Young man died after fatal errors made by Essex NHS trust report finds

Phephisa Mabuza's mother had contacted his GP multiple times in the lead up to his death
-Credit: (Image: Xolile Ngcobo)


A shocking mistake made in the guidelines of a hospital trust may have led to the death of a young man recent coroner’s report has revealed. The report details failings in the guidelines of the trust as well as a fault in the electronic system which logs prescription requests.

Phephisa Mabuza, from Southend, had been diagnosed with a psychotic disorder and was under the care of Essex Partnership University Trust (EPUT). After moving out of the area and registering with a new GP but not requesting a new prescription, Phephisa was no longer taking the medication he needed for his condition.

When returning to Essex, and choosing to live with his mother, Xolile, it became clear that Phephisa needed his medication and she contacted his GP on multiple occasions at the beginning of March last year to organise a new prescription. After not hearing back, she instead resorted to 111, where a mental health nurse spoke with Phephisa and Xolile in a “very brief” phone conversation.

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According to the Prevention of Future Deaths report, “The mental health nurse contacted the first response team to make a face-to-face appointment with Phephisa and also requested his general practitioner reconsider prescribing olanzapine again.

“A prescription was sent electronically to the pharmacy, but the spine system disconnected and the prescription request would not go through. The prescription was not therefore available for collection on March 13, when Phephisa’s mother went to collect it.”

It was also found that the policy used by the trust in these circumstances does “not reflect the scale on the 111 Triage form or the national guidance.” While national guidance says that the response to a category D “presentation” is three day, the trust’s guidance had been wrongly amended, so clinicians could respond within seven days instead. According to the report, Phephisa had “not taken olanzapine prescribed for psychosis for a number of months, and was hearing voices in the days before his death but had not voiced any intention to take his own life.”

Phephisa had travelled from Southend to Dover on the day his mother had attempted to pick up his prescription, and his body was found on March 14, 10 minutes before he was reported missing. In a letter responding to Phephisa’s death, the Chief Executive of EPUT stated: “I would like to begin by extending my deepest condolences to Phephisa Mabuza’s family. The Trust sympathises with their very sad loss.

After addressing and apologising for “identified errors,” the Chief Executive signed off in a letter sent to the coroner and Phephisa’s family: “Yours sincerel”.

In March this year, Director of Mental Health at the Care Quality Commission, Chris Dzikiti, warned: “Half a million children are receiving or waiting for mental health care and are having to wait on average 40 days to access care, but often much longer – with many reporting a deterioration in their mental health while waiting and some attempting to take their own life.

“Without access to good, timely care, children with mental health needs are at increased risk of harm and in some cases suicide. This issue is a ticking time bomb, and we will face the consequences if it’s not resolved.”

Phepisa’s mother Xolile Ngcobo said: “I will never forget my beautiful son and miss him every day. He was mistreated and failed by those who were supposed to protect him. Nothing will bring him back, but now all I want is justice for the thousands of people failed by the mental health services. This needless loss of life cannot be allowed to carry on.”

Adefolaju Sanda, Associate at Hodge Jones & Allen who represents more than 120 victims and families in the Lampard inquiry, said: “The case of Phephisa Mabuza known as “Jazz”, is truly tragic.

“This is emphasised by the Regulation 28 report in the prevention of future deaths, where the coroner highlighted that there were matters for concern in relation to Essex Partnership University Trust (EPUT) triaging policy.

Yet Jazz, is far from the only victim of the failings of mental health services in Essex, and indeed nationally. The same horrendous mistakes and abuses happened time and time again, resulting in too many lives lost and families left devastated as a result. It is why we have fought so long and hard to get this statutory inquiry and why it must deliver the justice our clients so desire.”

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