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


The evidence we have seen in the two investigations highlighted in this report points to significant and repeated failings over more than a decade at the North Essex Partnership University NHS Foundation Trust (NEP).

In particular, the investigations highlight issues with the Linden Centre in Chelmsford, where both the individuals, whose cases we are highlighting in this report, received care in the time leading up to their deaths.

We accept that, since the merger of NEP with South Essex Partnership University NHS Foundation Trust (SEP) in April 2017, which saw the formation of the Essex Partnership University NHS Foundation Trust (EPUT), improvements appear to have been made. These led to EPUT receiving a ‘good’ rating from the Care Quality Commission (CQC) in its latest inspection in 2018. 

It is important, however, that the NHS understands why the systemic issues identified in this report, through the wider timeline we have established, were allowed to continue for so many years. 

Our investigations relate to the treatment provided in a mental health unit and therefore also link to the report we published last year, Maintaining Momentum, which looked at problems in acute adult mental health care and treatment across the NHS.

If the Five Year Forward View for Mental Health as well as the cultural and leadership improvements highlighted in the NHS Long Term Plan are to achieve the system-wide change that is needed, learning from examples such as this needs to be embedded across the system to avoid the same mistakes being repeated. 

The Health and Safety Executive (HSE) continues to investigate how NEP managed its mental health wards in relation to reducing and removing potential ligature points. Its investigation looks at incidents between October 2004 and March 2015, an even broader timeline than we have set out.