Essex coroner's report leads to mental health support changes

Essex Coroners' Court in Chelmsford

Essex Coroners' Court in Chelmsford - Credit: Lucy taylor

A coroner's report said that urgent action should be taken to prevent future deaths, after a man took his own life while struggling to engage with Essex mental health services.

Steven Regoli died on June 26, 2020, due to multiple injuries following a collision with a train near Stansted Mountfitchet.

He was known to Essex Partnership University Foundation Trust and had underlying Adjustment Disorder, Mixed Anxiety and Depressive Disorder.

The trust said that a number of improvements have been implemented.

According to a courts and tribunal judiciary report, Steven, 42, had been predominantly living with his parents in Dunmow.

They told an inquest that they tried to get inpatient care for their son.

Essex Coroner’s Court heard that eight days before he died, Steven told his Care Coordinator he felt like ending his own life.

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The area coroner for Essex, Michelle Brown, said: “During the course of the inquest, it revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken.”

She said EPUT had set out in its earlier report into the death that it had “numerous opportunities” for Steven and his family to have more appropriate help.

This included the option of an inpatient stay for Steven given his history of overdoses and his worsening anxiety and depression.

She said: “During the inquest, there were clear signs that Steven needed more in depth help as did his family, but due to him not engaging, which was a major part of his symptoms, he was never given the pathway or help he needed and there were no systems in place for this to happen.

“There needs to be systems in place where people who do not engage are not left with family only to care for them.

“In my opinion urgent action should be taken to prevent future deaths and I believe you (EPUT) have the power to take such action.”

A spokesperson for Essex Partnership University NHS Foundation Trust said it has made improvements including its communications strategy so any revisions of patient treatment plans are now rapidly escalated to staff, patients and their families.

She said: “We offer sincere condolences to Steven’s family and those involved in this tragic incident.

“It is vital that every patient and their family receives excellent care, including specifically tailored patient engagement plans to meet their needs and we are fully committed to delivering this and acting further upon the Coroner’s findings.

“Patient safety is our top priority and we’ve made changes to improve our communication processes for those involved in a patient’s care and introduced staff sessions where learning and best practice can be shared, including how to best support a patient’s engagement with their treatment.”

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