Warren Green

Dear Madam,

Mr Warren James Green (RIP)

I write to set out the Trust’s formal response to the report made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, dated 12th January 2026 in respect of the above, issued to Essex Partnership University NHS Foundation Trust (EPUT) and Mid and South Essex NHS Foundation Trust (MSE) following the inquest into the sad death of Mr Green.

I would like to begin by extending my deepest condolences to Mr Green’s family. The Trust sympathises with their sad loss.

The matters of concern as noted within the Regulation 28 Report have been carefully reviewed and noted. I will now respond in full to the concerns as they relate to EPUT in the hope that this provides both yourself and Mr Green’s family with comprehensive assurance of changes that have been made at the Trust to address the concerns you have raised.

Concern 1) The evidence identified a risk of patients at high risk of self-harm being able to leave the acute ward without appropriate risk assessment

Response: We respectfully advise that this concern is for MSE to respond to.

Concern 2) The evidence identified a risk of patients at high risk of self-harm being able to leave the acute ward without the knowledge of the hospital staff

The above shows a lacuna in terms of patients’ safety and safeguarding.

Response: We respectfully advise that this concern is for MSE to respond to.

Concern 3) The evidence showed that the Mental Health Liaison Service relies on nurses to conduct initial assessments and follow up reviews of patients suffering with mental health issues and the mechanism by which escalation to a Consultants Psychiatric is decided and the factors to be taken into account for escalation are not at all clear. This leads to lack of Consultant’s oversight for these vulnerable patients

Response: In line with the assurance evidence presented to Court, we confirm that the ‘Core 24’ model is a nationally endorsed NHS best-practice standard for 24/7 liaison mental health services in acute hospitals. This model was applied in respect of the care afforded to Mr Green.

The ultimate purpose of this model is to ensure that patients presenting with mental health needs in Emergency Departments (EDs) and Acute inpatient wards receive timely, comprehensive biopsychosocial assessment and rapid formulation of care plans. The model mandates immediate mental health support, improved crisis response, and integrated working with acute hospital teams.

A full copy of this model can be provided to the Court as required.

In summary, the ‘Core 24’ model is specifically designed to provide:

• Rapid mental health assessment, typically within 1 hour in ED and within 24 hours for ward referrals, consistent with national urgent and emergency mental health care pathways

• Comprehensive biopsychosocial assessments, including: o Mental state examination o Risk assessment (self-harm, harm to others, vulnerability) o Physical health considerations o Psychosocial factors o Formulation and management planning

• Integrated liaison with acute clinicians to ensure safe discharge planning, admission avoidance where appropriate, and effective management of comorbid physical and mental health conditions.

These assessments must be completed by appropriately skilled mental health professionals working within the liaison service, ensuring both timeliness and clinical quality.

Further, the Model provides that the following multidisciplinary roles are typically enabled in order to undertake the ‘Core 24’ Mental Health Assessments, which goes to your specific concern re: Consultant oversight:

1. Consultant Psychiatrists o Provide senior clinical oversight and complex diagnostic assessments. o Offer medical leadership for risk formulation and treatment planning.

2. Mental Health Liaison Nurses (RMN-qualified) o Often the primary frontline assessors in Core 24 services. o Conduct full biopsychosocial assessments, risk assessments, care planning, and coordination with acute trust colleagues.

3. Mental Health Practitioners / Allied Health Professionals (Depending on local staffing models and competencies, this may include: Social Workers, Occupational Therapists, and Psychological Practitioners.) o Undertake assessments aligned to their professional scope. o Contribute to holistic biopsychosocial formulation and care planning.

4. Junior Medical Staff / Specialty Doctors (in some services) o Support assessments under supervision of senior medical staff. o Assist with medication review, diagnostic clarification, and ongoing medical oversight.

5. Multidisciplinary MDT Members o MDT involvement is emphasised to ensure that risk, mental state, social factors, and physical comorbidities are jointly considered. o Contribution varies by specialty but is integral to complex or high-risk assessments.

In summary, in respect of the future patients who require the support of the MHLT, Consultant/medical input is achieved by way of:

• Daily MDT reviews, which provides for all patients to be discussed with a senior medic. At Southend and Basildon Hospitals (where there is a MHLT service), twice daily MDT are undertaken where all patients are discussed, including all those that have been seen out of hours by nursing staff.

• MHLT processes provide ongoing assessment, advice and guidance for patients waiting for admission, to have a face to face senior medic review at earliest opportunity in order to both ensure purposeful admission and ensure any medication optimised. Patients waiting for admission would also be reviewed by the team on a daily basis

• By way of referral pathways, referral pathways:

o For medical or medication-related issues, team doctors provide direct patient review or advice based on liaison referrals. o For all other referrals, nursing staff complete an initial assessment (2.1 form), create a management plan, and discuss this in the next MDT. Further actions are agreed within that meeting.

• There are clinical meeting structures in place for the Liaison team which provides decision making for when Doctors need to undertake initial assessments / medical reviews if this is felt to be appropriate following referral.

• In respect of the arrangements for Consultant/senior medical oversight outside of working hours / in times of annual leave, this is covered by way of the on call doctor system, which allows doctors to be contacted at any time for any urgent matter. Liaison nurses are able to freely consult the on-call duty doctor and escalate to senior medical staff if significant concerns remain unresolved. Following on from an out of hours contact, the case will be further discussed and managed at the next working day.

• During consultant leave, the Specialty Doctor and Higher Specialist Trainee continue reviewing patients and seek advice from the covering consultant when necessary.

• The Specialty Doctor and the Higher Specialist Trainee are supported and overseen by consultants as required, with regular supervision in place for the SPR.

• In terms of the professional mix within the MHLT team, this consists of Nursing, health care assistants, Psychology and occupational therapy this provides a safety net of professionals who are accessible to referring colleagues and service users, as not all patients require Consultant review.

The Trust is currently reviewing its Standard Operating Procedure (SOP) in order to cover the above provisions. This will be completed by May 2026 we would be happy to share a copy of the same with the Court if required.

I hope that I have provided reassurances around the steps that we have taken to address the issues of concern contained within your report. We know there is an acute need to embed and effect change, hence we will monitor the above provisions to ensure these are contributing to our overall aim of keeping patents safe and delivering therapeutic care.

Please do let me know if you require any further information at this stage. We understand that the Court will share a copy of this reply with Mr Green’s family.