Stephen Neville
24 Oct 2025 · Coroner Sean Horstead · Essex
The coroner's concerns
1. lack of therapeutic engagement and interaction observations
“There was a failure on the part of EPUT nursing and (particularly) support staff to appropriately undertake and record the required therapeutic engagement and interaction observations”
2. quality assurance and auditing processes failure
“Further, the clear evidence also disclosed an on-going failure in the quality assurance and auditing processes deployed by EPUT”
3. absence of audit process for observation and engagement documentation
“Of even greater concern is that even after the move from paper to electronic observation records the same Beech Ward Manager (then and now) stated in evidence: "I have no audit tool .... I am not confident that the audits are accurate and complete now ... there is no audit process in place to check the quality of observation and engagement documentation."”
4. non-mandatory free text field leading to omitted audits
“The Deputy Director of Quality and Safety (Inpatient and Urgent Care) recognised in her written and oral evidence that the available free text box now included on the electronic version of the records relating to observation and engagement is "not a mandatory field" in the recording process and that: "it appears that at some point the Tendable audits were amended to omit the audits of the quality and nature of the observation records."”
5. inadequate audit mechanism relying on staff supervision and handovers
“It remains unclear how (or why) this came about, and I am very concerned that the apparent reliance on staff supervision (as per paragraph 7.1 of the Therapeutic Engagement and Supportive Observation Clinical Guideline (Inpatients)) and staff handovers to rigorously audit the nature and quality of the conduct and recording of therapeutic engagement and supportive observations remains a wholly inadequate mechanism for the purposes of achieving appropriate qualitative compliance monitoring”
6. weak quality assurance and auditing processes for critical observations
“The lacuna identified above gives rise to a real concern regarding the robustness of EPUT quality assurance and auditing processes generally, and particularly in the context of the on-going issues relating to the nature and quality of the conduct by EPUT staff of such critically important observations including the essential therapeutic engagements and interactions, with highly vulnerable inpatients at risk of suicide. This is a concern, I am told, also shared by the Deputy Director quoted above”