Delay in prescribing and administering therapeutic medication for first episode
Essex Partnership NHS Foundation Trust received 2 coroners' reports about this hazard between 7 May 2023 and 12 Aug 2025.
They came from 1 coroner. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“[REDACTED] Lorazepam was prescribed and administered on 25 May 2022 at hospital and evidence was that this was sub-therapeutic.”
Original on judiciary.uk ↗ Essex Partnership NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“The Trust is currently considering the need to expand the number and types of medications available for nurses to use via PGD. In order to inform these considerations, the Trust's Director of Pharmacy and Service Managers for urgent care pathways are collaboratively reviewing the medication needs for the services.”
Stated timescale: end of July 2023
- 2 years 3 months laterClosely relatedConfidence 0.80 · moderate
“(2) There was confusion about the mental health Trust prescribing dose for Ms [name redacted] antidepressant medication and an overreliance on discussions with her rather than checking the prescription dose and communication with the GP was delayed.”
Original on judiciary.uk ↗ Essex Partnership NHS Foundation Trust responded.Response (PDF) ↗Response (PDF) ↗
- All reports to Essex Partnership NHS Foundation Trust
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2023 → 2025Resmije Ahmetaj2 years 3 months after Bency Joseph · same coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight problems with the Trust's medication management for mental health patients, specifically delays or failures in ensuring appropriate prescribing and administration.
Bency Joseph · 7 May 2023
“[REDACTED] Lorazepam was prescribed and administered on 25 May 2022 at hospital and evidence was that this was sub-therapeutic.”
Original on judiciary.uk ↗ Resmije Ahmetaj · 12 Aug 2025
“(2) There was confusion about the mental health Trust prescribing dose for Ms [name redacted] antidepressant medication and an overreliance on discussions with her rather than checking the prescription dose and communication with the GP was delayed.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The Trust is currently considering the need to expand the number and types of medications available for nurses to use via PGD. In order to inform these considerations, the Trust's Director of Pharmacy and Service Managers for urgent care pathways are collaboratively reviewing the medication needs for the services.”
Stated action · timescale: end of July 2023
“The Trust is currently considering the need to expand the number and types of medications available for nurses to use via PGD. In order to inform these considerations, the Trust's Director of Pharmacy and Service Managers for urgent care pathways are collaboratively reviewing the medication needs for the services.”
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Essex Partnership NHS Foundation Trust at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2023 → 2025 | 0.63 | 0.05 | Closely related · 0.80 | same |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for Essex Partnership NHS Foundation Trust
This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.