Elise Sebastian

02 April 2026  

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, 

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

Tel: 0300 123 0808 

Elise Kay Louise SEBASTIAN (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  8th  February  2026  received  by  the  Trust  on  9th 
February 2026 in respect of the above, which was issued to Essex Partnership University NHS 
Foundation Trust (EPUT) following the inquest into the death of Elise (RIP). 

I  would  like  to  begin  by  extending  my  deepest  condolences  to  Elise’s  family.  The  Trust 
sympathises  with  their  very  sad  loss.    The  Trust  expresses  its  sincere  sympathies  and 
acknowledges the profound nature of their 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 raised in the hope that this provides both 
yourself  and  Elise’s  family  with  comprehensive  assurances  of  the  changes  that  have  been 
made at the Trust to address the concerns you have raised.  

Concern 1 
a) Elise was neurodiverse and staff were not trained in Autism 

Response:  
During the evidence provided at this Inquest, it was acknowledged that the Trust did not have 
autism training provisions in place at the time of the incident.  As part of the learning that has 
been taken from this case, the ‘Oliver McGowan’ training module has been implemented at the 
Trust. 

The  Oliver  McGowan  Mandatory  Training  on  Learning  Disability  and  Autism  is  named  after 
Oliver McGowan, whose death shone a light on the need for health and social care staff to have 
better  training.    It  is  the  standardised  training  that  was  developed  for  this  purpose  and  is  the 
government's preferred and recommended training for health and social care staff. There are 2 
Tiers, Tier 1 provides training on LD and ASD for those who require general awareness of the 
support Autistic People or those with LD may need.  

For Tier 2 the above is delivered alongside providing direct care and support.   

Course  outcomes  in  respect  of  Tier  2,  includes  the  training  on  understanding  the  lives  and 
experiences of people with a learning disability and recognise their strengths and contributions.  
The training explores factors which impact on the quality of care and support of people with a 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
 learning  disability.  It  aims  to  develop  an  understanding  on  the  key  findings  from  the  Learning 
from  Lives  and  Deaths  reviews  (LeDeR).  The  objective  is  to  understand  what  reasonable 
adjustments are and how to make them.  This was introduced at the Trust in June 2023. 

In  addition  to  the  above  training,  the  Children  and  Young  People’s  mental  health  services      
(CAMHS)  have  a  bespoke  CAMHS  Autism  training  which  is  part  of  a  4  day  specific  training 
module for substantive staff on appointment. Within this training, 2 days are focused on Autism 
awareness  training.    This  training  compliments  the  Oliver  McGowan  training  (details  of  this 
training package were shared during the Inquest).   

The  Trust  has  also  made  environment  adaptions  for  neurodiverse/  autistic  patients,  with  the 
CAMHS  service.  Examples  include  sensory  rooms  and  safe  spaces  within  the  High 
Dependency Unit.   

Concern b) Mental health Trust staff on Longfield Ward were inexperienced. The majority were 
new  bank  and  agency  staff  with  limited  experience  working  with  detained  children,  and  this 
matter had been raised by the Care Quality Commission about other Trust services in January 
2021.   

Response:  
As  outlined  at  the  Inquest  this  Concern  was  also  raised  by  the  Care  Quality  Commission  in  a 
Section 31 issued to the Trust.  In order to address this, the Trust developed a CQC S31 Action 
Plan  which  was  implemented  following  the  CQC  inspection  (the  action  plan  for  which  was 
shared  at  the  Inquest).    A  number  of  immediate  actions  were  taken  at  time  (April-July  2021), 
which included: 

•  A review of Rotas undertaken to ensure staffing requirements met including right staff 

with right training and competency skills. 

•  A  process  was  put  in  place  which  allowed  staff  to  be  placed  on  the  Unit  (bank  and 
agency)  who  hold  the  required  skills  and  competencies  and  who  have  completed 
CAMHS  induction  module.  Staff  can  only  book  this  support  if  they  have  completed 
TASID training; substantive staff receive the CAMHS induction currently.  

•  The formulation of an enhanced escalation process when roster requirements are not 

met.  This has been shared across all inpatient services. 

•  The  development  of  ongoing  systems  to  ensure  oversight  of  key  competencies, 
experience,  training  and  skills  of  all  agency  and  bank  staff  on  CAMHS  wards.  With 
self-reporting of this system to the CQC 

•  The development of an enhanced local induction programme 
•  The provision of a retention premium for band 5’s posts 
•  The immediate uplift by 1 qualified and 1 HCA per shift 
•  An  enhanced  leadership  for  the  CAMHS  with  the  appointment  of  a  new  Service 
Manager  for  CAMHS  and  Preceptor  support  role,  these  are  practice  development 
nurses who support a CAMHS specific preceptor programme.  

In  addition  a  further  long  term  improvement  plan  has  been  established  which  includes 
implementation of activity coordinators, in post on CAMHS Wards from September 2021. 

The CQC inspected the service in March/April 2022 and confirmed that improvements had been 
made including: 

“The ward environments were safe and clean. The wards had enough nurses and doctors. Staff 
assessed and managed risk well and followed good practice with respect of safeguarding.” 

 
 
 
 
 
 
 
 
 
 
 •  Work  has  continued  to  develop  staff  and  the  CAMHS  Preceptorship  programme  in 
place,  guided  practice  development framework,  led  by  band  6  practice  development 
role. 

•  The  Service  has  continued  to  undertake  workforce  planning  to  look  at  the  forward 
view of staffing needs, impact on skill mix to ensure can respond to children’s needs. 
•  The  Trust  has  introduced  the  use  of  the  ‘Mental  Health  Optimal  Staffing  Tool’ 
(MHOST)  which  is  an  easy-to-use  multi-disciplinary,  evidence  based  system  that 
enables ward based clinicians to:  

(i) 
(ii) 

assess patient acuity and dependency; and  
convert acuity  and  dependency  data  into  a  workload  index  and  required  Full  Time 
Equivalents 
that  ward 
establishments reflect patient needs. 

(FTEs)  using  built-in  staffing  multipliers 

to  ensure 

This tool is being used across the Trust.  

Concern  c)  Mental  health  Trust  staff  on  Longfield  Ward,  did  not  have  sufficient  staffing  to 
conduct observations required by the doctors for patients on the ward. This was known to the 
mental health Trust management and had been raised by the ward manager. During the time of 
Elise’s  admission,  the  staff  member  allocated  for  observations  for  patients  was  required  to 
conduct  approximately  66  observations  within  an  hour.  This  was  not  logistically  possible. 
Management knew that staffing allocation on Longview Ward was not sufficient to conduct the 
required  levels  of  observations  to  keep  the  patients  safe.  Evidence  was  heard  during  the 
inquest that there are still observations that are not being conducted either as required or at all 
within  the  Trust  and  remains  an  ongoing  concern.  Datix  reporting  incidents  are  not  always 
raised.  

Response:   
Alongside  the  assurance  set  out  above,  we  confirm  that  as  part  of  the  Trust  CQC  S31  Action 
Plan, the following actions were taken in April-July 2021: 

 

 

 

 

 

 

In June 2021 the Trust completed the new Engagement and Observation plan for  
each current inpatient, these were submitted to the CQC 
The Trust undertook a review of shift management and allocation of observations and  
set principle of no more than 3 patients on level 2 allocated to one member of staff.  
The Trust continues to adhere to this ratio in CAMHS  
Learning regarding observations was shared at the specialist services quality and  
safety meetings 
The Trust developed a daily handover checking audit to ensure observations were  
fully completed during shifts 
The Trust developed an engagement and observation weekly audit tool, which  
includes a provision for reviewing and monitoring if observations are being carried out 
in accordance with patient need 
The Trust has added a prompt to the Datix system to prompt a check of observation  
levels have been undertaken following an incident 

 

In  addition  as  part  of  the  long  term  improvement  plan  the  following  actions  were 
taken: 

(i)  Implementation  of  Positive  Behaviour  Support  Plan  (PBS), 

this 

includes 

information  

a.  to help staff understanding observation levels and risks and the best ways 

of engagement with each patient (Aug 2021) 

 
 
 
 
 
 
 
 
 (ii)  Reviewed process for updating care plans to show when changes to observation  

level are made (Oct 2021) 

A Trust Observation and Engagement project group was established in 2021 who took forward 
a number of actions Trust wide.  The CAMHS staff were part of this project.  Actions included: 

Implementation of electronic observations  

 
  Development of observation and engagement training videos for staff 
 
  A full review of policy and procedures taking into account new guidance CQC  

Introduction of Engagement and Observation Plan 

In  addition  to  the  above  the  CAMHS  service  has  further  strengthened  monitoring  and 
observation processes: 

  The  Nurse  in  Charge  checks  Observations  intermittently  during  the  day  to  ensure 
completed and takes immediate action with staff where any gaps are found in relation to 
administrative / recording errors.  

  Compliance admin team check all observations for accuracy of completion, for any gaps 

a Datix incident is raised and the staff member met with and gaps completed. 

  Where appropriate staff are referred to Conduct Concerns Panel (CCP).   if any gaps are 
noted  in  respect  of  required  observations  for  a  sustained  period  of  time  (examples  of 
letters issued to staff following missed observations were shared with the Coroner at the 
Inquest) 

  Random checks are completed at handovers 
  Trust  wide  observation  audits  were  added  to  the  Tendable  audit  system,  these  have 

since been combined into Matron and Ward Manager audits  

  The  Trust  continues  to  create  an  open  and  transparent  culture  encouraging  staff  to 
acknowledge  if  they  miss  an  observation  or  speak  up  if  they  witness  an  observation 
missed so appropriate action can be taken to safeguard the patient. 
Introduction of Oxevision gave the opportunity for all staff to be instructed on this system 
as part of observation handover 

 

  The  Nurse  In  Charge  has  to  give  permission  for  any  patients  on  level  2  or  level  3 

observation to access their bedrooms 

  Morning situation reports to include a conversation around observation levels 

Concern  d)  The  mental  health  Trust  implemented  a  system  called  Oxevision  with  a  Project 
Board to assist with the planning and roll out of the new system. There were difficulties with the 
roll out on St. Aubyns ward who were part of the pilot, due to WiFi coverage and the Oxevision 
system not operating correctly.  

Response:   
As covered at the Inquest, during the index period, the Oxevision system was being piloted with 
roll out being overseen by the Oxevision Project Board (TOR shared at inquest) 

As part of the Trust CQC S31 Action Plan the following actions were taken in April-July 2021 

  WiFi  solution  identified  by  IT,  with  an  additional  routers  installed  (July  2021)    Additional 

tablets were also provided to the ward 

  Across the Trust systems have been established to mitigate any internet signal drop out, 
where  staff  will  revert  to  paper  observation  record.    This  process  was  witnessed  by the 
CQC  at  their  re  inspection  in  2022  at  CAMHS.  Any  connectivity  issues  are  urgently 
reported. The Trust, through Oxevision has an additional safeguard to ensure therapeutic 
observations. 

 
 
 
 
 
 
  
 
 
 Concerns  e)  The  clinical  management  at  the  Trust  Project  Board  meeting  overseeing  the  roll 
out  for  Oxevision,  required  that  ward  staff  implement  a  procedure  where  the  Oxevision  fixed 
monitor  in  the  ward  office  be  observed  by  a  member  of  staff  whilst  the  WiFi  problem  was 
resolved. This did not happen on Longview Ward.  

Response: Please see below.  

Concern f) The Trust Project Group had reports that WiFi was not working and any issues were 
required to be reported as incident reports on Datix forms but these were not being completed. 
The Trust Project Board did not question why they were not receiving the Datix forms with the 
known  issues.  There  was  no  oversight  of  what  was  required  to  ensure  that  the  roll-out  was 
operating  appropriately  and/or  what  the  Project  Board  expected  in  the  interim  whilst  the  WiFi 
difficulties were being investigated.  

Response    
As covered during the Inquest, during the index period, the Oxevision system was being piloted 
with  roll  out  being  overseen  by  the  Oxevision  Project  Board.  The  terms  of  reference  for  this 
board has been disclosed to the Court).  

In  response to the  above  concerns,  the  Court  were  assured that  between  April-July  2021, the 
following had been actioned:  

  WiFi  solution  identified  were  acted  on  at  pace  by  the  Trust  Information  Technology 
department, with an additional routers installed in July 2021.  Additional hand-held tablets 
were also provided to the ward. 

  Across the Trust systems have been established to mitigate any internet signal drop out, 
with  staff  being  advised  on  the  need  to  revert  to  paper  observation  record  in  the  event 
that this does occur in order to ensure patient records are maintained.   This process was 
witnessed by the CQC at their re-inspection in 2022 at CAMHS. Again, any connectivity 
issues are promptly reported and resolved. 

It  must  be  noted  that  Oxevision  is  assistive  technology  which  "does  not  alter  or  diminish" 
clinicians'  responsibilities,  and  that  it  is  supportive  only  and  must  not  replace  in-person 
observations or therapeutic engagement. Training is provided on this assistive tool.  

Concern g) Not all the Trust staff on the ward were trained to use the Oxevision System.   

Response:   
By way of assurance, and in line with the evidence provided to the Court during this Inquest, the 
Trust undertook the following steps as part of the CQC S31 Action Plan over the course of April-
July 2021:  

•  Oxevision SOP approved and circulated to staff 
•  E-learning Oxevision training to be provided to staff 
•  Reminder to all staff, including ‘snap comms’, to ensure sound is switch remains ‘on’ 

for Oxevision 

•  A Oxevision task and finish group has worked with CAMHS units to understand how 

Oxevision would work best for them 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 •  Estates  solution  implemented  to  stop  plug  sockets  power  from  being  accidently 

turned off 

In  addition  the  Trust  has  developed  of  set  of  competencies  for  Staff  using  Oxevision  and  has 
implemented Oxevision audits.  

Concern h) There was disputed evidence about the volume on the fixed terminal for Oxevision 
in the office about whether the alert volume could be turned down or ‘muted’. It was established 
that there was an incident unrelated to Elise’s death where a doctor did turn this volume down 
on the ward.  

Response  
In  line  with  the  assurance  evidence  provided  to  the  Court,  and  as  part  of  the  Trust  CQC  S31 
Action Plan the following actions were taken in April-July 2021: 

•  Reminder  to  all  staff,  including  ‘snap  comms’,  to  ensure  the  sound  is  switch  on  for 

Oxevision 

•  Estates  solution  implemented  to  stop  plug  sockets  power  from  being  accidently 

turned off 

As per our evidence at this Inquest, configuration changes to the Oxevision system have been 
implemented.  This includes the reset functionality of a repeating audible and tile illumination of 
an alert with timer continuation after each successive reset of the alert in 3-minute intervals.  

A clinical review of the SOPs for Oxevision and Oxevision Observations has been undertaken to 
align terminology and updated versions of the SOPs have been implemented.    

Again, all clinical staff are being retrained or trained in the use of Oxevision and observations.  
In  line  with  the  Oxevision  SOP  and  the  Therapeutic  engagement  and  supportive  observation 
policy. 

Concern 2 
Elise’s medication changes whilst in mental health hospital were not correctly entered onto the 
medication chart: 

Concern  a)  Elise  asked  for  changes  to  her  medication  and  then  reported  that  these  changes 
were  not  therapeutic.  It  was  agreed  with  her  consultant  that  her  previous  regime  would  be 
implemented.  The  medication  was  crossed  out  and  removed  from  the  prescription  chart. 
Sertraline 200mg was re-prescribed by the consultant but not entered onto the medication chart 
and not administered.  

Response  
The Trust confirms that the medication card was re-written, in line with standard NHS practice; 
however  it  was  acknowledged  that  there  was  an  error  at  this  stage  made  by  the  person 
completing the  new  medication  card  and  one medication  provision  was missed,  whilst this  did 
not  have  a  causative  effect  to  the  sad  outcome  in  this  case,  this  was  regrettable.    The 
practitioner concerned has reflected upon this oversight.  

The  Trust  has  since  intruded  an  electronic  prescribing  and  medicines  administration  (ePMA) 
system.    This  new  system  provides  safeguards  around  prescribing.    ePMA  will  help  prevent 
inadvertent  omission  of  medicines  which  could  occur  when  a  paper  drug  chart  reached 
completion and has to be rewritten.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 It  is  not  uncommon  for  a  prescription  to  change  and  there  is  clear  legislation  guiding  nursing 
staff on administration of medication ensuring this is in line with the Prescription Card.  Nursing 
staff cannot administer medication not included on the card. 

To  strengthen  medicines  management,  medication  changes  are  discussed  at  the  MDT  and 
prescriptions are re-checked during this review.    

Medicines  reconciliation  is  undertaken  by  pharmacy  for  new  patients.  Whilst,  medicines 
reconciliation  is  not  relevant  in  this  case,  with  the  issue  being  the  need  to  ensure  that  the 
medicines  prescribed  on  admission,  reflect  those  prescribed  pre-admission  unless  there  is  an 
intentional  decision  to  omit  something.  It  is  noted  that  in  this  case  it  appears  that  the 
reconciliation would have already occurred and would not have changed the medication plan at 
all.  

In  addition,  Pharmacists  review  prescription  charts  for  accuracy  and  completeness,  identifying 
drug  incompatibilities,  providing  advice  to  the  healthcare  team  and  to  patients,  and  assessing 
the  pharmaceutical  needs  of  individual  patients.  This  enables  pharmacists  to  make  a 
comprehensive  assessment  of  medication  and  individual  risk  factors,  thereby  helping  to 
optimise the therapeutic management of each patient.   

Concern b) Nursing staff did not query the sudden cessation of medication for treating mental 
health with no replacement or explanation given. Elise suffered a significant deterioration in her 
mental health during this time, the frequency and severity of ligatures increased, and Elise had 
to be placed under section 3 Mental Health Act.  

Response 
Staff  have  been reminded  via  supervision  sessions  of the  importance  of  applying  professional 
curiosity and challenge as needed.  

The process in the medicines policy for the administration of medicines (CLP13 SOP 10) does 
include  taking  opportunities  to  engage  the  service  user  in  conversation  about  their  treatment, 
checking  knowledge  of  their  medication  and  offering  information  and  advice  about  the 
medicines, which would have been provided for Elise.   

Concern c) There was no pharmacist scrutiny just prior to the Bank Holiday and the medication 
error was only noted when questioned by Elise’s family when she went on home leave.  

Response  
In April 2021 three pharmacist posts were based at Colchester, one of which was vacant, one 
working from home due to COVID shielding, leaving only one (the most junior) on site. So whilst 
the clinical pharmacy rota included a weekly visit, that may not have been possible every week.  

Now with ePMA in place screening of prescriptions can take place remotely so whilst physical 
presence of a pharmacist on the ward is still important, options exist when it is not possible. A 
pharmacist generally visits twice weekly, and also now routinely attends weekly MDT meetings 
on both wards at the St Aubyn Centre 

Concern 3) There was poor communication between ward staff and vital information about self-
harm and ligaturing was not handed over on shift change. It was undisputed that Elise tied 12 
Ligatures between 7th and 14th April and that she was found in the presence of ripped bedding 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 on  15  April.  The  Datix  incident  recording  gave  minimal  details  and  only  the  ligatures  from  the 
13th and 14th were recorded on the whiteboard in the nurse’s office.  

Response  
Risk  is  based  on  both  level  of  harm  of  an  incident  and  number  of  incidents  that  have  taken 
place. 

Elise had multiple low harm incidents. These were promptly shared with staff and as a result her 
observations were maintained at levels 2 and 3’s in response to the identified risks. 

As  part  of  the  Trust  response  to  the  CQC  S.31  Notice,  an  enhanced  ligature  analysis  was 
undertaken.  This identified that door tops was one of the most used ligature items.  A review of 
the  doors  urgently  undertaken  and  new  doors  identified  for  Longview  and  Larkwood  for 
bedrooms and corridors. This was completed in November 2021.  

The  Trust  undertook  a  project  as  part  of  a  Trust-wide  CQC  action  plan  to  improve  incident 
reporting  (both  to  ensure  all  incidents  are  recorded  and  to  ensure  all  key  information  was 
captured in the incident).  Actions taken have included: 

•  A  survey  was  undertaken  with  staff  to  understand  barriers  in  reporting.    The 
outcomes  were  reviewed  revisions  made  to  the  incident  reporting  form  both  Datix 
Incident Form 1 and Datix Incident Form 2 

•  Enhanced systems for ensuring staff review a patient’s risk assessment following an 
incident.    This  included  an  added  an  automatic  reminder  in  Datix  prompting  staff  to 
review risk assessments.  

•  Develop and implement process for advertising changes made following incidents 
• 
•  Awareness  raising  for  handlers  of  importance  of  completing  key  fields,  which  then 

Implemented automatic feedback from Datix to reporters 

allows staff to obtain feedback on reported incidents.  

In  addition  to  the  above  the  CAMHS  has  also  undertaken  dedicated  improvement  work  within 
their services.  This has included: 

  Training with preceptor nurses as part of induction 
 
Involvement in ligature projects, including categorising ligature to indicate level of risk 
  All CAMHS Datix incidents are written in ABC format, this promotes learning through 
DBT – all staff trained in this.  This training allows for a clearer understanding of the 
behaviours  before,  during  and  after  an  incident,  and  support  DBT  focused 
approaches  to  understanding  emotions  and  identifying  linked  behaviours  in  order  to 
make changes through therapeutic interventions. 

  All  staff  asked  to  complete  action  taken  and  this  informs  chain  analysis  that  is 

undertaken by staff  

The  Trust  has  also  implemented  changes  to  handover  process  using  SBAR  –  an  electronic 
handover system.  

Concern  4)  Mental  Health  Trust  staff  falsified  Elise’s  observation  records  and  this  was  not 
identified by the Trust post-death investigation despite the availability of timings from Oxevision 
imaging. This matter arose in an inquest that significantly post-dated Elise’s death and there is 
concern  that  lessons  had  not  been  learned.  The  Trust  internal  investigation  does  not  refer  to 
this and these matters are arising with scrutiny within the inquest hearing.  

 
 
 
 
 
 
 
 
 
 
 
 
 Response  
The investigation followed the Patient Safety Incident Response Framework (PSIRF) approach.  
This  is  an  overarching framework for  how the  NHS  responds to  all  patient  safety  incidents for 
the purpose of learning and improvement within the Trust.  These reports should be shared with 
carers and families and can be a source of information supplied for the Inquest process.   

In  EPUT,  this  is  a  devolved  process  where the  investigators (Learning  Response  Lead  (LRL)) 
are  members  of  staff  within  the  organisation  carrying  out  different  roles.  These  reviews  are 
carried out at a point in time with the information that is available at that time. This model was 
chosen  because  of  the  benefits  of  having  staff  who  understand  the  service  areas  but  are  not 
involved in delivering care in that area.  PSIIs are signed off by the senior management in the 
Care Unit and Executive colleagues. 

Proposed Improvement in PSIIs 

•  Further develop the support for LRLs ensure that all relevant steps have been taken 
for  example  ensuring  all  relevant  Trust  documents  are  included,  these  documents 
need to be relevant to the time the incident took place, not the time the report is being 
written  and  also  be  applicable  to  the  area  of  practice  where  the  incident  happened 
and that all key patient records/documents have been pulled as a data source for the 
review.    Currently  the  checklist  is  more  general  and  completed  at  the  end  of  the 
review process.  This case has identified the need for this to be much more detailed 
and be used as a guiding framework throughout the investigation. 

•  Ensure direct confirmation with the care team where the incident has taken place to 
confirm  what  documents  have  been  used  to  guide  practice  and  when  and  how they 
have been accessed locally. This is to ensure alignment with those published by the 
Trust. 

•  Ensure that there is a mirroring checklist as a quality check to assist sign off by the 

organisation. 

•  Explore  whether  arranging  a  service  lead  contact  within  the  relevant  area  helps  the 

reviewer check information more easily. 

Concern 5) The observation level for each young person is decided by the medical staff at the 
Trust and can be altered dependant on the patient’s risk level. The Trust Policy had a protocol 
on how observations should be conducted. All observations should be recorded by the staff on 
formal observation sheets. There were sheets for Level 1 and another sheet for the levels 2,3 & 
4.  Risk  assessments  were  incomplete  and  not  all  ligatures  were  included  The  entries  in  the 
records  were  not  all  consistent,  some  contradicted  others  and  this  included  the  levels  of 
observations  required  to  keep  Elise  safe  on  the  observation  charts  that  were  required  to  be 
completed.  This was confusing and remains a concern as these are entries made by qualified 
Trust  staff  who  have  received  training  in  observations.  During  the  Trust  internal  investigation 
after  Elise’s  death,  the  investigator  visited  the  ward  and  found  observations  were  not  being 
conducted in accordance with the Trust Policy.  

Response  
Please see response to concern 1c 

Concern 6) Detained patients including Elise were not kept under observations by trained staff 
and  mealtimes  were  chaotic  with  patients  moving  between  areas  without  the  required 

 
 
 
 
 
 
 
 
 
 
 
 supervision.  On  17  April  the  activity  co-ordinator  left  a  box  of  mobile  phone  chargers  and 
headphones that posed a ligature risk, with a member of ward staff in a communal area, asking 
that  she  look  after  this  whilst  he  collected  some  takeaway  food  that  had  been  ordered  by 
patients  from  the  ward  entrance.  On  his  return,  the  box  was  unattended  in  the  presence  of 
patients with a high risk of ligature and suicide, with no member of ward staff present to keep 
patients  who  required  level  2  and  level  3  observations.  This  was  not  reported  to  the  nurse  in 
charge,  and  no  incident  report  was  completed.  Evidence  was  that  there  were  many  new  staff 
and that breaches of procedure were a regular occurrence. This left patients at risk. Evidence 
was heard that patients are still being left without the required observations since this death.  

Response  
The Trust acknowledges that there are times when observations are not carried out in line with 
observation  prescriptions.    This  is  often  down  to  human  error.    As  outlined  above  there  are 
robust systems in place to identify missed observations and the onward action that is addressed 
with staff. 

There  are  a  range  of  potential  environmental  risks  on  all  wards.    The  Trust  has  a  set  of 
Environmental  Standards  to  minimise  risks  and  utilise  reduced  ligature  products  but  it  is  not 
possible  to  eliminate  all  risks.    Part  of  environmental  risk  mitigation  is  the  observation  level 
assigned to each person, based on that individual persons risks.  Observation is about having a 
presence and engaging with patients and to empower staff to be curious and knowledgeable of 
the risks and mindful of the complexities of each individual patient. 

As  part  of  ongoing  work  to  make  our  environments  as  safe  as  possible,  without  introducing 
restrictive practice, the CAMHS units have introduced communal chargers. Charging points are 
in  place  to  ensure  the  safe  charging  of  devices  in  line  with  EPUT  fire  regulations  and  reduce 
ligature risk. 

Concern  7)  Oxevision  imaging  showed  Elise  entering  her  bedroom  alone  at  approximately 
18:10 hours and she remained in her room until she was found unresponsive at approximately 
18:29.  Elise’s  observation  logs  for  17:30-18:30  on  17  April  were  falsified  recording  that  Elise 
was in the communal area with checks completed at 17:30 17:40 17:50 18:00 18:10 and 18:20 
recorded  that  Elise  was  present  in  the  communal  area.  Elise  was  required  to  be  on  constant 
eyesight observations whilst in her bedroom.  

Response  
See  previous  answers  re  engagement  and  observation.    All  requests  for  patients  to  access 
bedrooms  are  now  approved  via  the  Nurse  in  Charge.  However,  the  Trust  acknowledges  that 
these entries were falsified with recording of observations not carried out as required. 

Elise was subject to constant eyesight observations when in her bedroom, and this level of care 
was not provided. The Trust accepts that this represents a serious failure to maintain her safety 
and a breach of expected professional and organisational standards. The Trust has processes 
in place to ensure that staff are held to account for their actions. This includes the use of formal 
internal human resources processes to address misconduct and, where appropriate, referral to 
the  relevant  professional  regulatory  bodies  so 
independently  consider 
fitness-to-practise concerns. 

they  can 

that 

The  Trust  is  committed  to  ensuring  full  transparency  in  understanding  how  and  why  patient 
safety  events  occurred,  to  taking  appropriate  action  in  relation  to  staff  accountability,  and  to 
implementing the necessary improvements to prevent any recurrence 

 
 
 
 
 
 
 
 
 
 
 Concern  8)  The  mental  health  Trust  were  on  notice  that  staff  must  have  falsified  the 
observations  logs  for  Elise  in  2021.  Another  inquest  for  a  St.  Aubyn’s  patient  who  died  on  12 
July  2022,  also  found  that  observation  logs  were  falsified  and  contained  errors.  Trust  staff 
falsification  of  records  were  not  further  investigated  or  monitored  after  Elise’s  death  at  St. 
Aubyn’s Centre.   

Response  
This concern is factually incorrect, the inquest on 12 July 2022 was for a patient under the care 
of the Derwent Centre, not St Aubyns. 

Please see responses above regarding improvement work for engagement and observation 

Concern 9) Elise’s key nurse was working nights and was not having the required 1:1 with Elise 
and  key  documents  were  not  completed  for  Elise’s  care.  Inaccuracies  and  inconsistencies  in 
record-keeping remains a concern.  

Response  
By way of assurance on this, the Court is advised that all staff are part of internal rotation, which 
includes nursing staff being rostered to work night and day duties. The night shifts start at 7pm; 
this  enables  staff  to  have  1:1  with  patients  during  the  course  of  the  evening.    This  is  often 
preferable for the young person depending on activities during the day. During the day, the unit 
provides  a  full  education  programme  and  therapeutic  programme  outside  of  education  hours. 
Therefore,  spending  time  with  key  nurse  outside  of  these  hours  often  means  this  is  quality, 
uninterrupted time. 

Patient’s  weekly  1:1  with  their  key  nurse  is  monitored  by  unit  charge  nurses,  this  includes  a 
review  of  the  corresponding  clinical  records.    Issues  and  concern  are  shared  with  the  ward 
manager and all key nurses.  The units also have weekly check-ins with family in order to keep 
families updated and engaged with care planning. 

Where gaps are found action is taken to ensure 1:1 are being completed, and where required 
the 1:1 will be reallocated if a staff member is absence. 

The  Trust  has  continued  with  a  Record  Keeping  Safety  Improvement  Programme  (SIP).  This 
SIP  program  is  focusing  on  improving  patient  safety  in  respect  of  documentation  specifically 
through education and development of appropriate guidance.   

Concern  10)  whilst  this  did  not  directly  cause  Elise’s  death,  there  were  plenty  of  staff  who 
responded quickly to the emergency when Elise was found unresponsive but there was a delay: 

In notifying the duty doctor who was not contacted for over 40 minutes.  

a.  bringing the grab bag to this emergency 
b.  obtaining and attaching the defibrillator.  
c. 
d.  The  expert  witness  was  of  the  opinion  once  the  defibrillator  was  attached,  it  was 
being  switched  on  and  off  in  the  first  few  minutes.  When  looking  at  the  machine 
analysis  there  appeared  to  be  3  analysis  checks  on the machine  within the  first few 
minutes  when  the  machine  is  set  to  conduct  analysis  at  set  intervals  which  is 
inconsistent with this.  

Response: 
As per the evidence provided to the Court, in line with the safety actions undertaken by the Trust 
following the CQC S.31 Notice, the following was put into place during April-July 2021:  

 
 
 
 
 
 
 
 
 
 
 
 
 The  Trust  has  made  the  decision  to  deliver  the  ‘gold  standard’  Resuscitation  Council  UK 
Immediate  Life  Support  (RCUK  ILS)  training  to  all  registered  nursing  staff  working  within  an 
inpatient  setting.  RCUK  ILS  training  was  rolled  out  from  September  2022.  The  one  day  face  to 
face training is accompanied by a RCUK ILS ‘hard copy’ training manual and is delivered on an 
annual basis. 

The RCUK ILS training focuses upon the identification and treatment of the deteriorating patient, 
using a structured and robust ABCDE assessment and non-technical human factors skills, such 
as  team  working  and  leadership  during  a  medical  emergency.  By  following  this  structured 
approach, staff are equipped with the skills to try and prevent deteriorating patients from reaching 
the point of cardiac arrest, and are trained in the interventions available at each step. The course 
follows the latest RCUK guidelines.  

Non  registered  staff  working  within  an  inpatient  CAMHS  setting,  receive  annual,  face  to  face 
Basic Life Support training. 

The ‘Assessing a Critically Unwell Patient’ Aide memoir document has been implemented within 
EPUT. The aim of the document is to help identify the deteriorating patient, treat and stabilise in 
order to prevent cardiac arrest and the resus bag will be taken to every unwell patient if an alarm 
is  raised.  The  tool  acts as  an  aide memoir  to  support the team  carrying  out the  physical  health 
assessment  of  the  unwell  patient.  The  aide-memoire  must  be  located  within  the  resus  bags  on 
the wards, so staff have easy access to the guidance during a medical emergency.  

The ‘Non-touch physical observation’ tool provides staff with an opportunity to observe patients’ 
vital  signs  in  a  non-  intrusive  way  and  provides  a  guide  when  to  escalate,  if  there  are  any 
concerns in relation to the parameters.  The tool was piloted on selected inpatient wards, before 
being  rolled  it  out  across  within  the  Trust.  This  use  of  this  tool  has  a  wealth  of  patient  safety 
benefits,  especially  where  physical  examinations  are  not  possible  or  would  be  disruptive  to 
patients. Guidance relating to the use of the tool is provided within CG52 Clinical Guidelines for 
the Pharmacological Management of Acutely Disturbed Behaviour and CG87 Clinical Guidelines 
on the Use of National Early Warning Scoring System (NEWS2). 

The use of the ‘Calling (9)999 in a Medical Emergency’ document was developed, implemented 
and  shared  as  an  EPUT  Internal  Safety  Alert  on  1st  June  2023  (INT  LL  2023  002)  ,  following 
lessons  identified  and  provides  information  for  staff  when  calling  (9)999,  including  a  prompt  for 
staff, to meet the Ambulance crew and facilitate access to the site. This poster is now displayed 
within the ward and a copy must be stored within the front pocket of the resus bag, 

The  above  tools  were  highlighted  within  an  EPUT  Lessons  Team  ‘Learning  Matters’  live  event, 
which  focused  upon  assessing  deterioration  patients  and  resuscitation, which  was  facilitated  on 
25th June 2025.  

The Head of Deteriorating Patient Pathways and Resuscitation Training Officer and The Head of 
Clinical  Transformation  have  facilitated  life  support  drop  in  refreshers  sessions  for  EPUT  staff 
working  within  a  CAMHS  setting.  These  sessions  are  an  opportunity  for  staff  to  refresh  their 
knowledge  of  BLS/ILS  in  small  groups,  in  between  their  mandatory  training  sessions,  including 
refreshers on topics such as chest compressions and airway management.  

The Essex Partnership NHS Foundation Trust’s CPR procedure document (CLPG14A) states the 
Ward  Manager,  Matron  or  Service  Manager/Clinical  lead  for  each  inpatient  setting,  will  be 
responsible for ensuring that medical emergency simulations are undertaken every three months 
in  the  clinical  environment.  Each  inpatient  setting  must  record  when  a  medical  emergency 
simulation  is  facilitated,  using  the  approved  ‘Medical  Emergency  Simulation  Practice  Report’ 

 
 
 
 
 
 
 
 
 
 document.  In  addition  the  facilitation  of  the  medical  emergency  simulation  can  be  supported  by 
the allocated Professional Nurse Educator or Resus Link Practitioner. 

The  Trust  has  also  introduced  the  role  of  Resus  Link  Practitioners  (RLP)  to  all  inpatient  ward 
settings.  These  volunteers  will  play  a  key  role  in  strengthening  the  response  to  medical 
emergency situations within the wards. The role is open to all nurses and HCAs/support workers 
and  the  RLP  will  act  as  a  link  between  the  Resuscitation  and  Deteriorating  Patient  Group  and 
their ward, promoting best practice and raising awareness. The RLP will: 

a.  help facilitate medical emergency simulations on their ward; 
b.  have  access to  a  fully-stocked  resus  bag (which  itself  is  checked  weekly  by  nursing 

staff) and training mannequin to help train staff; 

c.  help ensure all ward staff know what emergency equipment is on the ward, where it 

is, how to use it, and the importance of checking it regularly; 

d.  update colleagues on key life support messages and training; 
e.  participate in audit data collection; and 
f.  attend  bi-monthly  Resus  Link  meetings,  where  important  Resuscitation  Council  UK 
updates are shared, medical emergency simulation outcomes are discussed and RLP 
have a chance to raise any questions.  

The RLP role allows staff to build upon and enhance their own expertise, while having the ability 
to coach and empower their team, in order to be ready to respond quickly and effectively, in any 
medical emergency situation. 

In summary, risk assessment at the Trust have moved away from RAG rating and become more 
descriptive.   This  is  part  of  the  Trust  move  towards  personalised  risk  assessment  and  safety 
planning in line with NICE guidance. 

Risk assessment and care plans aim to be holistic so we would not necessarily have separate 
documents  for  all  risks/needs  but  a  separate  assessment  and  plan  would  be  considered  for 
significant  risks,  work  remains  ongoing  to  ensure  this  revolving  and  ongoing  duty  is  refreshed 
daily and given priority.  

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.   

Yours sincerely 

Chief Executive