Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0283, written 5 Jun 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Jun 2025 |
|---|---|
| Reference | 2025-0283 |
| Deceased | Nicholas Gray |
| Coroner | Sonia Hayes |
| Coroner area | Essex |
| Category | Alcohol, drug and medication related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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 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 1 August 2025 an investigation was commenced into the death of Nicholas Alan GRAY, AGE 63. The investigation concluded at the end of the inquest on 5 June 2025. The conclusion of the inquest was 1a Toxicity Suicide: Mr Gray took an overdose of life. Mr Gray was discharged home in the absence of a psychiatric review or recommended mental health risk assessment. with the intention to end his CIRCUMSTANCES OF THE DEATH Toxicity. Mr Nicholas Alan Gray died at home on 24 July 2023 of Gray had a history of suicidal thoughts and anxiety with low mood and depression contributed to by an exacerbation of pain of a chronic spinal condition with recent surgery. Mr Gray was receiving pain management and commenced an on antidepressant on 12 June 2023. Mr Gray made attempts to stab himself on 18 June 2023 with the intention to end his life and was seen by paramedics and the primary mental health team. Whilst en-route to hospital Mr Gray wished to go home, and an ECG raised concerns about an underlying cardiac issue. Further advice from primary mental health was that Mr Gray had capacity and therefore was taken home. No plan was put in place for assessment of Mr Gray’s mental health or risk to himself. On 22 June 2023 Mr Gray informed district nurses that he was going to end his life, this was escalated to his GP who contacted the mental health crisis team. Mr 1 Gray was conveyed to hospital. On 23 June district nurses updated the acute trust nurse that Mr Gray had knives in his bed at home, had attempted to hang himself, were concerned about Mr Gray’s safety at home and asked that he have a mental health assessment prior to discharge. Mr Gray was reviewed by and closed to mental health services on 24 June with no further action. Mr Gray was not referred to the psychiatrist during his 3-week admission and not reviewed by mental health services prior to discharge. Mr Gray received treatment for his physical healthcare and alcohol withdrawal and discharged on 17 July 2023. 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) The Trust PSIRF Decision Monitoring Tool completed after Mr Gray died contained inaccurate information, the dates of EPUT contact and the substance of the interactions were inaccurate: a. Self-harm was noted as “none known or recorded” b. There was no record of the mental health liaison nurse review on 24 June 2023 and the discharge of Mr Gray from EPUT. The information used to inform a potential investigation requirement contained significant omissions and was not consistent with the information known to the Trust. 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 31 July 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: 5 6 7 8 2 Family General Practitioner 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. 9 5 June 2025 HM Area Coroner for Essex Sonia Hayes 3
1 response 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.
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, Nicholas Alan Gray (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 5th June 2025 in respect of the above, which was issued following the inquest into the death of Nicholas Gray (RIP) . I would like to begin by extending my deepest condolences to Mr Gray’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 the concern raised in the hope that this provides both yourself and Mr Gray’s family with comprehensive assurance of changes that have been made at the Trust to address the concern you have raised. Concern 1) The Trust PSIRF Decision Monitoring Tool completed after Mr Gray died contained inaccurate information, the dates of EPUT contact and the substance of the interactions were inaccurate: a. Self-harm was noted as “none known or recorded” b. There was no record of the mental health liaison nurse review on 24 June 2023 and the discharge of Mr Gray from EPUT. The information used to inform a potential investigation requirement contained significant omissions and was not consistent with the information known to the Trust. Response The Trust PSIRF Decision Monitoring Tool (DMT) is designed to be a document which assists the Trust in understanding what type of investigation/learning review should be undertaken following a serious incident. Completion of the DMT is undertaken by a nominated person from the Care Unit where the incident happened. The Trust Patient Safety Incident Team assist the Care Unit in applying the DMT to the PSIRF framework and making the decision on what type of investigation will be undertaken. The template that was used to complete the DMT in relation into Mr Gray’s passing has been reviewed and amended. This was as a result of clinical staff feedback about the template’s effectiveness, the risk of duplication and the potential for confusion to be caused. The new DMT template came into use in January 2024. Since the new DMT template has been in operation, the Trust has not received any further concerns about the accuracy of information and completion of DMTs. Every completed DMT or investigation now has a Care Unit leadership Multi-disciplinary Team discussion and sign off process. This involves checks and challenges regarding the information provided, decision making and scrutiny of the learning identified. This process provides more robust governance and oversight regarding sign off of a DMT from a Care Unit and Trust wide leadership perspective. DMTs are also subject to further final scrutiny at the sign off stage by central Patient Safety and by those at Executive Director level. 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. Please do let me know if you require any further information at this stage, including copies of any of the documents referred to above. We understand that a copy of this reply will be shared with the family. Yours sincerely, Chief Executive
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