Missed opportunities: What lessons can be learned from failings at the North Essex Partnership University NHS Foundation Trust (June 2019)

Summary

The Parliamentary and Health Service Ombudsman (PHSO) has published a report following investigations into the deaths of two vulnerable young men. They found a series of significant failings in their mental health care and treatment. 

The PHSO are publishing the report and recommendations to alert parliament to systemic problems in care and treatment of patients with acute mental health problems at former North Essex Partnership University NHS Foundation Trust.

NHS Improvement has agreed to establish a review in line with our recommendations and will share any learning it identifies across the NHS as needed.

The North Essex Partnership University NHS Foundation Trust (now merged into the Essex Partnership University NHS Foundation Trust) has accepted the recommendations and are committed to continuing to work the PHSO to put things right.

It is important the NHS understands why this happened and what lessons can be learned to prevent it happening again.