Jillian Steedman

Essex County Council 
Adult Social Care  
PO Box 11, County Hall 
Chelmsford 
Essex CM1 1LX 

Private and Confidential                                                               03 December 2025 
HM Area Coroner, Ms Sonia Hayes  
Seax House 
Victoria Road South  
Chelmsford  
CM1 1QH 

Dear Ms Sonia Hayes, HM Area Coroner,  

Thank you for your Regulation 28 report regarding the death of Mrs Jill Steedman 
addressed to Essex County Council’s Chief Executive. I am responding on their 
behalf as Director for Adult Social Care South, Basildon and Brentwood. 

I know you will share a copy of this response with Mrs Steedman’s family and I 
would first like to express my condolences. Every death of a vulnerable person by 
suicide is a tragedy and the safety of those we support is our absolute priority. 

You have expressed concern related to the care and support provided by Essex 
County Council’s Adult Social Care service. Before addressing the areas you have 
raised in the PFD I think it may be useful to note that the provision of support for 
those with mental health needs involves several public bodies employing skilled 
professionals who together provide the multi-disciplinary care and support the 
person, and their family, requires.   

It may also be helpful to set out the responsibilities of Essex County Council’s Adult 
Social Care service in this case. Our involvement was limited to participating in the 
production of the S117 aftercare plan in line with our responsibilities under the 
Mental Health Act 1983, which covers the care and support required to minimise the 
risk of readmission to hospital, and to additionally consider any further needs in line 
with our duties under the Care Act 2014 and to meet any needs found to be eligible.    

We accept the recommendations made in the Prevention of Future Deaths Notice as 
they relate to Essex County Council’s Adult Social Care service. We are committed 
to learning the lessons from this tragic case and delivering the necessary reforms to 
ensure that vulnerable people are as safe as possible. 

In this case, it is clear there were failures of communication and coordination 
between system partners that resulted in missed opportunities to fully review Mrs 
Steedman’s support and risk assessment following her discharge from hospital. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 We have been working to address the failings identified in this PFD. Some of this 
work has been internal, by reviewing our own policy and processes, and some with 
system partners such as Essex Partnership University NHS Foundation Trust 
(EPUT).   

To ensure roles and responsibilities for investigating deaths are clear we have been 
working with our colleagues in EPUT to ensure that their Patient Safety Incident 
Response Framework (PSIRF) is robust. We have met with the EPUT lead in this 
area and have provided detailed comments on their PSIRF to ensure that 
safeguarding remains at the centre of the approach, patient safety investigations are 
appropriately dealt with, and, where Adult Social Care needs to be involved, we are 
engaged at the earliest opportunity. We will continue to work with EPUT as they 
further develop their PSIRF.  

We have also been working with system partners to improve the governance 
arrangements that support mental health care in our administrative area and are 
presently working on a revision to the Section 117 policy to ensure that it supports 
the effective delivery of care in this important area and incorporates the learning from 
Mrs Steedman’s sad death. This work is ongoing, but we anticipate it will be 
completed within the next six months. 

Critically the findings in this case, and in particular the recommendations set out in 
the PFD notice, have identified the need for us to take a detailed look at the 
operational delivery of care and support in this area. We have already started work 
by reviewing our policies associated with the delivery of our Mental Health Act 
obligations and are currently examining the operational configuration of our own 
Approved Mental Health Professional service, but we need to do more.   

In response to this PFD, we will undertake a full review of our community mental 
health social work arrangements, including the existing arrangements supporting 
joint working, to ensure roles and responsibilities are clear. We expect this work to 
take place over the next year and we are committed to ensuring that the outcome of 
this work is safer with better coordinated support for those using the service. 

I hope this response provides reassurance that we do take your concerns seriously 
and will act on them. Mrs Steedman’s death was a tragedy for her family and all 
those who knew and loved her, and we are committed to doing all we can to learn 
from her death. 

Yours Sincerely,  

Director for Adult Social Care South, Basildon and Brentwood

03 December 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, 

Jillian Anne Steedman (RIP)  

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

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 10th October 2025 in respect of the above, which was 
issued  to  Essex  Partnership  University  NHS  Foundation  Trust  (EPUT)  and  Essex  County 
Council following the inquest into the death of Mrs Steedman (RIP). 

I would like to begin by extending my deepest condolences to Mrs Steedman’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  concerns  relating  to  EPUT  in  the  hope  that  this 
provides  both  yourself  and  Mrs  Steedman’s  family  with  comprehensive  assurances  of  the 
changes that have been made at the Trust to address the concerns you have raised.  

Concern 1) There was a lack of information sharing between professionals involved in the care 
and treatment of Mrs Steedman who was a complex mental health patient with a long history of 
treatment resistant mental disorder.  

Response:  
The Trust appreciates the need to ensure information sharing between professionals is carried 
out  in  a  robust  and  timely  manner.  To  share  the  learning  on  this  point,  a  post-Inquest  debrief 
was held with the Community and the Crisis Response Team teams to discuss the Inquest and 
the concerns raised with regards to information sharing.   

We recognise the need for a structured approach in addressing the lack of information sharing 
between  professionals  caring  for  a  complex  mental  health  patient.  The  Trust  has  identified  in 
Mrs Steedman’s case that the root causes included systemic barriers of incompatible electronic 
health  record  systems,  cultural 
in 
communication during her transitions of care.  

issues  with  professional  silos,  and  process  gaps 

We  have  strengthened  our  governance  by  reviewing  our  information-sharing  protocols  with 
specific  reference  to  how  we  work  with  professionals  in  other  organisations.  We  have 
introduced  structured  communication methods for  handovers  and  shared  care  plans  which  we 
have  made  accessible  to  all  involved  professionals  including  care  home  and  social  care  staff. 
We are working in a more collaborative culture through regular multidisciplinary team meetings 
which  is  supporting  our  patient’s  safety  and  planning.  The  Trust  has  relooked  at  its  named 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 worker  roles  and  responsibilities  to  ensure  accountability  and  uses  audits  to  monitor 
compliance.  

Finally, we are continuing to involve patients and families by managing consent proactively and 
documenting preferences through advance statements throughout the patient’s journey.  

Concern  2)  Mrs  Steedman’s  consultant  responsible  for  ongoing  Electroconvulsive  Therapy 
(ECT)  was  not  informed  of  her  mental  health  deterioration.  Previous  adjustments  to  the 
frequency of ECT had proved beneficial.  

Response:  
Changes  in  a  patient’s  condition  is  discussed  within  the  MDT  and  this  is  communicated  to  all 
relevant  parties  who  play  a  valuable role  in  supporting  patients  and their  families.  Records  on 
MDT  meetings  are  inputted  onto  the  electronic  patient  record  (EPR)  allowing  for  these  to  be 
viewed by all interested parties 

Concern 3) There was a dispute in evidence between the mental health Trust care co-ordinator 
and other witnesses that this was a complex case with a complex discharge. Mrs Steedman had 
experienced a failed, and several delayed discharges due to the complexity of her case.  

Response:   
The  Trust  MDT  collectively  agreed  that  Mrs  Steedman’s  case  was  a  complex  case,  this  was 
evidenced  through  different  witness  statements  during  the  Inquest.   All  clinical  staff  will  have 
their own clinical judgement on a case based on experience and expertise, however the role of 
the  MDT  is  to  ensure  there  is  a  collective  approach  to,  and  understanding  to,  the  purpose  of 
supporting patients and their families. This would also be true for bank and agency staff.  For all 
staff  this  is  monitored  through  good  supervision,  agency,  and  audit  compliance.      one  of  the 
objectives  of  the  MDT  meetings  is  to  discuss  each  case  and  develop  a  collective  view  to  aid 
safe and efficient care.   

Concern 4) The mental health Trust staff involved in the discharge and community care of Mrs 
Steedman  were  put  on  notice  by  a  clinical  lead  on  16  March  2023  that  the  care  plans,  risk 
assessment  and  procedures  relevant  to  the  discharge  had  not  been  completed  and  were 
required  in  addition  to  the  integrated  plan  that  was  attached  to  the  email.  These  were  never 
completed. 

Response:   
Since  Mrs  Steedman’s  death,  the  importance  of recording  information  in the  care-plan  section 
has been addressed. This has included discussing in meetings with staff, supervision and audit.   

Concern  5)  Mrs  Steedman  was  discharged  to  the  care  home  on  11  April  2023  from  mental 
health  hospital  following  an  admission  of  over  12  months  and  previously  failed  discharges. 
Evidence was heard Mrs Steedman was not appropriately placed in the Care Home based on 
her needs and the local authority were on notice that another care home had refused to admit 
Mrs Steedman due to her mental health. There was no review and the s117 care plan had not 
been updated since 13 September 2022 

Response:  This concern is for Essex County Council (ECC) to respond to. 

Concern 6) The mental health Trust staff and the local authority social worker were visiting Ms 
Steedman.  The  integrated  plan  required  significant  visits  for  Mrs  Steedman  initially  every  day 
with  out  of  hours  support  available  with  a  slow  taper  off  over  weeks.  None  of  the  visiting 
professionals asked to review the care plans or risk assessments and any such scrutiny would 
have revealed these necessary documents had not been completed. 

 
 
 
 
   
 
 
 
 
 
 Response: 
We refer to our reply above under concern 4 in respect of care plans and risk assessments.  In 
addition, as part of team reflections in this matter, the importance of professional curiosity was 
discussed  and the  team  were reminded  that they  should review  care  home  paperwork  (where 
access  is  possible)  and  also  speak  with  carers  within  the  home.   Support  sessions  were 
provided on asking right questions using professional curiosity and how this would have given 
more opportunity to understand Mrs Steedman’s needs and risks, whilst acknowledging that the 
Care Home may in turn approach the Trust with regards to any information or support required.   

Concern  7)  Visiting  Professionals  did  not  complete the required  reviews  necessary  when Mrs 
Steedman was distressed and experiencing crises.   

Response  
The Trust has shared learning through the lessons team  available to all clinical and non clinical 
staff.  Information  regarding  patient  care  is  discussed  robustly  through  MDT’s  and  supervision, 
Caseloads are reviewed through audit.  

Concern  8)  The  appropriateness  of  the  placement  was  not  reviewed  following  a  crisis  on  15 
April 2023 just a few days after admission.   

Response:  This concern is for ECC to respond to. 

Concern  9) Mental  health resource  ‘Sanctuary’ became  involved  in supporting Mrs  Steedman 
as  a  consequence  of  the  handling  of  the  call  to  the  crisis  team,  this  was  not  part  of  the 
Integrated  Plan  and  should  have  raised  concerns  when  entries  appeared  in  the  mental  health 
records that this crisis had not been actioned with the appointed support teams involved. 

Response  
In  this  case  the  CRS  assessed  the  needs  of  Mrs  Steedman  and  identified  that  she  needed 
support  over  the  weekend.   They  were  aware  she  was  open  to  community  services.   The 
decision  was  taken  to  seek  support  from  Sanctuary  who  were  able  to  provide  non-clinical 
support,  thereby  providing  Mrs  Steedman  with  another  layer  of  support.  There  is  now  a  multi 
agency  Transfer  of  Care  hub  where  any  patient  who  has  had  contact  with  the  Urgent  Care 
Pathway will be discussed and a follow up action attributed.  

Concern 10) The Trust investigation following Mrs Steedman’s death did not: 

a.  Refer to any delay in the Trust completing the risk assessment or the omission of the 
agreed risk management for Mrs Steedman following the professionals meeting on 27th 
April  2023.  The  Care  Home  raised  concerns  with  the  Trust  that  Mrs  Steedman  had 
ongoing  expressed  suicidal  risk  and  that  she  was  travelling  unaccompanied  and  may 
divert the  taxi.  Mrs  Steedman  had  gone for  a  home  visit that morning  and  due  to the 
risk,  the  Care  Home  Management  had  directed  Mrs  Steedman  be  accompanied  by  a 
member of care home staff. The Care Home Management were directed by the mental 
health  Trust  team  that  they  must  not  interfere  with  the  Integrated  plan  and  that  Mrs 
Steedman  must  not  be  accompanied.  It  was  agreed  that  a  risk  assessment  and  risk 
management plan would be completed by the mental health Trust and provided to the 
Care Home. This had not been received by 5 May 2023 and the Care Home drafted its 
own risk assessment.  

b.  Note significant deficiencies in the mental health Trust risk assessment completed and 

sent to the Care Home later on 5 May 2023 that made no reference to: 

 
 
 
 
 
 
 
 
 
 
 
 c.  Contact  with  the  Trust  Crisis  Team  on  15  April  2023  where  Mrs  Steedman  was 

expressing suicidal thoughts and that she would throw herself in front of a train.  

d.  Concerns raised by the care home that Mrs Steedman was expressing ongoing suicidal 

thoughts and may divert the taxi to the train station. 

e.  Assessment of the current risk Mrs Steedman would harm herself by throwing herself 
in  front  of  a  train,  the  likelihood  of  the  risk  occurring  and  that  the  outcome  would  be 
fatal. 

f.  Assessment of the specific risk of Mrs Steedman taking a taxi home and may divert the 

taxi to the train station raised by the Care Home Management.  

g.  The absence of a Trust risk management plan to manage Mrs Steedman going home 
alone in a taxi and there was a lack of understanding that Mrs Steedman was paying 
the taxi driver in cash.  

h.  Delay in the attendance of the mental health Trust team following concerns raised by a 
Trust  health  care  assessment  that  Mrs  Steedman  was  experiencing  a  crisis,  was 
expressing suicidal thoughts and was so distressed she could not stand up on 10 May 
2023. The FIRST team had seen Mrs Steedman that morning as part of a planned visit 
to support out of hours and had made entries in the medical records with no significant 
concerns  at  that  time.  Evidence  was  that  the  FIRST  team  were  not  informed  of  the 
crisis,  should  have  been  and  were  available  and  would  have  attended  the  same  day. 
This was part of the integrated plan and this was not actioned. Instead, a decision was 
made  for  attendance  of  the  community  older  adults’  team  the  next  day  leaving  Mrs 
Steedman in distress. 

i.  Mrs Steedman was in significant distress on the visit on 11 May 2023 and the mental 
health nurse was unable to complete an assessment, did not alert the FIRST team for 
assistance and left Mrs Steedman in the care home in the care of staff with no mental 
health expertise.   

j.  Note  that  a  risk  assessment  following  the  visit  on  11  May  2023  was  entered  into  the 
medical records on 12 May 2023 after Mrs Steedman had died. This was not entered 
into the record as a retrospective entry and the medical record was accessed after Mrs 
Steedman’s death. 

Response  
There  is  an  important  need  to  afford  impartiality  to  the  author  /  the  family  in  respect  of  such 
reports  in  relation  to  agreed  Terms  of  Reference  (TOR).  The  internal  report  is  prepared  for 
learning purposes, with the TORs being agreed with families in advance (where they wish to 
engage with the investigation process). This then sets the framework of the review. It would be 
inappropriate for this framework to be influenced by any other process, in terms of what should 
or should not be covered within the investigation.  

Work is ongoing to increase the robustness of the patient safety incident reports, particularly 
around  the  setting  of  Terms  of  Reference  which  set  the  focus  for  the  review.  The  Care  Unit 
Incident Review Group and the establishment of the Patient Safety Lead role within the care 
unit has strengthened this process during 2025. 

There  has  been  joint  work  between  EPUT  and  ECC  that  has  led  to  an  improvement  in  joint 
working  on  patients  safety  investigations,  and  this  is  also  reflected  in  the  updated  PSIRF 
Policy 

 
 
 
 
 
 
 
 
 
 
 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, including copies of 
any of the documents referred to above.   

We understand that a copy of this reply will be shared with the family and ECC.   

Yours sincerely 

Chief Executive