The tragic stories of 12 people who died after failings by Essex mental health services since 2020

Clockwise from top left; Marion Michel, Michael John Woods, Michael Nolan, Angela Ling, Joshua Leader, Sophie Alderman,  Morgan-Rose Hart and Chris Nota
-Credit: (Image: Family handouts)


Next week, a huge public inquiry will begin to examine the deaths of more than 2,000 patients of Essex mental health services. The path to this inquiry has been a long, challenging road for so many families who lost loved ones who were under the care of the Essex Partnership University NHS Foundation Trust (EPUT), with some also under the North-East London Foundation Trust (NELFT).

The trust cares for thousands of patients with mental health issues across Essex, but in many cases that care has been found to be inadequate. So much so that patients have died on the trust's watch. Previously, a non-statutory inquiry was launched to examine serious failings at the trust over the years, and just what lead to so many people dying.

But this inquiry stalled, mainly due to the then chairman, Dr Geraldine Strathdee, stating she had difficulty in encouraging people to speak with her, as a non-statutory inquiry did not have the power to compell witnesses to give evidence. The Department for Health converted the inquiry to give it statutory powers in June 2023.

Read more: Inquiry into 2,000 Essex mental health deaths to investigate 'serious failings' at NHS trusts

Read more: Essex mental health patient 'laughed at' by staff at Linden Centre

This followed a lengthy campaign by Melanie Leahy, from Maldon, whose son Matthew died while under EPUT's care in 2012. She had long called for the inquiry to be given statutory powers, and now with them in place, public hearings will be held, with witnesses being required by law to attend should they be called.

In 2020, EssexLive ran the 'Death in Care' campaign highlighting the failings of the county's mental health services and telling the stories of the families fighting for justice for their loved ones. It is now four years later and we feel it is just as important for us to highlight this and call for change.

Now titled "The Lampard Inquiry", it will be lead by Baroness Kate Lampard, who previously led an inquiry into the crimes of Jimmy Saville, and will cover deaths that occurred between 2000 and 2023, extended from 2000-2020 which the previous inquiry focused on. Opening statements are expected to begin on Monday (September 9) at the Civic Hall in Chelmsford.

In 2020, EPUT appointed a new Chief Executive Officer, Paul Scott, and have stated since then that its leadership team are "driving continual improvement, putting patient safety at the heart of everything it does". But despite this, patients have still died, and through multiple inquests, a coroner has found failings by the trust in each case.

With the inquiry due to begin next week, we take a look back at some of the patients who have been failed by the trust since 2020, and the devastating, human impact there has been on their lives being lost.

Paul Scott, Chief Executive Officer of EPUT, said: “We know how painful this time will be for those who have lost loved ones and our thoughts are with them. We will continue to do all we can to support Baroness Lampard and her team to provide the answers that patients, families and carers are seeking.”

Stephanie Moyce

Stephanie Moyce had a lengthy history of mental health issues with episodes of depression from 1990. She received a diagnosis of bi-polar disorder in December 2006 before her death on July 31, 2021. The 55-year-old, who also had a history of alcohol misuse, a documented history of repeated drug overdoses dating back to 2000 and in the seven years or so preceding her death had been hospitalised following self-harm attempts.

Ms Moyce , who also suffered from a number of complicated physical health complaints, including the after effects of a badly broken leg, and received regular Carer Support arising from her mobility issues, was last seen by a psychotherapist on June 9 2021 when she was discharged back to the care of her GP from EPUT.

But evidence called at the inquest into her death established that there was no identifiable person responsible within the trust for her on-going care provision, her case had not been discussed at a multidisciplinary team meeting prior to or following her discharge from the psychotherapy and there had been no further care planning following the discharge from therapy. Coroner Sean Horstead concluded there was a "conspicuous lack of clarity" as to who was responsible for the oversight of Ms Moyce before her death.

Jayden Booroff

Jayden Booroff was sadly found dead near Chelmsford railway station after absconding from the Linden Centre
Jayden Booroff was sadly found dead near Chelmsford railway station after absconding from the Linden Centre -Credit:Unknown

Jayden, 23, who was living with mental health difficulties including delusional thoughts and periods of psychosis, died on October 23, 2020 after he was hit by a train in the Chelmsford area. He had previously been sectioned under the Mental Health Act at the Linden Centre in Broomfield - run by EPUT - but had absconded on October 23 by following staff out of the building.

Jayden was fatally struck by a train hours after leaving the centre. A jury concluded that multiple issues in his care at the Linden Centre contributed to his death, including the layout of the building, staff communication and poor awareness which led to delays in him being reported missing.

After the inquest, Jayden's mother Michelle Booroff said: "I've lost my son, he's lost his life at the age of 23. He should still be here, he should be able to follow out his dreams. He was talented and beautiful, and I still have his piano at home. I just wish he could still be playing his piano and live out his life and dreams, and that was taken away from him, because of these fatal errors. And they say 'lessons learned, lessons learned' - my son should not be a lesson learned."

Marion Michel

Marion Michel died at Brockfield House in March 2022
Marion Michel died at Brockfield House in March 2022 -Credit:Irwin Mitchell/Family Handout

Marion Michel, who lived with schizophrenia, tragically died in March 2022 at Brockfield House in Runwell after stabbing herself multiple times with a knife given to her by a staff member. Marion, 56, had lived with the condition most of her life and had been transferred to Brockfield House from her home in Jersey in 2018.

Following an inquest in 2023, a jury found there were multiple issues which could have "significantly contributed" to her death, including poor access controls to knives and a lack of risk assessments. Marion's family said she had been looking forward to being discharged later in 2022 and hope the conclusion was a "wake-up call" for EPUT.

They said: “Marion was a much-loved daughter, sister, aunt and friend, and she is very much missed. She was kind, generous and loyal to those she loved, and she maintained strong links with friends and family, including after she moved away from Jersey. We had assumed Marion would be safe in a secure setting and risk assessments and robust policies were in place to ensure this."

Michael John Woods

Michael John Woods was known as Mick to those who knew him
Michael John Woods was known as Mick to those who knew him -Credit:Tees Law

The inquest into the death of Michael John Woods - known as Mick - found there were a number of "missed opportunities" to prevent his death on Christmas Day at the Henneage mental health ward in Colchester University Hospital in 2020.

Area Coroner Sean Horstead advised that the number of missed opportunities "individually and cumulatively more than minimally contributed to the death of Michael Woods". The NHS North Essex Partnership Trust was fined £1.5 million in June 2021 for safety failings after the deaths of 11 patients in their care between 2004 and 2015, following a prosecution by the Health and Safety Executive.

The prosecution had pointed to the existence of fixed potential ligature points as breaches of safety laws. Yet, despite EPUT pleading guilty in November 2020, Mick was able to take his own life in December 2020.

Staff also failed to rescue Mick when he was found on Christmas Day, as a result of an inadequate emergency response. Lawyers representing Mr Woods' family said the death was "entirely preventable".

Chris Nota

Chris Nota, 19, from Southend, lived with Autism and was described as a "remarkable young man" by Area Coroner Sean Horstead
Chris Nota, 19, from Southend, lived with Autism and was described as a "remarkable young man" by Area Coroner Sean Horstead -Credit:Julia Hopper

Chris, 19, from Southend, died after falling from the Queensway Bridge in the city on July 8, 2020 following a long history of mental health issues including anxiety and depression. He had been under the care of EPUT in the months before his death following a deterioration of his mental health.

An inquest into his death - first held in September 2022 and then delayed by three months over issues with disclosure by the trust - examined the care he had been receiving. Area Coroner Sean Horstead ruled that there had been multiple failings by the trust in Chris' care, including a lack of support for his Autism and not acknowledging the input of his mother Julia Hopper about how he should be cared for.

The coroner stated that the above factors could have contributed to Chris' death. He stated there were "inappropriate and unprofessional judgements" made about Julia which had "little to no understanding" of her complex home environment, which led to Chris being placed "innapropriately" in Hart House in Southend - which he had been staying at in the days before his death.

Julia said: "I can't get Chris back so the only thing I can do is try to ensure other people don't join us. We need to make positive change. We will not give up and will not shut up - how can we?"

Danny Anderson

Mr Anderson, 35, received "absolutely no care" from EPUT who should have looked after him, a coroner found. The coroner has said Danny Anderson’s death was contributed to by cumulative failures, amounting to a gross failure, to provide mental health care to him.

The prevention of deaths report comes after an inquest which ruled Danny died as a result of suicide, contributed to by neglect. Essex coroner Nadia Persaud has said from the consultant level to the care coordinator level, staff do not fully understand how to assess and manage risk.

She added there was no safety plan on discharge from hospital, or prior to discharge from the community team, to address the clear risks that Danny posed. Danny, likely to have been suffering from paranoid schizophrenia started suffering from chronic mental health difficulties from around the age of 15.

Morgan-Rose Hart

Morgan-Rose Hart
Morgan-Rose Hart -Credit:Mollie-Mai Hart

Morgan-Rose Hart, 18, died six days after she was found unresponsive in the bathroom of her accommodation in the Derwent Centre in Harlow in July 2022. Morgan-Rose had been sectioned under the Mental Health Act prior to her death, and she was supposed to be in a place where she would be safe and cared for. But a jury in her inquest concluded that she was failed multiple times by staff while she stayed there, saying basic protocols were not followed.

The unit's staff made comments about Morgan-Rose's appearance - despite her history of living with body dysmorphia - falsified records claiming she had been properly observed, and staff failed to check in her for 50 minutes prior to her being found unresponsive in the bathroom of her en-suite room.

The inquest heard that at least three members of staff at the unit had been found to falsify observation records. It was also heard that an alarm which is activated on staff tablets when a patient has been in their bathroom for more than three-minutes went off, but it was manually turned off, and no one went to check on her.

Morgan-Rose had a history of Autism and Attention Deficit Hyperactivity Disorder (ADHD) as well as self-harm. In their conclusions, the jury said that her transfer to an adult setting was "not supported enough" and that staff had failed to recognise her changing behaviours, including spending more time alone and losing weight.

The jury said there was "limited therapeutic engagement" or attempts to engage with Morgan-Rose during her three-week stay at the Derwent Centre before her death. On the day she was found unresponsive, comments about her appearance had been made by staff, and some flowers had been sent to Morgan-Rose's room despite them not actually being for her.

Paying tribute to her daughter during the inquest, Morgan-Rose's mum Michelle Hart said: "She enjoyed many dog walks around the countryside. She was also very creative. Animal welfare was a huge part of Morgan-Rose and she was dedicated to making a difference in the world of animals. She was a kind and sensitive soul, but with that came a huge amount of empathy, she often put others before herself.

"She was a determined and rather old soul but also one that was very much young at heart. She was beautiful and had a vibrant personality and was full of kindness, and unfortunately others took advantage of this. Her loss has left a huge void in our lives and we miss her very much."

Nadia Wyatt

53-year-old Nadia Wyatt, who had worked as a counsellor for more than 15 years was found by her husband, who had become her carer, at their home in Devereux Way, Billericay, on July 26, 2023. Following an inquest which concluded on January 8, her cause of death was recorded as suicide. In a prevention of future deaths report published on January 15, assistant coroner Rebecca Mundy noted a number of areas of concern, which she warned could result in similar deaths should no action be taken.

Mrs Wyatt had struggled with long-standing issues with her mental health, namely severe anxiety, separation anxiety and depression which were flagged in 2014 and again in 2023. Most recently, on July 10 last year she received specialist in-patient care at the Peter Bruff Unit within Colchester General Hospital, run by EPUT.

After being discharged from the unit on July 17 under the care of the Crisis Home Treatment Team, who attended to her both in-person or virtually until July 25, Ms Mundy wrote that "despite a clear desire to want to get better, intervention from professionals and the support of a dedicated husband, Nadia’s mental health declined to such an extent that she appeared to be unable to cope with her life as it had become".

Michael Nolan

Warehouse operator Michael Nolan died while sectioned under the Mental Health Act
Warehouse operator Michael Nolan died while sectioned under the Mental Health Act -Credit:Hodge Jones & Allen

"Serious failures" were found in the care of Michael Nolan by EPUT following an inquest into the 63-year-old's death in 2022. Mr Nolan worked as a warehouse operator and was a member of a working men’s club for over 30 years.

Michael was married to his wife Janice for over 38 years and had a son called James. He seemingly lived a quiet life with a strong support network around him. However, Michael started to show signs of poor mental health following the passing of his mother, which led to him struggling to sleep and develop more volatile moods.

On June 22, 2022, Michael attempted to take his own life. Michael was subsequently taken to Basildon Hospital to care for his wounds, where he was placed under the care of EPUT after being detained under Section 2 of the Mental Health Act.

But on July 10, whilst under level two supervision, Michael was found unresponsive and not breathing by staff, and he eventually passed away later that day. During his time in the Kelvedon ward at Basildon Hospital, EPUT staff characterised Michael as “very happy” and “chirpy”, just hours before his death.

Following the inquest into his death, the jury delivered a narrative conclusion which found that there were “serious failures” regarding patient observation. They also said: “If the observations and engagements had been carried out correctly, there may have been a different outcome”. The jury added there were “serious concerns regarding the roles and responsibilities of the staff” during the night shift of Michael’s death.

James Nolan, Michael’s son, said: “I am grateful for the outcome of my father’s inquest. I have been in a state of shock since his passing. He should not have been able to take his own life whilst he was under EPUT’s care. He was meant to be in the safest possible place for him, and yet, he has been taken from us. I have lost faith in EPUT as an institution, and I hope that my father’s case will be a stark reminder of how bad things are and how much work needs to be done before we can trust EPUT to adequately care for our loved ones in their time of need.”

Joshua Leader

Joshua Leader died while under the care of the Essex Partnership University NHS Trust
Joshua Leader died while under the care of the Essex Partnership University NHS Trust -Credit:Leigh Day

35-year-old Joshua Leader was found dead in his flat in November 2020 - two days after his admission to a mental health facility was refused. The inquest into his death concluded that his death was suicide contributed to by neglect at EPUT, who were responsible for his care.

The coroner said there was "a gross failure to provide basic care", with no detailed safety plan to ameliorate Joshua’s suicide risk. A decision not to admit Joshua to hospital two days before he died contributed to his death, the inquest found. Joshua, of Wivenhoe, died just two days after his family had taken him to the Lakes Mental Health Hospital to ask for an urgent admission due to their serious concerns about his safety after repeated remarks about ending his life.

The nurse who refused Joshua admission told the inquest: "I can sit here and say now with the benefit of hindsight, I made the wrong decision, I should have admitted him to hospital.” The nurse admitted that during this assessment he “broke my own processes. I don’t know why”.

Following the conclusion, Joshua’s brother Dan Leader said: “We can only hope that Joshua’s inquest has shed a light on the deplorable way we believe families are treated by the EPUT team and that they will urgently review how they involve patients’ families in their care and how their concerns are considered and communicated between professionals responsible for an individual’s care. Our family’s primary wish now is that lessons are learned from Joshua’s death and that clear actions are taken as a result."

Sophie Alderman

Sophie Alderman, aged 27, died while on the Willow Ward of Rochford Community Hospital in August 2022
Sophie Alderman, aged 27, died while on the Willow Ward of Rochford Community Hospital in August 2022 -Credit:INQUEST/family handout

Tammy Smith, mother of Sophie Alderman, claimed her daughter was "failed" by the Willow Ward of Rochford Community Hospital over her death in 2022. Sophie, aged 27, had been sectioned under the Mental Health Act and was found unresponsive in the Willow Ward of Rochford Community Hospital on August 19, 2022. She tragically could not be saved and died on the ward, where she had been staying under the care of the EPUT since the end of June.

A jury concluded following her inquest that Sophie had died as a result of "misadventure". The inquest heard that Sophie had battled mental health issues for several years, and had been in and out of hospital, with a diagnosis of Emotionally Unstable Personality Disorder (EUPD) during her adolescence.

On August 19, Sophie had been involved in an altercation in the ward, and had previously told staff she had wanted to self harm when she was out walking the hospital grounds, which had resulted in her leave being suspended. Before she was found unresponsive, Sophie had been "head-banging" against the window of her room.

The jury returned the short-form conclusion of "misadventure". Sophie's family has expressed disappointment that the jury did not return any form of narrative conclusion, meaning there was no "context, or exploration of the wider circumstances of Sophie’s death". Speaking after the conclusion, her mum Tammy said: "While I am surprised and disappointed by the brevity of the jury’s conclusions, it was clear to me throughout the evidence that my daughter was failed by Willow Ward.

Angela Ling

A seven-day inquest concluded that 49-year-old Angela Ling died as a result of suicide contributed to by neglect on the part of EPUT. The inquest, which concluded in June this year, heard how Angela would have likely survived had she received the care and treatment she needed for a diagnosed recurrent Major Depressive Disorder.

Dr Dinesh Maganty told the inquest that several failings in Angela’s care, which included a failure to consult with Angela’s family throughout her care, a failure to provide consistent pharmacological treatment and a failure to provide any psychological treatment contributed to her death on December 1, 2021.

As part of a life letter about her daughter, Angela’s mother said: “Angela was never a person to do things by halves, in her own words, 'You know me I’m all or nothing'. She was a loving Mum and fiercely protective of her children, her family, her home and her children were everything to her."

In a joint statement, Angela’s children said: “Our mum was just 49 when she died. She was above all our mum, the most important job in the world to her, and we loved her more than we could put into words. Our hearts have been broken because she deserved better and so much longer, and it was a death that should have been avoidable.

“She was kind, generous, clever, bubbly and fun. She was feisty, tenacious and held strong opinions and was well educated entirely by her own determination. She loved spending time with her family and dogs.

“We were doing all we could to get mum the support she needed and we are glad the coroner recognised this in his conclusions. Sadly Mum did not get the help she needed but we hope things will change to mean that others are not put in the same position that we were.”