David Bennett

Dear Madam,

Mr David Wayne Bennett (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 17th February 2025 in respect of the above, which was issued to Essex Partnership University NHS Foundation Trust (EPUT) and Mid and South Essex NHS Trust following the inquest into the sad death of Mr Bennett.

I would like to begin by extending my deepest condolences to Mr Bennett’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 these concerns (in respect of EPUT’s care of Mr Bennett) in the hope that this provides both yourself and Mr Bennett’s family with comprehensive assurance of changes that have been made at the Trust to address the concerns you have raised.

Concern 1) Evidence was heard that the mental health crisis staff do not appear to have appropriate access to the primary care mental health SystmOne records and there is a risk that vital information is not being shared.

Response: As set out in evidence, we can confirm that the Mental Health Crisis team do have access to SystmOne electronic records, however at the time of Mr Bennett’s attendance in the department, the Mental Health Liaison team did not have access to SystmOne electronic records. This was because the Mental Health Liaison team did not use SystmOne to record contact information.

By way of assurance, the Mental Health Liaison team now have access to all key systems including SystmOne.

Concern
2) The Operational Policy Mental Health Urgent Care Department pathways Appendices are not clear and do not appear to accord with the implementation.

Response: We are undertaking a periodical review of the policy and associated standard operating procedure for the Mental Health Urgent Care Department and we will reflect this

observation in respect to ensuring clarity, as part of this review and for consistency of application.

Concern 3) Recent contact with the primary care mental health records did not appear to be accurately recorded in the SystmOne Records with suicidal ideation not recorded.

Response: SystmOne has a template to complete to record the Mental Health Assessment and also a template for risk assessment for the primary care nurse to complete. On the risk assessment there are boxes to check for suicidal thought and self-harm. If these are checked a dialogue box opens up for further information to be added. If the patient is not suicidal there will not be any information recorded. Although SystmOne training is mandatory for it to be used, the Trust will now arrange ensure training on how to use the system for recording suicidal ideation specifically as a focus. We can confirm that a training session for Basildon and Brentwood Mental Health Practitioners planned for the 29 April 2025, where fields for completion in the templates used on SystmOne will be reviewed to ensure all MHPs are proficient in using SystmOne.

Concern 4) Mr Bennett requested a GP appointment; a telephone appointment was made with the primary care mental health nurse. The primary care mental health nurse on 1st June did not escalate Mr Bennett to the GP or Community Psychiatrist when Mr Bennett was adamant he wanted to see a doctor and required an urgent medication review for his deteriorating mental health

Response: The pathway is that the patient calls the GP, the GP care navigator makes the decision whether to book the appointment with a GP or directly books the patient in to see the Mental Health Practitioner (MHP) for a telephone consultation. If the MHP assesses there to be a need for psychiatric review they will take this to the First Response team Multi-Disciplinary Team (MDT) and request their input (for example, if the Nurse Prescriber considers the patient’s medication need is out of his/her prescribing remit). If the need is physical the MHP will advise the patient to make an appointment with the GP. In this case the patient had wanted to see the GP and was duly advised to go back to the GP. Whilst the process for onward appointments is at the discretion of each GP surgery, there is a procedure in SystmOne for alerting GPs through the recording of a task for the GP practice to alert that their intervention is needed, unless there has been a request made by the GP that the patient should make direct contact with the surgery to make an appointment. At your discretion you may wish to write to the patients GP practice to advise of this procedure within SystmOne.

Concern 5) Mr Bennett had an open prescription for antipsychotic medication on his GP record that was not being requested and the primary care mental health nurse did not ask about this and the nurse did not inform the GP or seek any advice from her line manager who was a nurse prescriber.

Response: Current and historic prescriptions can be viewed on SystmOne by practitioners based within a GP practice, hence prescriptions / history are available to view as required by attending practitioners. Planned training for Basildon and Brentwood MHP’s will ensure all MHP’s are aware of where to allocate current and historical prescriptions in SystmOne. In addition the team is working with the local private provider on exploring if there are additional modules available on Systmone which will further support care delivery pathways.

As set out in evidence, the MHP ought to have discussed this case with a Nurse Prescriber or the Line Manager, the request for medication could have been looked into further. Whilst this would provide insight into medication history, the Line Manager has confirmed that he would not have prescribed any medication for Mr Bennett in light of the fact this is out of his remit. Mr Bennett’s case would have be presented at the First Response Team’s (FRT)

Multidisciplinary Team meeting for advice from the Psychiatrist, at the first FRT MDT following the appointment in primary care.

Concern 6) Mr Bennett attended the acute hospital Trust for his deteriorating mental health. The acute Trust hospital nurse sought advice from the mental health liaison nurse. The acute Trust nurse did not have access to the mental health or GP records and not all available information was shared with the acute Trust nurse.

Response: We respectfully advise that MSEFT are best placed to respond to this concern, regarding access to GP records. With regards to access to the mental health records, the Trust in partnership with MSEFT are currently developing a new unified Electronic Patient record system across EPUT and MSEFT. The strategic ambition to unify care pathways remains at the centre of the programmes commitment including the bidirectional integration with primary care. The new UEPR (NOVA) is expected to go live across the Trust in February 2027.

Concern 7) The mental health liaison nurse asked the acute Trust nurse to undertake the risk assessment for Mr Bennett’s mental health. This is the role and purpose of mental health liaison.

Response: EPUT absolutely recognises the role of risk assessment tools which are routinely utilised and that clinical expertise and judgment is paramount when undertaking risk assessment of an individual service user. Clinical judgement includes the specific circumstances pertaining to the individual in terms of their presentation. It is therefore maintained that the mental health risk assessment is a standard, joint responsibility. The assessment carried out by the acute A&E nurse was undertaken prior to her seeking advice from mental health liaison nurse, and following her conversation with the mental health liaison nurse, having received the advice she sought.

In line with other Mental Health Trusts we are moving towards a “Safety Planning” approach to keeping people safe. This approach is welcomed and championed by those with mental health needs. This approach promotes a collaborative approach to keeping patient’s safe. It would be impractical and a failure of the use of learned and professional expertise to have mental health nurses only carrying out risk assessments. Again, mental health risk assessments is a joint responsibility.

The Trust is working to ensure, as far as we can, we take a consistent approach to patient care, however as each case is different, there is a need to apply clear clinical judgement to each patient interaction. The two experienced practitioners in this matter (the A&E Nurse and the Mental Health Liaison Nurse confirmed in evidence that they have worked together for a number of years and there would have been no hesitation in seeking any further support as required).

Further, the Trust is continuously seeking to improve our joint working approach with acute colleagues. EPUT has applied and been accepted to be part of the “NHS Confederation Mental Health and Acute in ED Interface Improvement Programme” and we seek to engage with all five Essex Acute Trusts around improved working and patient care.

The Inpatient and Urgent Care Divisional Directors of Quality and Safety have reached out and are establishing regular quality forums with the Directors of Nursing in Acute hospitals with the aim of improving joint working and also identify barriers as they arise in our (joint) working practices.

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 Bennett’s family.