Julie Beasley

23 July 2025 

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

Dear Ms Hayes, 

Julie Sheila Beasley (RIP)  

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

Tel: 

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 28 May 2025 in respect of the above, which was issued following the 
inquest into the death of Julie Beasley (RIP) . 

I would like to begin by extending my deepest condolences to Ms Beasley’s family. The Trust 
sympathises with their very 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 the hope that this provides both yourself 
and Ms Beasley’s family with comprehensive assurance of changes that have been made at the 
Trust to address the concerns you have raised.  

Concern 1)  
Mrs Beasley was seen at home following a call to the mental health crisis team and required a 
full V4 mental health assessment that did not take place and instead an SBAR review was 
completed, and the nurse did not scrutinise the medications and medication changes that had 
been previously made and made errors about the doses. Mrs Beasley was informed she was 
discharged back to her GP, but no actions were sent by the mental health Trust to the GP.  

Response:  
The Trust has continued to review our assessment processes to ensure that the appropriate 
reviews are undertaken in a timely manner and are supported through the MDT approach 
which then supports a joined up approach to patient assessments.  Staff in the Mental Health 
Crisis team are required to undertake a mental health assessment for all patients, which is 
monitored and audited via supervision meetings and compliance reviews. 

Further, the Trust issued a Trust-wide safety alert, in respect of Electronic Assessment 
Documentation, which re-enforces and reminds colleagues that all sections of the Initial 
Assessment form should be completed or a clear rationale for why it is not possible to 
complete a section should be given e.g ‘Patient is unable to provide this information at present 
due to their current presentation’. 

The expectation is that a full and robust Biopsychosocial assessment is completed for all 
patients requiring an assessment (for which there are clinical polices which corresponds with 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 the Trust approved assessment documentation). The audit and monitoring of this expectation 
is detailed below. 

In addition, the Trust has developed a new electronic handover tool process which will aid 
clearer documentation and clarity in respect of follow up actions.   

By way of evidence provided to the Court, the team have clear processes for GPs to be 
emailed following any patient contact.  Clinical staff are supported by the Team administrative 
personnel who are tasked with sending assessment details to GP’s, which includes highlighted 
actions. 

A process has also been initiated whereby communication is not sent to an individual, but will 
be sent to the MDT.  This ensures there are no delays in communication / actions requiring 
attention. 

Monitoring of the quality of assessments, noting the concerns above has been enhanced with 
monthly assessment quality audits.  The audits are evidence based (NICE Guidance) and 
undertaken by each lead reviewing 10 cases each month.  The lead will feedback to staff the 
themes they have found, good practice and areas for improvement, as a means of ‘spot 
checking’ the assessments that are being carried out. In addition to the team monthly audits, 
An EPUT wide audit carried out in April 2025 for urgent care, showed overall for the 5 teams, 
sections regarding Patient Details, Consent & Capacity, Carers, Referral Details and 
Assessment attained results at 91% or above regarding compliance.  
Alongside this we have been supporting all registered clinicians across our urgent care 
pathways to access STORM training, storm training is a three day training course focussed on 
safety assessment, formulation and planning. As part of our trust year 1 priorities for suicide 
prevention we set a target of 50% by April 2025 of registered urgent care practitioners 
completing the 3 day training, this was achieved. Compliance in June 2025 reported an 
increase to 73% compliance of training attendance in this area against a target of 95% to be 
achieved by April 2026.  The Trust’s plan to achieve full compliance includes an increase of 
Trust facilitators training. A further 8 facilitators commence in September 2025, increase 
training capacity. 

Concern 2)  
Following  this  Mrs  Beasley  contacted  crisis  mental  health  explaining  that  she  had  vital 
information that she had not shared following a visit by a psychiatric nurse at her home. Mrs 
Beasley was not asked what the information was. Mrs Beasley contacted the crisis team again 
a few days later repeating that she had not shared information and again was not asked what 
the information was and was not given an appointment. Mrs Beasley’s telephone contacts were 
noted in her medical record with no details recorded as to what the additional information Mrs 
Beasley wanted to share. Mrs Beasley did not receive the appropriate psychiatric assessment 
following her contact with the crisis team.  

Response:  
A Quality and Learning event, Trust wide for urgent care teams has been held. This included 
Crisis Response and Home Treatment team leaders, clinical managers and service mangers.   

This event was led by the Director of Quality and Safety and Operational Associate Director on 
the 19th August 2024 with a focus on assessment and family involvement. A follow up Urgent 
care away day took place on 1st May 2025 to review all learning, data and incident reporting 
across 2023- 2024 for urgent care to ensure joined up thematic learning and review.  
The scrutiny of deadlines and impact continues to be reviewed at the monthly Urgent care 
Quality and safety meetings. 

 
 
 
 
 
 
 
 
 
 
 
 The learning that has been derived from this case, has been taken forward so as to ensure, 
we pick up and note the lessons to be learnt including the review of systems and processes. 

Again, adherence to policy which includes the management of calls by the Crisis Team, is 
monitored via supervision meetings and audit.  Such reviews also highlight expectations for full 
and clear documentation and the need to apply professional curiosity when new information is 
being offered.   The reviews also help inform and feature in our urgent care quality 
improvement plan. 

The Service is currently seeking to apply for Royal College standard accreditation, which 
provides a robust evidence based framework for service delivery. The Quality Network for 
Crisis Resolution and Home Treatment Teams aims to work with teams to assure and 
improve the quality of crisis resolution and home treatment services for people with 
acute mental illness and their carers. 

The Trust Community Response Home Treatment  Policy is currently under review as part of 
routine review processes, the learning to be taken from this case will be considered as part of 
the review. 

By way of further assurance, reflective supervision is being undertaken with the individual staff 
member who did not speak with Mrs Beasley. 

Concern 3)  
Mrs  Beasley  was  conveyed  to  hospital  having  taken  an  overdose  of  medication  and  was 
reviewed by the Trust mental health liaison team.  

Review of the mental health Trust medical records would have shown that Mrs Beasley had an 
SBAR review rather than a V4 mental health assessment. This should have alerted staff to the 
fact that an urgent assessment was required when Mrs Beasley attended mental health liaison 
following an overdose of her medication. This did not happen.  

Response:   
We refer to the reply set out under concern 1 above, namely that the Trust has continued to 
review our assessment processes to ensure that the appropriate reviews are undertaken in a 
timely manner. Additionally, the Mental Health Liaison Service have been reminded of the 
requirement for a V4 assessment to be completed for all patients. Team Leads will seek the 
advice of HR in respect of any individual staff concerns as required, in light of the need to 
ensure correct and adequate documentation is completed in a timely manner.  Staff have been 
advised of the expectation for clear written rationale in circumstances where the 
documentation has not been completed (as highlighted under response 1 above).    

Concern 4)  
Mrs Beasley had been requesting an urgent appoint and responded immediately to a letter from 
the  Trust  informing  her  she  needed  an  urgent  psychiatric  appointment.  When  Mrs  Beasley 
contacted the crisis team, she was again informed incorrectly that she had recently had a V4 
psychiatric assessment and did not require an urgent appointment.  

Response:   
We refer to the reply set out under concern 1 above. Additionally, by way of assurance, the 
Trust handover protocols are now more robust and are carried out electronically using a rolling 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 document with detail about patient’s presentation, action points for carry over to next shift and 
any emerging risk factors. This electronic record can be accessed by all crisis staff. 

Psychiatrist review requests are now all sent to an MDT email address rather than to individual 
psychiatrists, so that this may be actively, and in a timely way attended to by the MDT review. 
The team is now supported by three senior leads within the team.  

Concern 5)  
Multiple  experienced  members  of  the  mental  health  teams  had  contact  with  Mrs  Beasley 
between  January  and  March  and  did  not  make  detailed  entries  into  the  medical  ?  or  ask 
questions of Mrs Beasley about what additional information she had to provide about her risks 
of  harm  and  suicidal  ideation,  review  of  her medication given  her  deteriorating mental  health 
and calls to the crisis team disclosing increasing suicidal thoughts and ideation accompanied by 
acts and plans. There was a lack of professional curiosity and poor record keeping and rationale 
for decision-making.  

Response:   
The  Trust  has  put  in  place  ‘STORM’  training  which  is  a  three  day  training  package  that 
encompasses best practice, research, evidence, and lived experience in self-harm and suicide 
prevention and related fields. The benefits of this training include: 

 
 
 

Developing and enhancing skills 
Improving attitudes 
Increasing confidence in helping someone who is in distress 

This training is offered to all registered clinicians across our urgent care pathway and we have 
a case for change developed through our trust wide suicide prevention group focussed on 
widening this to all registered clinicians cross the whole Trust. The case for change also 
details EPUTs plan to move away from risk stratification to align with latest NHSE guidance 
‘staying safe from suicide’ published in April 2025.  

As part of our trust year 1 priorities for suicide prevention we set a target of 50% by April 2025 
of registered urgent care practitioners completing the 3 day training, this was achieved. 
Compliance in June 2025 reported an increase to 73% compliance of training attendance in 
this area against a target of 95% to be achieved by April 2026.  The Trust’s plan to achieve full 
compliance includes an increase of Trust facilitators training. A further 8 facilitators commence 
in September 2025, increase training capacity 

I hope that I have provided some 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 a copy of this reply will be shared with the family.   

Yours sincerely, 

Chief Executive