Jayden Booroff
27 Jan 2023 · Coroner Sonia Hayes · Essex
The coroner's concerns
1. reduction in observations levels on the ward
“Essex Partnership NHS Foundation Trust risk assessments missed key risk information that led to a reduction in observations levels on the ward.”
2. misunderstanding of patient status and communication to emergency services
“of understanding at Essex Partnership NHS Foundation Trust level about the difference between: a. a patient who has been granted section 17 leave under the Mental Health Act who does not return from a period of authorised leave, and b. a patient who being subject to detention under the Mental Health Act, who has escaped from the confines of the ward and who has not been granted section 17 leave by the Responsible Clinician”
3. miscommunication between services
“Miscommunication between: a. Essex Partnership NHS Foundation Trust to emergency services b. Essex Police to Essex Partnership NHS Foundation Trust c. Essex Police to other emergency services”
4. absence of senior single point of contact for emergency communications
“Lack of an Essex Partnership NHS Foundation Trust senior single point of contact for communications with emergency services who would provide any further information or receive updates and how this could be managed across change of shifts”