Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0089, written 17 Feb 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Feb 2025 |
|---|---|
| Reference | 2025-0089 |
| Deceased | David Bennett |
| Coroner | Sonia Hayes |
| Coroner area | Essex |
| Category | Suicide (from 2015) · Mental Health related deaths |
| Organisation named | Mid and South Essex NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive of Essex Partnership University NHS Trust 2. Chief Executive OF Mid & South Essex NHS Trust 1 2 3 4 CORONER I am Sonia Hayes, Area Coroner, for the coroner area of Essex CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. INVESTIGATION and INQUEST On 20 June 2023 I commenced an investigation into the death of DAVID WAYNE BENNETT, AGE 42. The investigation concluded at the end of the inquest on 29 January 2025. The conclusion of the inquest was 1a Hanging. Suicide: Mr Bennett did not receive an assessment of his mental health deterioration on 1 June or 6 June 2023 when he sought assistance and medication for his mental health deterioration. CIRCUMSTANCES OF THE DEATH David Bennett died due to hanging on 13 June 2023 at where he was found suspended by a ligature ingestion of cocaine and alcohol. Mr Bennett had a history of drug induced psychosis that had been treated in the past with antipsychotic medication. Family raised concerns with the GP who advised to call mental health crisis services about Mr Bennett’s safety on 25 May 2023 due to a deterioration in his mental health. The crisis team advised that a person would need to be with Mr Bennett for assessment, there was no follow-up. Mr Bennett’s request for medication for psychosis on 1 June 2023 to the primary care mental health services was not actioned or escalated and at the time there was a current prescription of antipsychotic medication on his GP records. Mr Bennett with 1 attended the acute Trust emergency department on 6 June and informed staff that the Mental Health Urgent Care Centre was closed. Mr Bennett requested medication for psychosis and lack of sleep. Mr Bennett was not assessed or reviewed by mental health services at hospital and was signposted back to primary care and substance misuse services. Mr Bennett was sent a copy of his GP summary and said he was going to try to access a ‘treatment clinic’. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) Evidence was heard that the mental health crisis staff do not appear to have appropriate access to the primary care mental health System One records and there is a risk that vital information is not being shared. (2) The Operational Policy Mental Health Urgent Care Department pathways Appendices are not clear and do not appear to accord with the implementation. (3) Recent contact with the primary care mental health records did not appear to be accurately recorded in the System One Records with suicidal ideation not recorded. (4) Mr Bennett requested a GP appointment; a telephone appointment was made with the primary care mental health nurse. The primary care mental health nurse on 1st June did not escalate Mr Bennett to the GP or Community Psychiatrist when Mr Bennett was adamant he wanted to see a doctor and required an urgent medication review for his deteriorating mental health. (5) Mr Bennett had an open prescription for antipsychotic medication on his GP record that was not being requested and the primary care mental health nurse did not ask about this and the nurse did not inform the GP or seek any advice from her line manager who was a nurse prescriber. 2 (6) Mr Bennett attended the acute hospital Trust for his deteriorating mental health. The acute Trust hospital nurse sought advice from the mental health liaison nurse. The acute Trust nurse did not have access to the mental health or GP records and not all available information was shared with the acute Trust nurse. (7) The mental health liaison nurse asked the acute Trust nurse to undertake the risk assessment for Mr Bennett’s mental health. This is the role and purpose of mental health liaison. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 14 April 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Family I have also sent it to Care Quality Commission who may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 6 7 8 9 17 February 2025 3 HM Area Coroner for Essex Sonia Hayes 4
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
24th April 2025 Private and Confidential Ms Sonia Hayes HM Area Coroner Coroner’s Court Seax House Victoria Road South Chelmsford CM1 1QH Dear Madam, Mr David Wayne Bennett (RIP) Chief Executive Office The Lodge Lodge Approach Wickford Essex SS11 7XX Tel: 0300 123 0808 I write 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 17th February 2025 in respect of the above, which was issued to Essex Partnership University NHS Foundation Trust (EPUT) and Mid and South Essex NHS Trust following the inquest into the sad death of Mr Bennett. I would like to begin by extending my deepest condolences to Mr Bennett’s family. The Trust sympathises with their sad loss. The matters of concern as noted within the Regulation 28 Report have been carefully reviewed and noted. I will now respond in full to these concerns (in respect of EPUT’s care of Mr Bennett) in the hope that this provides both yourself and Mr Bennett’s family with comprehensive assurance of changes that have been made at the Trust to address the concerns you have raised. Concern 1) Evidence was heard that the mental health crisis staff do not appear to have appropriate access to the primary care mental health SystmOne records and there is a risk that vital information is not being shared. Response: As set out in evidence, we can confirm that the Mental Health Crisis team do have access to SystmOne electronic records, however at the time of Mr Bennett’s attendance in the department, the Mental Health Liaison team did not have access to SystmOne electronic records. This was because the Mental Health Liaison team did not use SystmOne to record contact information. By way of assurance, the Mental Health Liaison team now have access to all key systems including SystmOne. Concern 2) The Operational Policy Mental Health Urgent Care Department pathways Appendices are not clear and do not appear to accord with the implementation. Response: We are undertaking a periodical review of the policy and associated standard operating procedure for the Mental Health Urgent Care Department and we will reflect this observation in respect to ensuring clarity, as part of this review and for consistency of application. Concern 3) Recent contact with the primary care mental health records did not appear to be accurately recorded in the SystmOne Records with suicidal ideation not recorded. Response: SystmOne has a template to complete to record the Mental Health Assessment and also a template for risk assessment for the primary care nurse to complete. On the risk assessment there are boxes to check for suicidal thought and self-harm. If these are checked a dialogue box opens up for further information to be added. If the patient is not suicidal there will not be any information recorded. Although SystmOne training is mandatory for it to be used, the Trust will now arrange ensure training on how to use the system for recording suicidal ideation specifically as a focus. We can confirm that a training session for Basildon and Brentwood Mental Health Practitioners planned for the 29 April 2025, where fields for completion in the templates used on SystmOne will be reviewed to ensure all MHPs are proficient in using SystmOne. Concern 4) Mr Bennett requested a GP appointment; a telephone appointment was made with the primary care mental health nurse. The primary care mental health nurse on 1st June did not escalate Mr Bennett to the GP or Community Psychiatrist when Mr Bennett was adamant he wanted to see a doctor and required an urgent medication review for his deteriorating mental health Response: The pathway is that the patient calls the GP, the GP care navigator makes the decision whether to book the appointment with a GP or directly books the patient in to see the Mental Health Practitioner (MHP) for a telephone consultation. If the MHP assesses there to be a need for psychiatric review they will take this to the First Response team Multi-Disciplinary Team (MDT) and request their input (for example, if the Nurse Prescriber considers the patient’s medication need is out of his/her prescribing remit). If the need is physical the MHP will advise the patient to make an appointment with the GP. In this case the patient had wanted to see the GP and was duly advised to go back to the GP. Whilst the process for onward appointments is at the discretion of each GP surgery, there is a procedure in SystmOne for alerting GPs through the recording of a task for the GP practice to alert that their intervention is needed, unless there has been a request made by the GP that the patient should make direct contact with the surgery to make an appointment. At your discretion you may wish to write to the patients GP practice to advise of this procedure within SystmOne. Concern 5) Mr Bennett had an open prescription for antipsychotic medication on his GP record that was not being requested and the primary care mental health nurse did not ask about this and the nurse did not inform the GP or seek any advice from her line manager who was a nurse prescriber. Response: Current and historic prescriptions can be viewed on SystmOne by practitioners based within a GP practice, hence prescriptions / history are available to view as required by attending practitioners. Planned training for Basildon and Brentwood MHP’s will ensure all MHP’s are aware of where to allocate current and historical prescriptions in SystmOne. In addition the team is working with the local private provider on exploring if there are additional modules available on Systmone which will further support care delivery pathways. As set out in evidence, the MHP ought to have discussed this case with a Nurse Prescriber or the Line Manager, the request for medication could have been looked into further. Whilst this would provide insight into medication history, the Line Manager has confirmed that he would not have prescribed any medication for Mr Bennett in light of the fact this is out of his remit. Mr Bennett’s case would have be presented at the First Response Team’s (FRT) Multidisciplinary Team meeting for advice from the Psychiatrist, at the first FRT MDT following the appointment in primary care. Concern 6) Mr Bennett attended the acute hospital Trust for his deteriorating mental health. The acute Trust hospital nurse sought advice from the mental health liaison nurse. The acute Trust nurse did not have access to the mental health or GP records and not all available information was shared with the acute Trust nurse. Response: We respectfully advise that MSEFT are best placed to respond to this concern, regarding access to GP records. With regards to access to the mental health records, the Trust in partnership with MSEFT are currently developing a new unified Electronic Patient record system across EPUT and MSEFT. The strategic ambition to unify care pathways remains at the centre of the programmes commitment including the bidirectional integration with primary care. The new UEPR (NOVA) is expected to go live across the Trust in February 2027. Concern 7) The mental health liaison nurse asked the acute Trust nurse to undertake the risk assessment for Mr Bennett’s mental health. This is the role and purpose of mental health liaison. Response: EPUT absolutely recognises the role of risk assessment tools which are routinely utilised and that clinical expertise and judgment is paramount when undertaking risk assessment of an individual service user. Clinical judgement includes the specific circumstances pertaining to the individual in terms of their presentation. It is therefore maintained that the mental health risk assessment is a standard, joint responsibility. The assessment carried out by the acute A&E nurse was undertaken prior to her seeking advice from mental health liaison nurse, and following her conversation with the mental health liaison nurse, having received the advice she sought. In line with other Mental Health Trusts we are moving towards a “Safety Planning” approach to keeping people safe. This approach is welcomed and championed by those with mental health needs. This approach promotes a collaborative approach to keeping patient’s safe. It would be impractical and a failure of the use of learned and professional expertise to have mental health nurses only carrying out risk assessments. Again, mental health risk assessments is a joint responsibility. The Trust is working to ensure, as far as we can, we take a consistent approach to patient care, however as each case is different, there is a need to apply clear clinical judgement to each patient interaction. The two experienced practitioners in this matter (the A&E Nurse and the Mental Health Liaison Nurse confirmed in evidence that they have worked together for a number of years and there would have been no hesitation in seeking any further support as required). Further, the Trust is continuously seeking to improve our joint working approach with acute colleagues. EPUT has applied and been accepted to be part of the “NHS Confederation Mental Health and Acute in ED Interface Improvement Programme” and we seek to engage with all five Essex Acute Trusts around improved working and patient care. The Inpatient and Urgent Care Divisional Directors of Quality and Safety have reached out and are establishing regular quality forums with the Directors of Nursing in Acute hospitals with the aim of improving joint working and also identify barriers as they arise in our (joint) working practices. I hope that I have provided reassurances around the steps that we have taken to address the issues of concern contained within your report. We know there is an acute need to embed and effect change, hence we will monitor the above provisions to ensure these are contributing to our overall aim of keeping patents safe and delivering therapeutic care. Please do let me know if you require any further information at this stage. We understand that the Court will share a copy of this reply with Mr Bennett’s family. Yours sincerely, Chief Executive
H.M Area Coroner Ms Sonia Hayes SEAX House Victoria Road South Chelmsford Essex CM1 1QH Our Ref: 11 April 2025 Dear Ms Hayes Regulation 28 Report to Prevent Future Deaths – Mr David Bennett I write further to your Regulation 28 Report to Prevent Future Deaths dated 17th February 2025, relating to the Inquest of Mr David Bennett. We have considered your concerns and set out our formal response to each matter using your numbering as follows. Matters of Concern Care sought and provided to Mr Bennett before 6 June 2023 (1) Evidence was heard that the mental health crisis staff do not appear to have appropriate access to the primary care mental health System One records and there is a risk that vital information is not being shared. (2) The Operational Policy Mental Health Urgent Care Department pathways Appendices are not clear and do not appear to accord with the implementation. (3) Recent contact with the primary care mental health records did not appear to be accurately recorded in the System One Records with suicidal ideation not recorded. (4) Mr Bennett requested a GP appointment; a telephone appointment was made with the primary care mental health nurse. The primary care mental health nurse on 1st June did not escalate Mr Bennett to the GP or Community Psychiatrist when Mr Bennett was adamant he wanted to see a doctor and required an urgent medication review for his deteriorating mental health. (5) Mr Bennett had an open prescription for antipsychotic medication on his GP record that was not being requested and the primary care mental health nurse did not ask about this and the nurse did not inform the GP or seek any advice from her line manager who was a nurse prescriber. I understand from my colleagues in attendance at the Inquest hearing, that these matters of concern; points 1 – 5, do not relate to Mid and South Essex NHS Foundation Trust (MSEFT), and we have not identified any action to be taken in respect of these. Episode of care on 6 June 2023 (6) Mr Bennett attended the acute hospital Trust for his deteriorating mental health. The acute Trust hospital nurse sought advice from the mental health liaison nurse. The acute Trust nurse did not have access to the mental health or GP records and not all available information was shared with the acute Trust nurse. Access to medical records- Shared Care Record We have several projects under development to improve the sharing of patient information between us, primary care, social care, and NHS colleagues. We are in the process of devising a ‘Shared Care Record’ with colleagues across the Integrated Care Board enabling unified access to patient records. The collaboration includes us, Essex Partnership University Trust (EPUT), Primary Care, Social Care and other key stakeholders set out below. We are already sharing Emergency Department (ED), maternity and inpatient discharge letters as part of the Shared Care Record, and we will continue to expand on this. We are currently testing the provision to share details of outpatient appointments. As you will be aware, the Mental Health Liaison Team (MHLT) is a service delivered by EPUT, and they are based at our Basildon Hospital site. They have access to our acute care portal (ACP). ACP holds information including test results, appointments, and clinical documentation, (which has been scanned in) from us, and has an in-context link to the Shared Care Record. The MHLT are also able to access the Cerner Health Information Exchange (CHIE) which has some information from other providers such as GPs. Notification, training guidance and videos about the Shared Care Record are currently being disseminated to our ED clinical staff as part of the rollout programme. Once the Shared Care Record is embedded, our clinical colleagues will have access to patient records from other agencies themselves, via ACP, enabling them to have a fuller picture of the patient’s clinical background. Staff will have the potential to be alerted to previous mental health interactions or concerns outside of the acute setting, without relying on the patient’s own disclosure. The types of records currently available are set out in the graphic below. Current Data Slide – February 2025 Unified Electronic Patient Record- NOVA The Nova programme is our long-term plan working to implement a unified electronic patient record (EPR) utilising the Oracle Health platform. This will be a joint platform across acute, community and mental health, enabling a more streamlined, transparent approach to patient care. It will link in with our shared care record (Orion) to allow GPs visibility of information and vice versa, as well as some information being sent to the patient portal, for example discharge letters, results, and questionnaires. The NOVA platform is expected to go live for us in September 2026 and for EPUT in February 2027, allowing all staff to see the entirety of the patient record. The NOVA project is a key priority for us, and staff are updated on progress at my monthly all-staff briefings to ensure awareness and engagement. A full launch programme will be planned, with training package for all staff prior to implementation in 2026. Mental Health Working Group We recognise that patients in mental health crisis must find our services accessible and to achieve this we have established a Mental Health working group to develop specific ED treatment pathways for mental health patients. The working group includes partnership with multiple agencies including EPUT and North East London Foundation Trust (NELFT). Expertise and from neighbouring acute trusts, (Princess Alexandra Hospital and Colchester Hospital) to ensure the pathways developed are robust and straightforward to navigate. The pathways are in the final stages of drafting, for review and approval by all involved agency’s governance structures. The final stage of the plan will include a rollout programme and training for ED staff prior to launch. (7) The mental health liaison nurse asked the acute Trust nurse to undertake the risk assessment for Mr Bennett’s mental health. This is the role and purpose of mental health liaison. I understand you were satisfied that the Trust’s Advanced Nurse Practitioner (ANP) sought the appropriate advice from the MHLT, we have not identified any action for us to take in relation to this concern. Independent Mental Health Liaison Safety Review In addition to the steps taken above, we have commissioned an independent review of the MHLT adult services supplied to us by EPUT. The review was finalised in January 2025 and several recommendations were made to improve the MHLT service. Key areas of focus included: • Responsibilities, accountability & governance • Patient safety • Quality and Patient Experience • Commissioning • Leadership • Continuous Learning, Innovation & Improvement We have devised an action plan to deliver the required improvements to the MHLT service, and this is a key area of focus for us moving forward. We are working in partnership with the Mid and South Essex Integrated Care Board and EPUT to develop a Mental Health Liaison service in all of our hospitals that meets the needs of patients in mental health crisis whilst they await care and treatment in the appropriate mental health care setting. I trust that we have addressed your concerns, however, if I can assist further with these matters, please do not hesitate to contact me. Yours sincerely Chief Executive Mid and South Essex NHS Foundation Trust
See every Prevention of Future Deaths report matching Mid and South Essex NHS Foundation Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.