Stuart Berry

27 March 2026 

Private and Confidential 
Mr Sean Horstead  
HM Area Coroner 
Coroner’s Court  
Seax House 
Victoria Road South 
Chelmsford 
CM1 1QH 

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

Dear Sir, 

Mr Stuart Christopher James Berry (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 
the Trust, the Ministry of Justice, HM Prison and Probation Service and HCRG following the 
inquest into the sad death of Mr Berry. 

I would like to begin by extending my deepest condolences to Mr Berry’s family. The Trust 
sympathises with their sad loss.  

This letter sets out Essex Partnership University NHS Foundation Trust’s formal response to 
your Regulation 28 report of 12 January 2026.  

We have carefully considered the concerns you raised and, where they relate to EPUT, we 
describe below the actions taken and the further improvements underway. For 
completeness, Appendix 1 summarises: 

(1) relevant PFDs received, (2) assurances provided, and (3) implementation of changes. 
National Policy Context – The Changing Role of the “Care Coordinator” AND System 
Responsibility 

We note your concerns about the performance of the Community Mental Health Team 
(CMHT) and the allocated Care Coordinator (CC). We fully acknowledge the importance of 
robust care planning, risk assessment, documentation, and integrated working. We would 
also respectfully place these issues within the nationally recognised transition away from the 
historic Care Programme Approach (CPA) care coordinator model toward team-based, 
place-based, multidisciplinary models of care: 

•  NHS England’s Community Mental Health Framework (2019) explicitly set the 

direction for replacing CPA for community services, retaining its principles (good 
coordination and care planning) while shifting to a whole-person, whole-system 
approach delivered by multidisciplinary teams and partners.  

•  NHS England’s CPA Position Statement (v2.0, 1 March 2022) confirms that the 

Community Mental Health Framework has superseded CPA, encouraging systems to 
move away from the single CC/CPA construct and embed a broader team-based 
model and universal standard of high-quality care planning.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 In practical terms, these national policies recognise that in today’s complex system, it is not 
realistic or safe to expect one individual (the CC) to carry the full responsibility for system 
integration, multi-agency coordination and continuous risk oversight. The drive is to organise 
care around MDTs, shared pathways, and integrated hubs, with clear escalation routes and 
shared accountability, rather than reliance on a single practitioner.  

Health systems across England are implementing this change to move away from CPA 
within a hub-based model, underlining that this is a national transition, not an EPUT-specific 
issue.  A 2026 peer-review analysis of 586 health related PFD reports (2013-2025) found 
that coroners increasingly identify inter-agency coordination, care planning, risk and safety 
management and hand overs as key factors in death.  

The study reports that concerns have shifted over time from access and resources toward 
joint working failures, record keeping, and risk assessment, all issues directly tied to 
traditional CPA/care coordination functions.  These themes mirror the issues raised in Mr 
Berry’s case.  

In March, the Executive Chief Nurse, Transformation Lead, and Director for Community 
Services in NE Essex met with NHS England to further explore the national direction and 
forthcoming guidance relating to community mental health transformation. At present, there 
remains limited clarity from NHSE, and as a result EPUT is working closely with regional 
colleagues to navigate this transition safely, pragmatically, and in a way that preserves 
meaning and clinical integrity. This shift will require significant cultural change both within the 
organisation and across our wider system partners, as expectations around care planning, 
personalised care, and shared responsibility continue to evolve. 

To support this work, Community First engagement events have been held with key 
stakeholders across both North and South Essex in February 2026. These events have been 
essential in fostering open dialogue, strengthening joint understanding, and enabling 
genuine system collaboration as we move towards more integrated models of community 
mental health care. This partnership-based approach is central to ensuring that changes to 
practice, documentation, and communication processes are not only operationally feasible 
but also aligned with the realities faced by our frontline staff and external agencies. 

This partnership approach is grounded in developing an authentic, trusting relationship with 
our Lived Experience Ambassadors, who play a central role in the redesign of services and 
in redefining the roles and responsibilities of all stakeholders, including the person and their 
wider community. Their involvement has been essential in shaping a more meaningful, 
person-centred model of community mental health care. 

We have now reached a stage where our Lived Experience Ambassadors have worked 
alongside us throughout this journey and are actively supporting the recommendations for 
the Complex Needs Pathway within community mental health services—an area that would 
traditionally have been managed under the CPA framework. The development of this 
pathway has taken place over a longitudinal period at the request of our Lived Experience 
Ambassadors, who have been clear that accelerating the process or imposing a model 
prematurely would risk repeating longstanding challenges experienced nationally and locally. 
They have emphasised that a genuine co-produced approach requires time, reflection, and 
psychological safety. 

We have respected this position and consciously worked at a pace that maintains 
psychological safety, supports genuine collaboration, and avoids replicating historic patterns 
of rushed or top-down change. We acknowledge that the length of time required to 
co-produce these new models may be frustrating from an external perspective, including for 

 
 
 
 
 
 
 
 
 the Coroner. However, sustainable change cannot be achieved overnight. For these 
pathways to be effective, credible, and meaningful for the communities we serve, the roles, 
responsibilities, and expectations within them must be carefully developed, supported, and 
embedded. 

Aligned to this, the Patient Safety Incident Response Framework (PSIRF) requires the NHS 
to adopt a systems-based approach to safety—understanding contributory factors across 
teams, workflows and environments, and moving beyond a purely individualised lens when 
learning from incidents.  

Finally, with regard to governance expectations, CQC Regulation 17 (Good Governance) 
requires effective assurance and auditing systems or processes to monitor and improve 
quality and safety; it does not prescribe that every single care plan or case be audited, but 
expects proportionate systems that assess, monitor and mitigate risk and drive 
improvement.  

We offer this context not to diminish the seriousness of the failings identified in Mr Berry’s 
case, but to explain the nationally endorsed direction of travel and the structural changes we 
have been implementing locally to reduce the likelihood of recurrence. 

The  Regulation  28  Report  issued  following  Mr  Berry’s  death  raises  a  number  of  concerns 
which we address as follows -  

(a) Performance of the CMHT and the allocated Care Coordinator (under CPA/EPUT 
policy) 
EPUT maintains a governance framework that includes regular clinical supervision, weekly 
MDT forums, escalation procedures, and case auditing to identify and address gaps. We 
recognise the expectation that staff practise in line with Trust policy. 
Trust-wide audit requirements were reviewed in January 2026. While the final Trust standard 
is being confirmed through the Community First Project, our interim approach combines: 

•  Local, bi-monthly sample audits in certain localities (e.g., 5 cases per practitioner 

every two months), and 

•  Themed Trust-wide sampling, with the next cycle scheduled March 2026 (targeted 

sample across teams to test compliance and learning themes). 

This sample-based method is proportionate to caseload size, supports thematic learning, 
and is consistent with Regulation 17 expectations for effective, risk-based assurance rather 
than exhaustive case-by-case auditing.  

Audit results are shared through local governance structures to ensure learning is shared. 
Supervisors use MaST (Management and Supervision Tool) and monthly performance 
reporting to monitor documentation timeliness and CPA/care-planning activity, with targeted 
follow-up where deficits are identified. The mandatory use of MaST was implemented in 
January 2025. In the Thurrock community team, auditing of case loads were commenced in 
June 2025 and case load issues were noted in the 6-to-8-week supervision requirement. 
EPUT`s Community First project will clarify the frequency of auditing required as MaST only 
identifies that documentation is in place and not the contents and quality.  

Thurrock has an assigned lead who has been tasked to carry out 5 such audits for each staff 
member every 2 months.  This process has been intermittent due to available resource, and 
the Trust has re-enforced the importance of these audits with the next audit due to be carried 
out in the month of March 2026.  

Similar audit processes are already in place in other community mental health teams across 
EPUT, though with slight variations in who carries them out. Work is currently underway to 

 
 
 
 
 
 
 
 
 
 standardise this approach, with community services being the first area to adopt the unified 
approach.  

This sample-based method is proportionate to the size of our commissioned workforce and 
reflects established custom and practice across community mental health services 
nationally. 
Given the scale and complexity of community caseloads, it is not operationally feasible nor 
required to monitor all cases individually.  

National audit examples in social care similarly use sample-based caseload audits as part of 
their quality assurance frameworks. 

b. Failures in Care Planning  
In reviewing Mr Berry’s case, there is no evidence to suggest a systemic organisational 
failure. The required systems, governance structures, and escalation processes were in 
place and functioning. The concerns identified relate to professional practice, rather than a 
failure of the systems themselves. 

Mr Berry had been known to the Team for just over three months. During this period, the 
Management and Supervision Tool (MaST) showed that documentation was in date. 
However, MaST only identifies whether Care Plans or reviews meet the mandated 
six-monthly cycle. It does not analyse the content of those documents and therefore cannot 
detect when a review should be completed earlier due to a change in clinical risk. Identifying 
such changes and initiating an out-of-cycle update remains a core clinician responsibility. 

Supervision took place, and no acute concerns were raised by the Care Coordinator. Staff 
were also routinely reminded to use the weekly MDT to escalate any emerging risk. Despite 
these available mechanisms, Mr Berry’s case was not brought forward. 

It is important to recognise the complexity of the Care Coordinator role within community 
mental health systems. Care Coordinators manage high caseloads, navigate multiple 
systems, and hold significant clinical responsibilities. This level of complexity can sometimes 
affect consistent completion of all required tasks, particularly in a system undergoing 
transformation toward more distributed, multidisciplinary models of care. This is one of the 
reasons the Trust has been shifting away from models where a single Care Coordinator is 
responsible for every aspect of a service user’s care. 

As part of strengthening practice, EPUT has developed a Care Planning Training Package, 
initially piloted in North East Essex and reviewed across the EPUT-wide safeguarding 
forums during 2024/25. The pilot was complex, partly due to delays in the release of updated 
national CPA guidance from NHS England. In response, EPUT adopted a pragmatic interim 
approach, embedding the updated care planning principles into a holding training package. 
This approach has been agreed collaboratively with regional colleagues through NHS 
England forums to ensure best practice while awaiting the final national framework. 

This Care Planning Training is now a mandated requirement for all community staff and roll 
out began in February 2026. It has been rolled out across the organisation, targeting 
community and primary care services. The programme provides clinicians with a framework 
underpinning safe and effective care planning, including: 

•  core principles of community mental health practice, 
•  expectations around clinical governance and risk management, 
• 
•  best practice guidance, 
•  case studies, learning themes, and clinician reflection. 

the responsibilities associated with timely documentation and escalation, 

 
 
 
 
 
 
 
 
 
 regular supervision, 

During the period in question, the following governance structures were in place within the 
Team: 
• 
•  weekly MDT forums for escalation, 
•  MaST oversight of CPA compliance, and 
• 

reintroduced local audits. 

Given the size of the caseload—approximately 380 patients—it is neither operationally 
feasible nor supported by existing resources for senior staff to proactively review every case 
in detail. The system therefore relies on clinicians applying sound judgement, using 
supervision effectively, and escalating concerns appropriately through MDT structures. 
These processes were available, embedded, and repeatedly communicated. In Mr Berry’s 
case, they were not utilised as required, and the necessary out-of-cycle CPA update 
following a change in risk did not take place. This represents a professional practice failure, 
not a failure of organisational systems. 

The practitioner involved is currently subject to the Trust’s capability process. To 
complement formal training, EPUT is in the process of introducing a Care Coordination 
Competency Framework for all new starters. This framework will sit alongside the valued 
and essential on-the-job learning already provided within teams and will form a core 
component of each new staff member’s probationary period.  

This ensures that new colleagues not only receive structured learning but can also evidence 
their skills, knowledge, and decision-making in practice. In parallel with the interim Care 
Planning Training Package, the Trust has been contributing to the development of a new 
Care Planning Framework, which is currently in the final stages of review. The full 
organisational roll-out is scheduled to commence in Summer 2026. This framework is 
intentionally aligned with the national shift away from the traditional CPA model and towards 
a more personalised care agenda. As such, significant time and collaboration have been 
invested to ensure that the framework is authentic, meaningful, and genuinely reflective of 
modern person-centred practice, rather than creating a task-based or overly procedural 
approach to competencies. 

This deliberate development approach is essential to ensure that personalised care is 
embedded in a way that strengthens clinical practice, supports professional judgement, and 
improves service user experience. The Trust has been clear that it did not want to adopt a 
checklist-driven model but instead wanted a framework that supports thoughtful, relational, 
and safe care planning that distributes responsibility across the multidisciplinary team.  
addition, the Trust are piloting a scheme in which “care coordination” staff undertake a 
structured self-evaluation against the competency framework, supporting a systematic 
assessment of their development needs.  

The next scheduled session within this pilot is taking place on 09 March 2026 in Mid Essex. 
This process will directly inform each staff member’s individualised training plan for the 
following two years and ensure we continue to strengthen the skills, capabilities, and 
confidence of our existing workforce. 

This enhanced emphasis on competencies, reflective learning, and ongoing development 
forms a key component of the Trust’s wider approach to improving safety and quality of care. 
It aligns closely with the PSIRF emphasis on human factors, team capability, and 
system-level learning, moving beyond reliance on audits or isolated changes to 
documentation. By supporting staff to critically appraise their practice, identify developmental 
needs, and engage in structured learning pathways, the Trust is working to build a more 
resilient, skilled, and confident workforce—one better equipped to meet the needs of service 
users in complex community settings. 

 
 
 
 
 
 
 c and d. Failures in Risk Assessment and Documentation  
EPUT recognises that failure to document in line with quality standards and clinical 
guidelines can pose risks to continuity of care, clinical decision-making, and patient safety. 
To understand the underlying factors that influence staff’s ability to document to the standard 
they aspire to, the Trust has undertaken a number of targeted pieces of work. 

This has included hosting two large engagement events with Care Coordinators from across 
all areas of Essex, enabling the organisation to gather direct feedback and identify common 
themes affecting documentation quality, workload management, and pressures within the 
role. A consistent and strongly expressed theme from the community workforce has been 
frustration about the need to balance documentation requirements with spending meaningful 
time with patients and their families. Staff reported that, although they fully recognise the 
importance of high-quality documentation, the competing demand between administrative 
requirements and relational, patient-facing work remains a significant challenge. 

Alongside staff engagement, two “Patient Experience: Real Versus Imagined” workshops 
were held in November 2024 and October 2025, exploring how documentation, 
communication, and care planning are perceived by service users. These sessions aimed to 
ensure that improvements in documentation also translate into improved lived experience, 
supporting a more personalised and relational approach to care. 

In March 2026, the Trust also hosted a Safety Improvement Programme Workshop, bringing 
together leads from all ongoing safety improvement initiatives. The purpose was to 
cross-reference learning across programmes, ensure alignment with PSIRF principles, and 
examine how safety improvement activities interface with the actual day-to-day challenges 
faced by Care Coordinators—including those relating to documentation burden, system 
navigation, and competing priorities. 

Collectively, these activities reflect the Trust’s commitment to understanding the human, 
systemic, and environmental factors that impact staff practice. This work supports the wider 
organisational shift toward a PSIRF-aligned approach that prioritises continual learning, 
capability building, and system-level improvement—not simply process compliance or 
changes to forms. 

To further support sustainable improvements in documentation quality and workflow, EPUT 
is reviewing the need  for an interim post dedicated to assisting with documentation and 
workflow management ahead of the planned implementation of NOVA, the Trust’s new 
electronic patient record (EPR) system. 

Once implemented, NOVA will enable real-time documentation, supported by improved task 
management functions and the ability to auto-populate forms using information already 
recorded elsewhere in the system. This functionality is expected to significantly reduce 
administrative duplication, improve accuracy, and free up more staff time for direct clinical 
work with patients and families. 

Until NOVA is fully operational, EPUT continues to maintain robust interim monitoring 
arrangements to support safe and timely documentation. Alongside this, the Trust is 
currently reviewing the requirements for personalised care planning and safety planning 
documentation, with the aim of determining whether the existing EPR can accommodate a 
single, consolidated place for recording and update associate standard operating 
procedures. This work is intended to reduce the burden associated with navigating multiple 
tabs and scattered documentation fields, making it easier for clinicians to record care 
consistently and for teams to access essential information quickly. 

 
 
 
 
 
 
 
 
 
 These developments sit alongside the broader organisational work to strengthen 
competencies, reduce unnecessary administrative load, and ensure that clinical 
documentation supports both personalised care and safer decision-making. 

As set out in our earlier response to the Prevention of Future Deaths report, we continue to 
monitor adherence to the 95% target for clinical documentation to be completed within 24–
48 hours of patient contact. This is overseen through a combination of: 

• 

• 

Caseload reviews within line-management supervision, where documentation quality, 
timeliness, and risk-related entries form a routine part of the discussion. 
Monthly performance reports, which provide clear visibility of each clinician’s activity, 
including any incomplete or overdue documentation. Where gaps are identified, 
managers hold individual discussions with staff to ensure timely completion and 
address any underlying issues impacting their ability to meet required standards. 

These measures demonstrate that monitoring and governance systems remain firmly in 
place, consistent with the expectations previously outlined following the case of Robert 
Moore (February 2022).  

They also strive to ensure that any risks associated with delays or omissions in 
record-keeping are identified and acted upon promptly while we transition toward a more 
modern, streamlined digital system under NOVA. 

EPUT maintains systematic performance monitoring and governance oversight, which is 
formally reviewed each month through established reporting structures.  

Performance, quality, risk, and safety indicators are presented to the Executive Team and 
Senior Leadership Team, ensuring a clear and consistent feed-up, feed-down governance 
approach. This process is embedded within our internal Accountability Framework, which 
was developed as part of our wider quality-improvement and patient-safety programmes.  

The framework enables operational issues, risks, themes, and areas of concern to be 
escalated appropriately, while ensuring that learning, expectations, and quality standards are 
communicated consistently back to operational teams. This ensures that leaders at every 
level have visibility of performance, and that staff receive the guidance, feedback, and 
support required to maintain safe, high-quality care. 
As previously outlined, the Team has established systems in place to monitor compliance, 
including the use of the MaST (Management and Supervision Tool) in staff supervision and 
oversight against the monthly Performance Reports. These tools have been used actively 
since 2024 and provide assurance that reviews are in date against the mandated 
six-monthly cycle, while also highlighting when documentation is overdue. 

However, as noted earlier, MaST only identifies whether documentation is up to date within 
the required six-monthly timeframe. It does not analyse the content of those documents and 
therefore cannot detect when a document requires updating outside the routine cycle due to 
a change in clinical risk. This responsibility remains with the clinician. 

In Mr Berry’s case, he had been with the Team for just over three months, and MaST 
correctly showed the documentation as in date. However, the required out-of-cycle update 
following a change in risk did not occur, and the case was not raised through supervision or 
MDT structures. This reflects a professional practice issue, not a failure of the monitoring 
systems previously described. 

e and f. Failures in Joint Working  

 
 
 
 
 
 
 
 
 
 
 Thank you for highlighting the concerns regarding joint working in this case. I acknowledge 
the coroner’s observations and set out below our response in relation to the identified 
failures and the steps we have taken to ensure improvement. 

e. Failure in Joint Working Internally  
We recognise that the Care Coordinator did not escalate concerns or seek consultation with 
colleagues through our established internal pathways, including the weekly Multidisciplinary 
Team (MDT) meeting or alternative professional forums. These structures exist precisely to 
support shared clinical decision-making, risk formulation and case escalation, and the failure 
to utilise them represented a missed opportunity to review the patient’s presentation 
collaboratively. 

Since the incident, we have introduced measures to support staff in consistently meeting 
expectations around escalation and collaborative working. We recognise that embedding 
these behaviours is a gradual process and requires ongoing reinforcement, supervision and 
oversight, which we will continue to prioritise through: 

• 

Strengthened escalation expectations: Clear guidance has been reissued to all staff 
outlining mandatory escalation routes when risk indicators change or when there is 
clinical uncertainty. This is evidenced via the introduction of an MDT Agenda, which 
ensures that governance around this important area is kept under review.  To provide 
an example, the Thurrock Team have developed a weekly MDT agenda which is 
circulated ahead of the MDT to all staff to ensure all staff are reminded of high-risk 
cases to discuss. A copy of one such agenda is attached, together with case 
presentation templates as reviewed in September 2025. 

• 

MDT attendance and oversight: All teams are now required to document which cases 
need MDT discussion, with team leaders reviewing compliance weekly. 

Training and supervision improvements: Care Coordinators are receiving targeted training 
on recognising complexity and the thresholds for escalation, supported through reflective, 
restorative supervision. This was rolled out in 2024.   Monthly CPD review sessions are in 
place for staff (these have been in place since beginning of 2025) which incorporate 
elements of restorative supervision, as appropriate. Staff 1:1 and staff mediation sessions 
also remain in place. 

The roll-out of restorative supervision across our community teams will further strengthen 
our internal measures. Evidence from both national and local implementation shows that 
restorative supervision reduces staff stress and burnout, improves wellbeing, increases 
compassion and professional resilience, and supports more effective decision-making. It 
also enhances staff’s emotional capacity to engage constructively with other professionals, 
enables them to better understand and maintain healthy boundaries at work, and contributes 
to a calmer, more reflective workforce. 

As these benefits embed over time, we expect restorative supervision to improve staff ability 
to make full and effective use of the systems already in place, and to support stronger team 
functioning and more consistent multi-agency working. 

Significant changes to the Dual Diagnosis pathway will support a reduction in ‘refer-on’ 
practices and minimise the passing of individuals between teams.  

Under the revised Essex County Council model, Care Coordinators will be trained to support 
dual diagnosis needs within their own clinical practice, with access to trained Dual Diagnosis 
Ambassadors embedded in each team.  This represents a deliberate shift away from a 
traditional referral-based approach, which is inherently limited by the receiving team’s 

 
 
 
 
 
 
 
 
 
 capacity to accept and act on referrals—particularly in the context of ongoing reductions in 
funding. Instead, the Trust has moved towards a model in which dual diagnosis is 
recognised as everyone’s business. This approach is now embedded across community 
teams and reflects the expectation that all staff have the capability to identify and respond to 
co-occurring mental health and substance misuse needs as part of routine practice. 

The intention behind this shift is to ensure that dual-diagnosis issues are addressed earlier, 
more consistently, and within the patient’s existing therapeutic relationships, rather than 
relying on transfer to a separate team. This supports better continuity of care and 
strengthens multi-agency collaboration, while also making more effective use of the internal 
expertise available within multidisciplinary teams. 

We are confident that these measures will support more consistent use of MDT processes, 
enhance internal consultation pathways, and improve the quality and timeliness of 
intervention for individuals with co-occurring needs.  In addition, across our South Essex 
localities we have implemented a Mental Health Transfer of Care Hub (MH TOCH) as part of 
our approach to ensuring safe and coordinated follow-up for individuals who have recently 
had contact with local crisis services. The MH TOCH model was introduced in February 
2024 in Basildon, September 2024 in Southend, and December 2024 in Thurrock. Meetings 
are held three times per week and provide senior oversight from Team Leads and Managers 
to ensure that all patients who have accessed crisis services receive an appropriate and 
timely follow-up plan. 

Where an individual is already under Care Coordination, the representative from the 
Community Mental Health Team will take forward the required actions and ensure that the 
allocated worker undertakes a review of the person’s needs, risk, and management plan. All 
discussions held within the MH TOCH are recorded directly in the person’s electronic record 
to support continuity, transparency, and clinical accountability. 

Similar meetings take place in other areas of the Trust; however, the terminology and 
structure vary. As part of the Community First standardisation programme, we are currently 
working to align the naming, format, and core functions of these meetings across all 
localities to ensure consistency, equity of practice, and clearer organisational expectations. 

Failure of Joint Working Externally (concern f) 
In parallel, we are expanding the rollout of STORM training, which has been successfully 
embedded within Crisis Teams, into our Community Mental Health Teams. This training 
supports high-quality, evidence-based assessment, safety planning, and risk 
documentation—all of which are critical components of safe community mental health 
practice. These capabilities are also essential for effective internal and external joint working, 
ensuring that when multiple agencies are involved in a person’s care, information is clear, 
risk is articulated consistently, and actions are well-coordinated. High-quality documentation 
and shared understanding of risk enable safer handovers with partners such as primary 
care, crisis services, social care, ambulance services, and police, and they support more 
timely and informed decision-making across agencies. 

Collectively, these initiatives form part of a broader organisational commitment to 
strengthening documentation standards through system-level improvements, better-aligned 
workforce support, and reductions in unnecessary administrative burden. This approach 
allows staff to engage more effectively with external partners and maintain safer 
multi-agency coordination, rather than relying solely on audit processes or adjustments to 
paperwork. 
EPUT recognises that developing meaningful and sustainable community-thematic learning 
is a journey rather than an immediate outcome.  

 
 
 
 
 
 
 
 This work must progress alongside the realities of demanding caseloads, operational 
pressures, and the complex human factors that shape practice in community mental health 
settings. While we have implemented all appropriate actions and assurances arising out of 
Coronial proceedings with integrity and urgency, we are also aware that lasting change 
cannot be achieved overnight.  Rapid, surface-level change risks being unsustainable; our 
focus is instead on creating the conditions for deep, cultural improvement in the way staff are 
supported, supervised, and equipped to learn from incidents. 

Failure in Communication (concern g) 
EPUT recognises that failures in communication—whether in escalating concerns, 
documenting changes in risk, or sharing vital information across teams—can significantly 
compromise patient safety. To address this, the Trust is shifting towards a more holistic 
approach to staff wellbeing, training, and psychological safety. Safe practice is strengthened 
when staff feel supported to speak up, seek help, and communicate uncertainty or concern 
at the earliest opportunity, rather than attempting to manage increasing pressure alone. This 
cultural work is fundamental to improving the consistency and reliability of documentation, 
clinical decision-making, and risk management, all of which depend on timely, accurate, and 
transparent communication. 

At the same time, practitioners continue to be held to account through their professional 
registration. Organisational support is designed to enhance—not replace—individual 
responsibility for clear communication, proper documentation of risk, and use of escalation 
pathways. 

Our aim is to build a system in which thematic learning, strong communication behaviours, 
staff support, and professional accountability operate together. This balanced approach 
provides the best foundation for sustained improvement in community mental health 
practice, rather than relying on short-term corrective actions that fail to address the deeper 
human and systemic factors contributing to communication breakdowns. 

Despite extensive work to strengthen learning from deaths and improve the reliability of care 
planning and risk processes, we recognise that lasting improvement cannot be achieved 
solely through changes to forms or systems. Communication failures often stem from human 
factors, workload pressures, and the complex realities of community mental health work. 
This reinforces the need for a proactive, supportive, and system-wide approach that mirrors 
national expectations: that the safety and quality of community mental health services are 
best improved through continuous learning, psychologically safe environments, effective 
supervision, and whole-team safety thinking, rather than through narrow corrective actions 
following individual incidents. 

To that end, our PSIRF (Patient Safety Incident Response Framework) aligned approach 
places emphasis on understanding the broader organisational, systems and environmental 
factors that shape practice; supporting staff through restorative supervision; and developing 
the conditions for safe, reflective, and sustainable care. These priorities complement, 
traditional audit processes.  

While we maintain proportionate, systematic auditing of a sample of cases each month, we 
acknowledge that audits alone cannot mitigate the full range of human and contextual 
factors present in community mental health work and therefore must be part of a wider 
learning-focused safety system. 

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 patients safe and delivering therapeutic care. 

 
 
 
 
 
 
 
 We remain fully committed to ongoing monitoring, transparent reporting, and open 
engagement with you and with Mr Berry’s family. Should you require any further information, 
we will be pleased to provide it. 

Yours sincerely  

Chief Executive

HCRG Care Group 
The Heath Business & Technical Park 
Runcorn 
Cheshire 
WA7 4QX 

9th March 2026 

For the attention of His Majesty’s Senior Coroner for Chelmsford Mr Horstead 

Regulation 28 Report issued following the inquest into the death of Stuart Berry 

We  would  like  to  express  our  sincere  condolences  to  the  family  of  Stuart  Berry.  We  recognise  the 
seriousness of the matters raised by the Coroner and have carefully considered the concerns identified in 
the  Regulation  28  report.  We  are  committed  to  learning  from  this  Mr  Berry’s  death  and  to  taking 
proportionate, meaningful action to reduce the risk of similar incidents occurring in the future. 

Understanding of the Coroner’s Concerns 

It is our understanding that the coroner’s concerns relate to the following areas: 

• 
Information Sharing:  A failure to share the Prisoner Warning Notice with custodial colleagues. 
•  Documentation:  A  failure  to  document  the  risk  of  self-harm  and  suicide  in  SystmOne  by  the 

reception Nurse. 

•  Conduct  Assessment:  A  failure  to  recognise  the  level  of  risk  of  self-harm  and  suicide,  raising 
concerns regarding the adequacy of staff training and the monitoring of standards, supervision, and 
quality assurance processes. 

•  Escalation / Referral: A failure to refer for an urgent review by the mental health team. 

We  are  focusing  on  strengthening  the  interfaces  between  healthcare  and  custodial  services,  retraining 
reception nurses, and introducing a dedicated Early Days in Custody (EDiC) Nurse role. 

The  EDiC  Nurse  is  leading  an  action  plan  to  improve  standards  in  early  days  in  custody  care.  We  are 
currently working to a 3-month turnaround for the action plan, with completion targeted for 26 May 2026. 
The  EDiC  Nurse  will  provide  clinical  supervision,  oversee  quality  assurance,  and  monitor  delivery  against 
the  action  plan.  Progress  and  performance  against  the  plan  will  be  reported  through  the  Clinical 
Governance structure, with oversight from the Clinical Governance Lead. 

HCRG Care Services Ltd, company number 7557877 registered in England and Wales at The Heath Business and Technical Park, Runcorn, Cheshire WA7 4QX 
Send any correspondence to the address at the top of this letter 

 
 
 
 
 
 
 
 Actions Already Taken 

Since Mr Berry’s death, the following actions have been completed or initiated: 

•  Quality Assurance and Oversight of Early Days in Custody (EDiC): 

A dedicated EDiC Nurse role has been created to manage and oversee risks during the early days in 
custody,  in  close  partnership  with  the  custodial  and  safer  custody  teams.  Reception  has  been 
identified as a key risk point for those new in Custody. The EDiC Nurse role provides leadership and 
quality assurance for reception screening, mental health risk assessment, information sharing, and 
escalation  pathways.  This  role  commenced  in  January  2026  and  has  been  temporarily  filled  by  a 
long-standing dual qualified nurse pending the onboarding of a substantive post holder.  

•  Prisoner Warning Notices (PWN):  

The  PWN  is  received  into  the  prison  via  secure  email  and  it  is  the  responsibility  of  the  Reception 
Nurse to review this notification on receiving a patient into custody, consider it in their assessment 
of  patient  risk  and  take  immediate  appropriate  action,  including  sharing  with  Custodial  Managers 
and Officers covering reception.  

A  formal  communication  logbook  has  been  implemented  to  provide  clear  assurance  of  PWN 
sharing. The logbook records the date and time of receipt, the staff member with whom the PWN 
was  shared,  and  confirmation  that  risks  were  communicated and  acknowledged.  All relevant  staff 
have been trained on this new process.  

The  EDiC  Nurse  reviews  the  logbook  to  ensure  compliance,  timeliness,  and  effective  two-way 
communication  of  risk  information  alongside  providing  supervision  and  training  to  all  Reception 
Nurses. 

The Safeguarding Administration and Patient Experience lead (appointed September 2025) reviews 
all  PWN  alerts  on  a daily  basis,  ensuring  the  information  is  recorded  within the  patient’s records, 
and alerting all health care professionals, particularly Mental Health, to risk information concerning 
suicide and self-harm.  

• 

Improving SystmOne Documentation and Clinical Recording 
Targeted SystmOne (the Clinical Computer System we use) training has been introduced to reinforce 
expected standards. North of England Care System Support (NECS) have been commissioned by NHS 
England  to  provide  support  for  SystmOne  and  have  arranged  for  all  staff  to  have  access  to  their 
training portal which has a suite of training packages. Our induction paperwork has been adapted to 
ensure  that  all  new  staff  are  provided  with  access  and  are  required  to  attend  SystmOne  basic 
training. Existing members of staff have been provided with refresher training.  

HCRG Care Services Ltd, company number 7557877 registered in England and Wales at The Heath Business and Technical Park, Runcorn, Cheshire WA7 4QX 
Send any correspondence to the address at the top of this letter 

 
 
 
 
 
 
 
 
 In addition, the EDiC Nurse role provides structured supervision and coaching to reception nurses, 
including regular review of SystmOne entries, case-based feedback, and support to improve clinical 
reasoning and documentation. This approach provides ongoing assurance that mental health risks 
are clearly recorded, appropriately escalated, and visible to all relevant professionals. 

Documentation  quality  is  monitored  by  the  EdiC  Nurse  through  monthly  audits  and  review  of 
supervision  records,  with  learning  and  themes  fed  back  to  the  wider  team  to  support  continuous 
improvement.  This  is  a  key  agenda  item  on  the  monthly  Clinical  Governance  Meeting  and  team 
meetings.  A  daily  staff  handover  meeting  has  also  been  commenced  to  ensure  staff  are  aware  of 
current issues and any patient or safety concerns. These quality assurance processes are undertaken 
by the EDiC Nurse with the support of the local Quality Lead.  

Our  Quality  Lead  attends  monthly  induction  meeting  with  new  starters  and  provides  further 
bespoke training.  Help sheets are circulated to all staff giving hints and tips on appropriate clinical 
documentation and guidance on incident reporting process. 

•  Referral to the NMC 

HCRG  reflected  on  the  Coroner’s  recommendation  to  reconsider  referring  the  Reception  Nurse  to 
the Nursing and Midwifery Council. Given the Nurse is currently on maternity leave, HCRG sought 
advice from the NMC as to the timing of the referral. In line with advice from the NMC, the referral 
was made on 18 December 2025 in accordance with our professional regulatory requirements. Our 
internal HR processes are also being followed to ensure concerns are addressed in parallel with the 
NMC  referral  directly  with  the  individual.  This  action  sits  alongside  internal  clinical  governance 
review and system learning to reduce the risk of recurrence. 

Further Actions Planned 

We continue to make changes to improve the service and embed learning, including:  

•  Strengthening Mental Health Awareness and Screening at Reception 

Targeted 1-1 training was introduced on 27 January 2026 to enhance staff understanding of suicide 
and  self-harm  risk  factors,  acute  mental  distress,  and  the  impact  of  early  custody  on  mental 
wellbeing. The newly established EDiC Nurse role provides clinical leadership and quality assurance 
through  supervision,  coaching,  and  review  of  reception  assessments,  supporting  nurses  to  move 
beyond  checklist-based  screening  and  to  apply  professional  judgement  when  identifying  and 
escalating mental health risk. This approach supports earlier identification of risk and timely referral 
for mental health assessment. The Edic Nurse also supports and supervises staff in identifying the 
appropriate ACCT observation levels and carries out reviews of ongoing ACCT observation levels to 
check their appropriateness.  

HCRG Care Services Ltd, company number 7557877 registered in England and Wales at The Heath Business and Technical Park, Runcorn, Cheshire WA7 4QX 
Send any correspondence to the address at the top of this letter 

 
 
 
 
 
 
 • 

Improving Identification and Escalation of Urgent Mental Health Referrals 
The  Mental  Health  Operational  Standard  Operating  Procedures  and  referral  processes  are  being 
reviewed,  clarifying  thresholds  for  urgent  mental  health  referrals,  escalation  routes,  and  agreeing 
expected response times as within 24 hours. This is audited by the EDiC Nurse. This review will be 
completed by 30 April 2026. Reception nurses are being supported to identify and escalate urgent 
presentations  through  targeted  training  on  assessing  the  risk  of  suicide  and  self-harm  alongside 
ongoing supervision.  

The newly established EDiC Nurse role provides quality assurance by reviewing referrals, supporting 
timely  escalation,  and  monitoring  referral  times  to  ensure  that  urgent  mental  health  needs  are 
prioritised  and  responded  to  within  the  set  24-hour  timescale.  Referral  timeliness  and  escalation 
decisions are monitored through case review and audit, with learning fed back through supervision 
to support sustained improvement. 

We  would  like  to  thank  the  Coroner  for  the  opportunity  to  respond.  While  we  are  confident  that  this 
response addresses the points raised in your Report, if the Coroner has any ongoing concerns or queries in 
respect of the actions we have taken, we would welcome the opportunity to provide further information.  

Yours sincerely, 

Regional Director 

HCRG Care Services Ltd, company number 7557877 registered in England and Wales at The Heath Business and Technical Park, Runcorn, Cheshire WA7 4QX 
Send any correspondence to the address at the top of this letter

Director General of Operations 
HM Prison and Probation Service 
8thFloor Ministry of Justice 
102 Petty France 
London 
SW1H 9AJ 

Sean Horstead 
Area Coroner, for the Coroner Area of Essex 
Ground Floor  
Seax Houe  
Essex County Council 
Victoria Road South 
Chelmsford 
CM1 1LX  

6 March 2026 

Dear Mr. Horstead, 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: MR STUART BERRY 

Thank you for your Regulation 28 report of 12 January 2026, addressed to the Chief Executive 
Officer of Essex Partnership University NHS Foundation Trust, The Ministry of Justice, HM 
Prison and Probation Service and HCRG. I am responding on behalf of HMPPS as the Interim 
Director General of Operations. 

I know that you will share a copy of this response with Mr. Berry’s family, and I would first like 
to express my condolences for their loss. Every death in custody is a tragedy and the safety 
of those in our care is my absolute priority. 

You have raised concerns regarding: the amount of time within national prison officer training 
dedicated to recognising and recording triggers, risk factors, and protective factors and the 
approach to understanding and addressing ligature-related considerations linked to window 
bars in Victorian or similar prison cells. 

Recognition of the risks and triggers that may increase a prisoner’s risk of suicide and self-
harm  is  a  vital  skill  for  prison  officers.  The  Safety  Support  Skills  training  within  Foundation 
Training, formerly Prison Officer Entry Level Training (POELT), comprises approximately 18 
hours of the overall curriculum and of this, the dedicated session on identifying and managing 
risk  factors and  triggers  accounts  for between  45  minutes  to one  hour  of  the  training. The 
risks, triggers and protective factors module is currently under national review in collaboration 
with Prison Learning Design and Delivery (PLDD). While this work progresses, the National 

 
 
 
 
 
 
 
 
 
 
 
 
 Safety  Group  has  developed  interim  upskilling  sessions  focused  specifically  on  risk 
identification at the point of the prisoner’s arrival in custody. These sessions will be delivered 
across  the  reception  estate  by  the  National  Safety  Group  and  Group  Safety  Leads,  with 
completion anticipated by June 2026, subject to confirmation.  

Further, a comprehensive review of the Reception Officer training has commenced, and the 
National  Safety  Group  have  already  proposed  enhancements 
that  will  strengthen 
risk
identification skills and improve support for individuals who may be particularly vulnerable 
during their early days in custody. The revised training will be completed once PLDD capacity 
‑
allows.  

Outside  of  foundation  training  we  provide  other  training  modules  which  comprehensively 
cover all areas of self-harm and suicide, including risks and triggers. These include the ACCT 
case review and assessor training, self-harm and suicide training and Investigating Concerns 
training. 

Nationally,  we  recognise  that  older  cells  can  contain  multiple  potential  ligature  fixtures—
including plumbing, furniture, and electrical fittings. HMP Chelmsford have submitted a local 
business case seeking to upgrade Victorian

style windows to anti

ligature designs. 

‑

‑

‑

term solution is the redevelopment of cells to a fully ligature

resistant (LR) standard. 
The long
Although  newer  prisons  and  refurbished  wings  are  built  to  this  specification,  much  of  the 
estate predates the LR standard and does not currently include extensive LR provision. We 
are  concluding  a  project  to  convert  50  cells  across  13  locations,  prioritised  according  to 
assessed levels of risk. This includes HMP Chelmsford, where four LR cells were completed 
in 2025. While LR cells are valuable, they are not always appropriate for individuals requiring 
supervision  cells  offer  greater 
constant  supervision.  In  such  cases,  purpose
visibility  for  staff,  are  the  safer  alternative,  and  several  are  already  available  at  HMP 
‑
Chelmsford. Subject to funding, we aim to increase the provision of LR cells nationally in the 
coming financial year. 

built  constant

‑

‑

It is important to note that LR cells alone cannot eliminate the risk of self
inflicted death. They 
must be used alongside other protective measures as identified in ACCT plans, observation 
levels, and supportive intervention. Where LR cells are unavailable, alternative safeguards 
remain essential and are frequently effective. 

‑

I hope this response provides assurance that HMPPS is actively addressing the issues raised 
in your report. We remain committed to improving early
custody safety, strengthening 
training, and reducing the risk of self

days
inflicted deaths across the prison estate. 

in

‑

‑

‑

Yours sincerely, 

‑

Interim Director General of Operations