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Missed opportunities: What lessons can be learned from failings at the North Essex Partnership University NHS Foundation Trust

The timeline

From our investigations, we have developed a broader timeline about what happened at NEP during and after the cases that came to us. 

Reflecting on this timeline, as we concluded our most recent investigation and considered our recommendations, our concern was that it highlighted very similar warnings that reoccur across a significant number of years. Despite their seriousness, the pace of change appears incredibly slow.

In our view, this warrants review by the NHS at the national level. We set out our recommendations in the next chapter. 

The timeline that links to the cases summarised in this report is set out below.

  • December 2008 – Mr R is admitted to Galleywood Ward, one of NEP’s two acute adult inpatient wards at the Linden Centre in Chelmsford. He dies shortly after this.
  • July 2009 – Serious Incident Panel Inquiry into Mr R’s death notes that ‘the Trust failed [Mr R], did not discharge its obligations to him and must learn from this’. 17 recommendations for improvement are made by the Panel in relation to the replacement and development of staff, ensuring NICE guidelines are followed and more robust risk assessment of ligature points.
  • November 2012 – Four years after Mr R’s death, Mr Matthew Leahy also dies shortly after being admitted to the Linden Centre.
  • January 2013 – Serious Incident Panel Inquiry into Matthew’s death makes further recommendations about the management of observation levels, care planning, record keeping, the recruitment of permanent staff and the management of environmental risks, specifically a review of equipment to reduce the risk of self-ligature.

    During its investigation, NEP also found that Matthew’s care plan had been written after his death, which led to disciplinary action against the staff involved and a referral to the Nursing and Midwifery Council.
  • January 2015 – A Coroner’s inquest finds Matthew, ‘was subject to a series of multiple failings and missed opportunities over a prolonged period of time by those entrusted with his care. The jury found that relevant policies and procedures were not adhered to impacting on [Matthew’s] overall care and well-being leading up to his death.’
  • February 2015CQC’s inspection report, published in May 2015, finds a number of high-risk ligature points around NEP’s mental health wards at the Linden Centre, which had not been identified by its own safety audits. The inspection report refers to Matthew’s case. CQC says NEP had trialled options to remove ligature points but had not fully addressed the issue. CQC also finds a lack of detail in risk assessments and care plans. It requires NEP to make improvements in these areas.
  • August 2015CQC’s inspection report published in January 2016 rates NEP as ‘requiring improvement’ overall and rates its acute wards for adults of working age and psychiatric intensive care units as ‘inadequate’.

    Almost seven years after Mr R’s death, its inspection report highlights concerns about whether NEP is learning from incidents and if it is taking action to prevent them from reoccurring. For example, it notes that the Trust, ‘had a high percentage of delayed incident investigations. This meant that there was a potential delay in identifying the learning from these. For example, 51% of the serious incident investigations were ongoing and of these, 86% were overdue at July 2015. The oldest serious incident ongoing had been open for over 12 months created on 24th April 2014 and was a "suicide by outpatient".’
  • December 2016 – Eight years after Mr R’s death, CQC’s Chief Inspector of Hospitals takes enforcement action against NEP to force improvement in the quality of care it provides. The enforcement action is in the form of a warning notice following a further inspection of NEP in September 2016. This highlights that its inspection found that, ‘improvements were needed in a number of areas … [including] the trust’s assessment and management of risks for fixed ligature points on wards … and learning from incidents need to be shared with staff.’
  • January 2017 – Essex Police and the Health and Safety Executive (HSE) begin a scoping exercise to determine whether they should launch an investigation into a number of deaths at NEP, including Mr R’s and Matthew’s.
  • February 2017 – PHSO concludes its investigation into Mr R’s death, finding a number of failings and recommending that within three months (by May 2017),‘the Trust should explain the action taken; set out the evidence gathered that demonstrates change has happened and explain how improvements in its service will be monitored.’
  • April 2017 – Merger takes place creating a new Trust, EPUT, in place of NEP.
  • August 2017 – Following the scoping exercise, a joint Essex Police and Health and Safety Executive (HSE) investigation begins into a number of deaths at NEP, including Mr R’s and Matthew’s.
  • July 2018 – CQC publishes its first comprehensive inspection report into the new EPUT. This establishes that it has, ‘increased the pace of their work to improve patient safety’ and that, ‘leaders had oversight of safeguarding and incident reporting and shared lessons learnt’, leading to an overall rating of ‘good’. Despite that, however, the safety of services was still rated by CQC as ‘requiring improvement’.
  • November 2018Essex police announce that they are unable to meet the threshold for corporate manslaughter charges. The statement from Detective Superintendent Stephen Jennings of the Kent and Essex Serious Crime Directorate notes, however, that, ‘As part of our investigation we identified clear and basic failings which in our opinion should have been easily overcome. These, however, did not meet the evidential threshold to proceed for a charge of manslaughter.’
  • June 2019 – PHSO concludes its investigation into Matthew’s death, setting out that it had found, ‘significant failings … including [in] key elements of care … [and] NEP’s investigations were not robust enough’. It also noted that, ‘NEP was not open and honest [with the complainant] … about the steps being taken to improve safety at the Linden Centre’.

Although our timeline concludes at this point, it should be noted that HSE’s investigation is still underway and there remains a possibility of criminal charges being brought against the Trust once that investigation is concluded. We have taken this into account in forming our recommendations in the next chapter.