Skip to content
recurance

Stephanie Moyce

25 Feb 2022 · Coroner Sean Horstead · Essex

A similar concern from this report was raised again 1 time later. See the linked reports.

The coroner's concerns

  1. 1. lack of discharge plan responsibility

    “Evidence confirmed a conspicuous lack of clarity as to who, amongst EPUT clinicians/staff, is responsible for ensuring that a clear and comprehensive discharge plan is formulated for those coming to the end of a course of psychotherapy where a Care Coordinator is no longer in place/has not been replaced”
  2. 2. lack of post-discharge oversight

    “Evidence confirmed a conspicuous lack of clarity as to who, amongst EPUT clinicians/staff has the responsibility for oversight of patient care following discharge, including responsibility for ensuring adequate and appropriate safety- netting is in place in the event of relapse, where a Care Coordinator is no longer in place/has not been replaced”
  3. 3. missed multidisciplinary team discussion

    “patients under psychotherapy are not presently routinely discussed in the locality multi-disciplinary team meetings prior to their 2 discharge leading to a missed opportunity: (a) to share information about the specific progress, vulnerabilities and risks of relapse of the patient (and measures to mitigate or deal with the same); as well as (b) to organise and follow up the overall discharge planning”
  4. 4. carer not treated as equal partner in after-care plans

    “The evidence in this case indicated that, contrary to EPUT's own established Protocol, a patient's carer (in this case her long-term partner where no confidentiality issues were identified) are not in practice always”

Linked reports

Raised again laterDarren Turner17 Mar 2025 · 3 years 1 month later
Closely relatedConfidence 0.80 · moderate

This report

“Evidence confirmed a conspicuous lack of clarity as to who, amongst EPUT clinicians/staff, is responsible for ensuring that a clear and comprehensive discharge plan is formulated”

Later report

“(d) Failure to allocate a Care Coordinator as required under the Care Programme Approach (CPA) and as mandated by EPUT policy.”
Original on judiciary.uk ↗
Full chain: Lack of discharge plan responsibility and unclear care coordinator allocation

Responses

No published response was found on judiciary.uk.

  • Built with
  • NVIDIA Nemotron Nano, Super and Ultra
  • Nebius Token Factory inference
  • Qwen3 Embedding 8B on Token Factory
  • Tavily follow-up web search
  • Postgres and pgvector search
  • Next.js site

Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error