement from the Trust’s  Director of Pharmacy 
would be required, however the Trust acknowledges that when the report was reviewed by the 
Clinical Review Group,  the  Group  should have picked  up  on this  point and  requested  input 
prior to final approval of the report. This learning has been shared with the Chair of the Clinical 
Review Group. 

The Trust wrote to Mr Joseph on 18 July 2022 to advise him that a Family Liaison Officer (FLO) 
had been allocated to support him throughout the review process; the letter provided the name 
and contact details of the FLO. The FLO contacted Mr Joseph to explain the review process 
and enquire as to whether Mr Joseph had any questions he would like addressed within the 
report. Unfortunately, despite further contacts on 3 October 2022 and 19 November 2022, Mr 
Joseph  did  not  provide  any  questions  and  therefore  the  report  was  completed  without  any 
questions from the family. This is not an unusual occurrence; we are mindful of not imposing 
on families during their time of grief. In such cases the FLO provides reassurance that whilst 
the review process will continue, any questions can be addressed following completion of the 
report and the Trust does not put a timeframe on engaging with families post report approval. 
Mr  Joseph  was  in  contact  with  the  FLO  following  Mrs  Joseph’s  inquest  and  the  Trust  has 
recently responded to this. 

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. 

Yours sincerely, 

Deputy CEO