Nicholas Gray
5 Jun 2025 · Coroner Sonia Hayes · Essex
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. inaccurate information in PSIRF Decision Monitoring Tool
“The Trust PSIRF Decision Monitoring Tool completed after Mr [name redacted] died contained inaccurate information, the dates of EPUT contact and the substance of the interactions were inaccurate”
2. lack of self-harm documentation
“Self-harm was noted as "none known or recorded”
3. missing mental health liaison nurse review and discharge record
“There was no record of the mental health liaison nurse review on 24 June 2023 and the discharge of Mr [name redacted] from EPUT”
4. significant omissions in investigation information
“The information used to inform a potential investigation requirement contained significant omissions and was not consistent with the information known to the Trust”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“The Trust investigation was materially incomplete and there was a lost an opportunity to:”
This report
“The information used to inform a potential investigation requirement contained significant omissions and was not consistent with the information known to the Trust.”
Closely relatedConfidence 0.80 · moderate
Earlier report
“During the waiting period of up to 72 hours, Mental Health Liaison will not attend the acute ward or make assessment of the presenting risks of self-harm”
This report
“There was no record of the mental health liaison nurse review on 24 June 2023 and the discharge of Mr [name redacted] from EPUT.”