Warren Green

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

06 March 2026 

Private and Confidential 
Dr Jeane Mellani   
HM Assistant Coroner 
Coroner’s Court  
Seax House 
Victoria Road South 
Chelmsford 
CM1 1QH 

Dear Madam, 

Mr Warren James Green (RIP)   

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 12th January 2026 in respect of the above, issued to 
Essex Partnership University NHS Foundation Trust (EPUT) and Mid and South Essex NHS 
Foundation Trust (MSE) following the inquest into the sad death of Mr Green. 

I would like to begin by extending my deepest condolences to Mr Green’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 the concerns as they relate to EPUT in the 
hope that this provides both yourself and Mr Green’s family with comprehensive assurance 
of changes that have been made at the Trust to address the concerns you have raised.  

Concern 1) The evidence identified a risk of patients at high risk of self-harm being able to 
leave the acute ward without appropriate risk assessment  

Response:   
We respectfully advise that this concern is for MSE to respond to. 

Concern 2) The evidence identified a risk of patients at high risk of self-harm being able to 
leave the acute ward without the knowledge of the hospital staff 

The above shows a lacuna in terms of patients’ safety and safeguarding. 

Response:   
We respectfully advise that this concern is for MSE to respond to. 

Concern 3) The evidence showed that the Mental Health Liaison Service relies on nurses to 
conduct  initial  assessments  and  follow  up  reviews  of  patients  suffering  with  mental  health 
issues and the mechanism by which escalation to a Consultants Psychiatric is decided and 
the  factors to  be taken  into  account for  escalation  are  not  at  all  clear.  This  leads  to  lack  of 
Consultant’s oversight for these vulnerable patients 

 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Response:  
In line with the assurance evidence presented to Court, we confirm that the ‘Core 24’ model 
is a nationally endorsed NHS best-practice standard for 24/7 liaison mental health services in 
acute hospitals. This model was applied in respect of the care afforded to Mr Green. 

The ultimate purpose of this model is to ensure that patients presenting with mental health 
needs in Emergency Departments (EDs) and Acute inpatient wards receive timely, 
comprehensive biopsychosocial assessment and rapid formulation of care plans. The model 
mandates immediate mental health support, improved crisis response, and integrated 
working with acute hospital teams.   

A full copy of this model can be provided to the Court as required.  

In summary, the ‘Core 24’ model is specifically designed to provide: 

•  Rapid mental health assessment, typically within 1 hour in ED and within 24 hours for 
ward referrals, consistent with national urgent and emergency mental health care 
pathways 

•  Comprehensive biopsychosocial assessments, including:  

o  Mental state examination 
o  Risk assessment (self-harm, harm to others, vulnerability) 
o  Physical health considerations 
o  Psychosocial factors 
o  Formulation and management planning 

• 

Integrated liaison with acute clinicians to ensure safe discharge planning, admission 
avoidance where appropriate, and effective management of comorbid physical and 
mental health conditions. 

These assessments must be completed by appropriately skilled mental health professionals 
working within the liaison service, ensuring both timeliness and clinical quality. 

Further, the Model provides that the following multidisciplinary roles are typically enabled in 
order to undertake the ‘Core 24’ Mental Health Assessments, which goes to your specific 
concern re: Consultant oversight: 

1. Consultant Psychiatrists 

o  Provide senior clinical oversight and complex diagnostic assessments. 
o  Offer medical leadership for risk formulation and treatment planning. 

2. Mental Health Liaison Nurses (RMN-qualified) 

o  Often the primary frontline assessors in Core 24 services. 
o  Conduct full biopsychosocial assessments, risk assessments, care planning, and 

coordination with acute trust colleagues. 

3. Mental Health Practitioners / Allied Health Professionals (Depending on local staffing 
models and competencies, this may include: Social Workers, Occupational Therapists, 
and Psychological Practitioners.) 

o  Undertake assessments aligned to their professional scope. 
o  Contribute to holistic biopsychosocial formulation and care planning. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 4. Junior Medical Staff / Specialty Doctors (in some services) 

o  Support assessments under supervision of senior medical staff. 
o  Assist with medication review, diagnostic clarification, and ongoing medical 

oversight. 

5. Multidisciplinary MDT Members 

o  MDT involvement is emphasised to ensure that risk, mental state, social factors, 

and physical comorbidities are jointly considered. 

o  Contribution varies by specialty but is integral to complex or high-risk 

assessments. 

In summary, in respect of the future patients who require the support of the MHLT, 
Consultant/medical input is achieved by way of:  

•  Daily MDT reviews, which provides for all patients to be discussed with a senior medic. 
At Southend and Basildon Hospitals (where there is a MHLT service), twice daily MDT 
are undertaken where all patients are discussed, including all those that have been 
seen out of hours by nursing staff. 

•  MHLT processes provide ongoing assessment, advice and guidance for patients 

waiting for admission, to have a face to face senior medic review at earliest opportunity 
in order to both ensure purposeful admission and ensure any medication optimised. 
Patients waiting for admission would also be reviewed by the team on a daily basis 

•  By way of referral pathways, referral pathways: 

o  For medical or medication-related issues, team doctors provide direct patient 

review or advice based on liaison referrals. 

o  For all other referrals, nursing staff complete an initial assessment (2.1 form), 

create a management plan, and discuss this in the next MDT. Further actions are 
agreed within that meeting. 

•  There are clinical meeting structures in place for the Liaison team which provides 
decision making for when Doctors need to undertake initial assessments / medical 
reviews if this is felt to be appropriate following referral.  

• 

In respect of the arrangements for Consultant/senior medical oversight outside of 
working hours / in times of annual leave, this is covered by way of the on call doctor 
system, which allows doctors to be contacted at any time for any urgent matter. Liaison 
nurses are able to freely consult the on-call duty doctor and escalate to senior medical 
staff if significant concerns remain unresolved. Following on from an out of hours 
contact, the case will be further discussed and managed at the next working day.  

•  During consultant leave, the Specialty Doctor and Higher Specialist Trainee continue 
reviewing patients and seek advice from the covering consultant when necessary. 

•  The Specialty Doctor and the Higher Specialist Trainee are supported and overseen by 

consultants as required, with regular supervision in place for the SPR. 

• 

In terms of the professional mix within the MHLT team, this consists of Nursing, health 
care assistants, Psychology and occupational therapy this provides a safety net of 
professionals who are accessible to referring colleagues and service users, as not all 
patients require Consultant review. 

 
 
 
 
 
 
 
 
 
 
 
 The Trust is currently reviewing its Standard Operating Procedure (SOP) in order to cover 
the above provisions.  This will be completed by May 2026 we would be happy to share a 
copy of the same with the Court if required. 

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 Green’s family.   

Yours sincerely, 

On behalf of
Chief Executive

FAO Dr Jeane Rosa Mellani 
His Majesty’s Assistant Coroner  
SEAX Court 
Chelmsford 
Essex 

Dear Madam,  

Basildon Hospital 
Nethermayne 
Basildon 
Essex 
SS16 5NL 

13 March 2026 

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 12 January 2026 in respect of the above, which 
was  issued  to  Mid  and  South  Essex  NHS  Trust  and  Essex  Partnership  University  NHS 
Foundation Trust (EPUT) following the inquest into the sad death of Mr Green. 

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 Mr Green’s family with additional assurances from the Trust to address 
the concerns you have raised. 

Concerns 
(1) The evidence identified a risk of patients at high risk of self-harm being able to 
leave the acute ward without appropriate risk assessment  
(2) The evidence identified a risk of patients at high risk of self-harm being able to 
leave the acute ward without the knowledge of the hospital staff 

Response: The Trust has reviewed an updated relevant policies and flowcharts to assist 
clinical staff with guidance and processes when managing high risk of self-harm patients in 
an inpatient setting, to ensure the appropriate risk assessments and supervision are put in 
place  to  maintain  their  safety  and  minimise  their  ability  to  leave  a  ward  without  staff 
knowledge or appropriate supervision.  

Enhanced Supervision and Engagement Policy 
I enclose a copy of the Trust’s policy for Enhanced Supervision and Engagement, together 
with its appendix Safe and Supportive Non-clinical Supervision of Staff, which provides staff 
with a risk assessment and decision-making tools to guide and inform decision making. This 
policy aims to provide a safe, lawful and supportive framework for the assessment, provision 
and de-escalation of increased levels of non-clinical supervision. It aims to ensure that all 
our patients being treated in the MSE group of hospitals and requiring increased levels of 
non-clinical supervision; 

-  are  assessed  and  managed  lawfully  with  respect  to  the  Mental  Capacity  Act, 

Deprivation of Liberty and Safeguarding requirements 

- 

receive the least restrictive level of supervision necessary to maintain their safety and 
that of those around them for the least possible time 

 
 
 
 
 
 
 
 
 
 
 -  are regularly reassessed for their level of supervision requirements 

- 

receive  supervision  which  is  supportive,  engaging  and  personally  tailored  to  the 
individual needs of the patient  

Mental Health Policy 
I am also including a copy of the staff guidance regarding Section 5(2) Mental Health Act 
which has now been included in the Trust’s Mental Health policy. This legal framework is an 
option for ward clinicians to use in  situations where a patient has been assessed as high 
risk and attempts to leave the ward, or voices intent to leave the ward. 

In circumstances such as those of Mr Green, Section 5(2) assessment could be considered 
as an option to prevent him leaving the ward until such time as the mental health team are 
able to review. 

I  can  confirm  the  Trust’s  Mental  Health  Lead  and  Prevent  Lead  Nurse  is  undertaking  a 
programme to raise awareness of this updated staff guidance at the Nurses' Grand Rounds. 
A  training  session  is  also  delivered  every  6  months  to  the  FY2  doctors  as  part  of  their 
induction, in which this topic around Section 5(2) assessment of the Mental Health Act is 
covered.  In addition, this has now been added into the Trust’s Mental Health Act training 
that is delivered each month online.  

Flowchart for Missing Persons and Absent Without Leave (AWOL) process 
The  Trust’s  flowchart for Missing  Persons  and  AWOL  process  for patient’s  who  abscond 
from hospital, which is part of the Mental Health Policy is also attached to demonstrate the 
detailed guidance provided to ensure staff undertake urgent and prompt key actions when 
a patient has left a ward or department or there are concerns about their absence.  

I  hope  that  I  have  provided  reassurances  around  the  current  Trust  policies  in  place  that 
cover some of the key concerns contained within your report.  

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 Green’s family. 

Yours sincerely 

Interim Chief Nurse 
Mid and South Essex NHS Foundation Trust 

Enclosed:  
i) 

Enhanced Supervision and Engagement Policy – MSEPO21228 

 
 
 
 
 
 
 
 
 
  
 
 ii) 

Appendix  Safe  and  Supportive  Non-clinical  Supervision  of  Staff  for  Enhanced 
Supervision and Engagement Policy 
Mental Health Flowchart within Mental Health Policy  

iii) 
iv)  MSE  Missing  Person  and  AWOL  process  for  patients  who  abscond  from  hospital 

Flowchart dated 18.02.2025