Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Sharon Langley · 27 Feb 2023 · Sonia Hayes, Essex
“Significant examples of cut and paste including out-of-date risk information at all grades of ward staff, and omissions in multi-disciplinary decision-making”
judiciary.uk/…/sharon-langley-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Sharon Langley (27 Feb 2023) · stated timescale: May 2023
“EPUT's Head of Deteriorating Patient Pathways and Resuscitation Training Officer is working closely with mental health wards to facilitate drop-in 'refresher' life support training for clinical and administrative staff dealing with emergency situations. During 1 the training, the importance of calling for help as soon as possible (i.e. use of pinpoint alarm) is highlighted and discussed in detail (1a, 1b, 1c, 1d).”
judiciary.uk/…/2023-0075-Response-from-Essex-Partnership-Univer…
Stated action 2 · response to Nadia Wyatt (15 Jan 2024) · stated timescale: April 2024
“The Trust has revised line management supervision forms to include quality of record keeping, their professional responsibilities, Trust policy and values, and NMC accountability frameworks in respect of record keeping. In addition to discussions during supervision the Crisis Response and Home Treatment Service has been reminded of this in their team meetings.”
judiciary.uk/…/2024-0024-Response-from-Essex-Partnership-NHS.pdf
Stated action 3 · response to Nadia Wyatt (15 Jan 2024) · stated timescale: April 2024
“Bespoke training on the importance of documentation is being arranged for all staff working in the urgent care pathway in April 2024.”
judiciary.uk/…/2024-0024-Response-from-Essex-Partnership-NHS.pdf
4 further stated actions are listed on the full chain page.
What recurred
- 15 Jan 2024 · Nadia Wyatt · Rebecca Mundy · Closely related · confidence 0.80 (moderate)
- 12 Aug 2025 · Resmije Ahmetaj · Sonia Hayes · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Sharon Langley · 27 Feb 2023
“Significant examples of cut and paste including out-of-date risk information at all grades of ward staff, and omissions in multi-disciplinary decision-making”
Later · Resmije Ahmetaj · 12 Aug 2025
“The mental health Trust record-keeping did not contain all relevant information relating to the care and treatment there were omissions relating to symptoms and potential signs of deterioration and compliance with medication.”
What happened next
No web check of the stated actions has been published for this chain.