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


I am laying this report before Parliament under section 14(4) of the Health Service Commissioners Act 1993.

The investigations summarised in this report found that there were a series of significant failings in the care and treatment of two vulnerable young men who died shortly after being admitted to North Essex Partnership University NHS Foundation Trust (NEP).1 

There are a number of parallels between the two incidents. In both cases, the young men died soon after being admitted to the Linden Centre and NEP failed to manage environmental risks and carry out an adequate risk assessment. 

We have established a timeline that demonstrates wider systemic issues at the Trust, including a failure over many years to develop the learning culture necessary to prevent similar mistakes from being repeated.

It is important to understand why change took so long despite the feedback from patients’ grieving families and the numerous investigations and inspections highlighting that it was so clearly needed.

We have therefore recommended and agreed with NHS Improvement (NHSI) that it will conduct a Review of what happened at NEP. This should include consideration of why the necessary improvements in patient safety only appear to have been completed in 2015, three years after the second death and eight years after the first. The lessons learned from this review should be disseminated across the wider NHS.

In laying this report, I hope that Parliament will also look more closely at the issues I have raised and consider the findings of NHS Improvement’s review.

Serious failings by organisations providing mental health services can have catastrophic consequences for patients. NHS trusts must ensure timely improvements to ensure patient safety and protect patients who are at risk of taking their own life.

Rob Behrens, CBE 

1 In April 2017, NEP merged with the South Essex Partnership University NHS Foundation Trust (SEP) to become what is now the Essex Partnership University NHS Foundation Trust (EPUT).