Latest news with #EPUT
Yahoo
29-05-2025
- General
- Yahoo
Mum's promise to help end mental health deaths
A heartbroken mother said she would do "everything I can" to make sure the circumstances that led to her daughter's death were not repeated. Elise Sebastian was 16 when she was found unresponsive in her room at the St Aubyn Centre mental health unit in Colchester in April 2021. An inquest jury at Essex Coroner's Court concluded that "poorly administered observations" contributed to her death. Victoria Sebastian said she would be taking part in the ongoing Lampard Inquiry, which is investigating the deaths of more than 2,000 mental health patients in Essex. "I will be fighting with the inquiry and doing everything I possibly can to make sure, no matter how painful it is for me and my family, nobody else has to do this because it is heartbreaking," she said. The Essex Partnership University NHS Foundation Trust (EPUT) runs the unit, and chief executive Paul Scott apologised to Elise's family. Elise, a big Harry Potter and music lover, lived in Southminster near Maldon. She had been diagnosed with autism and her parents became increasingly concerned about her anxiety and depression, and in March 2021, she was admitted to the unit for a second time. The inquest heard she was supposed to be receiving one-to-one care, but on 17 April, she was left in her room for 28 minutes. Jurors were told how staff muted an audible alert that was part of a new infrared monitoring system, that had been installed in the unit two months previous. EPUT accepted the trust's failures were "causative of her death" and its lawyer Pravin Fernando said: "[It] failed in its responsibility by allowing her to enter her bedroom unsupervised." Speaking after the conclusion, Mrs Sebastian said her daughter was "dramatically and horrendously" failed and that she was treated as an "inconvenience" in the unit. "She was meant to be safe, but instead she was allowed to make several attempts to take her own life in the days leading up to her passing, until she finally succeeded," she continued. "There have been too many deaths. "It is the most painful thing ever to lose a child and I will do everything I can to make sure it doesn't happen to somebody else's child. "Lessons should have been learnt and I should still have had my beautiful baby girl." The Lampard Inquiry team has been monitoring the progress of the inquest. Mr Scott said: "I want to say sorry to Elise's family and to everyone who loved her that she did not receive the care she deserved, and I offer my deepest condolences." If you have been affected by this story or would like support then you can find organisations which offer help and information at the BBC Action Line. Follow Essex news on BBC Sounds, Facebook, Instagram and X. Neglect at unit led to teenager's death - inquest Alert muted before teen died at unit, inquest told NHS trust admits failures led to teenager's death Essex Partnership University NHS Foundation Trust
BBC News
29-05-2025
- General
- BBC News
Grieving Essex mother pledges to help end mental health deaths
A heartbroken mother said she would do "everything I can" to make sure the circumstances that led to her daughter's death were not Sebastian was 16 when she was found unresponsive in her room at the St Aubyn Centre mental health unit in Colchester in April inquest jury at Essex Coroner's Court concluded that "poorly administered observations" contributed to her Sebastian said she would be taking part in the ongoing Lampard Inquiry, which is investigating the deaths of more than 2,000 mental health patients in Essex. "I will be fighting with the inquiry and doing everything I possibly can to make sure, no matter how painful it is for me and my family, nobody else has to do this because it is heartbreaking," she Essex Partnership University NHS Foundation Trust (EPUT) runs the unit, and chief executive Paul Scott apologised to Elise's family. Elise, a big Harry Potter and music lover, lived in Southminster near had been diagnosed with autism and her parents became increasingly concerned about her anxiety and depression, and in March 2021, she was admitted to the unit for a second inquest heard she was supposed to be receiving one-to-one care, but on 17 April, she was left in her room for 28 were told how staff muted an audible alert that was part of a new infrared monitoring system, that had been installed in the unit two months accepted the trust's failures were "causative of her death" and its lawyer Pravin Fernando said: "[It] failed in its responsibility by allowing her to enter her bedroom unsupervised." Speaking after the conclusion, Mrs Sebastian said her daughter was "dramatically and horrendously" failed and that she was treated as an "inconvenience" in the unit."She was meant to be safe, but instead she was allowed to make several attempts to take her own life in the days leading up to her passing, until she finally succeeded," she continued."There have been too many deaths."It is the most painful thing ever to lose a child and I will do everything I can to make sure it doesn't happen to somebody else's child."Lessons should have been learnt and I should still have had my beautiful baby girl."The Lampard Inquiry team has been monitoring the progress of the Scott said: "I want to say sorry to Elise's family and to everyone who loved her that she did not receive the care she deserved, and I offer my deepest condolences."If you have been affected by this story or would like support then you can find organisations which offer help and information at the BBC Action Line. Follow Essex news on BBC Sounds, Facebook, Instagram and X.
BBC News
28-05-2025
- Health
- BBC News
EPUT: Neglect at mental health unit led to death of Elise
Neglect at a mental health unit contributed to the death of a "happy and outgoing" 16-year-old, an inquest jury has Sebastian, from Southminster near Maldon, Essex, was found unresponsive in her bedroom at the St Aubyn Centre in Colchester, in April teenager was supposed to have been receiving one-to-one care but, the inquest heard, an infrared alert system - which warned staff if she had been in her bathroom for too long - was muted, and she had been left alone for 28 inquest jury at Chelmsford Coroner's Court unanimously agreed that Elise's death could have been prevented if it were not for multiple failures in her care. The St Aubyn Centre, described in the hearing as "chaotic", is run by the Essex Partnership University NHS Foundation Trust (EPUT), currently the subject of an ongoing public Fernando, representing EPUT, admitted that Elise's room should have been locked to prevent the teenager entering alone, adding: "The trust accepts that these failings were causative of her death." The inquest heard Elise had secured a place at Writtle College to work with animals and her parents described her as a "happy, outgoing, funny little girl".She had been diagnosed with autism and her parents has become increasingly concerned about her anxiety and 4 March 2021, after she had self-harmed a number of times, she was admitted for the second time to a ward at the unit. 'Poor Wi-fi' Essex area coroner Sonia Hayes heard how Elise had asked to go to the toilet, and although some doors may have been left open, others needed a staff swipe card to let her ward had introduced an infrared monitoring system two months earlier as part of a trial, to reduce the risk of patients self-harming in isolated monitoring tablets were not working because of poor Wi-fi, and the unit's clinical lead, Brian O'Donnell, did not think having someone allocated to monitoring the alerts on the main computer would be a "good use of their time". During the inquest, expert witness Prof Jasmeet Soar said that when Elise was found, she had been in cardiac arrest for nine said there had been a four to five minute delay in staff using an oxygen mask, and a defibrillator took seven minutes for staff to use, instead of the three minute maximum mentioned in guidelines."Someone should have got the defibrillator and started it earlier," he Soar said the defibrillator also did not appear to have been used properly, from the readings he obtained, and had been switched on and said: "Some of the delays could have been avoided if staff would have known how to use the equipment." The inquest also heard how the majority of staff in the unit were bank and agency workers who would not have known the children Hayes said she heard the ward "was clearly short staffed" and described how medical records appeared to be incomplete at O'Donnell said he had "constantly" raised concerns about staffing numbers with senior management, adding: "Our budget would always be overspent - my argument was that we were underfunded."The inquest heard how observations should have a therapeutic interaction but some thought that was impossible to child and adolescent psychiatrist Dr Malcolm Bourne also told the hearing that "staff needed support to deal with children who were challenging and that autism could make depression more difficult to treat". Shortly after Elise's death, the ward at the St Aubyn Centre was closed to new admissions by the Care Quality CQC report found understaffing was a "significant concern" made worse by managers not ensuring staff had the appropriate skills and experience to look after vulnerable patients. 'Deepest condolences' The jury foreman told the inquest there were two main factors that may have caused the teenager's first was "poorly administered observations due to poor staffing levels and falsified information on observation forms".He said the second was "Elise being able to gain access into her room and her observation level in an isolated area not being considered", which the jury believed had directly led to Elise's death. The coroner said she would write a prevention of future death report (PFDR) which would recommend changes to make sure failures were not Scott, chief executive of EPUT, said: "I want to say sorry to Elise's family and to everyone who loved her that she did not receive the care she deserved, and I offer my deepest condolences." Follow Essex news on BBC Sounds, Facebook, Instagram and X.
BBC News
20-05-2025
- Health
- BBC News
Lampard Inquiry: What has happened so far?
Eight months into its 25-month timeline, the Lampard Inquiry is beginning to expose deep-rooted issues in NHS mental health services in Essex. With more than 2,000 deaths in inpatient units between 2000 and the end of 2023, the inquiry is examining not only local failings but also whether these reflect wider national problems. Here is what has emerged so far. A system under scrutiny The inquiry is named after its chairwoman, Baroness Kate is a former barrister who oversaw the NHS investigations into abuse by former television presenter Jimmy is primarily focused on Essex Partnership University NHS Foundation Trust (EPUT), formed in 2017 from the merger of North and South Essex Partnership Trusts. It is also looking at the deaths of patients from Essex at inpatient units run by private providers and 215 facilities run by other NHS organisations, such as North East London NHS Foundation former health ombudsman Sir Rob Behrens said on average, 5% of all mental health cases received by his team between 2011 and 2023 were related to called the failures in care "the National Health Service at its worst".During testimony from the relatives and friends of those who died, it emerged that they were individuals from a range of backgrounds, including a chef, bus driver, heating engineer, former head teacher, and parish councillor. Lack of staff The inquiry has heard evidence of a long-term reduction in registered mental health nurses, with increased reliance on healthcare support workers across England. This shift has been linked to reduced patient engagement and increased chief nurse Maria Nelligan told the inquiry this was because healthcare support workers were "cheaper" and said the shift compromised therapeutic Paul Davidson, a consultant psychiatrist, described how staff across England were "rushed off their feet," contributing to a workplace culture where professionals feared being blamed "whatever decision they took". Paul Scott, chief executive of EPUT, stated the trust had reduced its use of agency staff by 30%. Poor data The inquiry has also highlighted issues with data collection and transparency. Deborah Cole, from the charity Inquest, described how there was no "complete set of statistics in relation to those who die in mental health detention". Dr Davidson added: "There is good information in relation to deaths by suicide, [but] this is not a helpful tool by which to assess how mental services are being provided overall."Baroness Lampard has warned that the inquiry may never uncover the full scale of deaths linked to failings in Essex mental health stated that while a figure would be published, it was likely to be approximate, due to incomplete or inconsistent data over the 24-year period under review Regulating trusts The inquiry has examined the complexity of the regulatory system overseeing NHS trusts. Mr Scott described being "overwhelmed" by the number of regulatory bodies -19 in total - each issuing recommendations. This, he said, made it difficult to implement consistent from the inquiry, in October 2024, the health secretary stated that the government intended to reform the regulatory was in response to a review of the way the Care Quality Commission (CQC) inspected trusts, called the Penny Dash Review, which said the framework was too Lampard Inquiry will consider the CQC's role in relation to events in Essex. Analysis Three systemic issues raised by the inquiry - staff shortages, poor data, and regulatory complexity - have been longstanding concerns. The Royal College of Nursing, the CQC and a 2023 Public Accounts Committee report all flagged staffing shortages and burnout. A 2023 review found Norfolk and Suffolk NHS Foundation Trust had lost track of patient death data, while a 2025 Health Services Safety Investigations Body (HSSIB) report called for a unified national dataset. Regulatory reform is also under way following multiple critical reviews. While Baroness Lampard is expected to reference these reports, the inquiry is also under pressure to uncover new families have expressed concern regarding its pace, and limited focus so far on cultural have also noted that safeguarding issues, such as patients absconding from units, have received little attention - a relevant issue given a recent inquest into the death of an 18-year-old who died while on escorted leave from an EPUT unit. Transparency and whistleblowing Only 11 out of 14,000 staff came forward during the earlier non-statutory phase of the inquiry. Baroness Lampard has said she will use statutory powers to compel evidence if necessary. Mr Scott acknowledged that "closed cultures" existed at EPUT but said the trust was encouraging openness. During a recent inquest into the death of a 16-year-old patient, a manager testified that staff were reluctant to raise safety concerns. Brian O'Donnell, clinical lead at the St Aubyn Centre in Colchester, said there was a "real concern about safety on the wards, and staff are too worried to say anything about it".Families have also raised concerns about delays in evidence disclosure, including a postponed inquiry session on a Oxevision, an infrared monitoring system, due to late submission of information by Baroness Lampard said her decision to delay the hearing "should not be viewed in any way as enabling EPUT to avoid answering questions about its use of Oxevision". What comes next? In July, the inquiry will focus on the two former trusts that merged to form EPUT. Mr Scott has said, when he arrived at the trust in 2000, the legacy of the merger was that "there was too much focus on governance and management and not enough on patient safety".Families are calling for detailed scrutiny of individual deaths, but the inquiry is more likely to use selected cases to illustrate broader systemic issues such as governance, and Scott has apologised for deaths under the trust's care and stated that he believes EPUT should remain the provider of mental health services in Essex. Follow Essex news on BBC Sounds, Facebook, Instagram and X.
Yahoo
17-05-2025
- Health
- Yahoo
Tributes to 'caring' woman who died on A12
Tributes have been paid to a young woman who was hit by a car while on "escorted leave" from a mental health facility. Katherine Frost, 18, was killed while walking on the A12 near the Colchester United stadium shortly after 19:30 BST on 22 April. Her family said: "Katherine was a beautiful daughter, sister, granddaughter, auntie, niece and cousin who was loved by so many beyond measure." Care provider Essex Partnership University NHS Foundation Trust (EPUT) called it a "tragic loss" of life, after an inquest heard Ms Frost was on a planned trip away from the St Aubyn Centre in Colchester. A brief inquest hearing at Essex Coroner's Court was told she died from multiple traumatic injuries in a road traffic collision. "At the time of her death, she was a patient at the St Aubyn Centre in Colchester," coroner's officer Andy Flack said. "Miss Frost was on escorted leave with a member of staff when she was struck by a vehicle on the southbound A12." A full inquest will take place at a future date. Miss Frost's family paid tribute to her, saying: "There are not enough words to describe Katherine. She was so caring and putting others' needs before her own. "Touching the hearts of so many who got to know her and loved to put others at ease by making them laugh, with a massive passion for animals. "She will be missed and remembered every day. May she rest in peace. "We request privacy at this unbelievably difficult time." Essex Police said it was continuing to investigate the collision, and appealed for dash cam footage or witnesses. Follow Essex news on BBC Sounds, Facebook, Instagram and X. Woman walked in front of car while under NHS care Teenager dies in crash that shut A12 for hours
