A 68 year-old’s death was contributed to by “neglect’ after a series of serious failings from his health carers, the coroner for Essex has determined. Stephen Neville died on December 18, 2021 because of what coroner Sean Horstead said was a cumulation of faults “amounting to a gross failure” to provide him with basic medical care reports the Local Democracy Reporter.
He had been diagnosed with severe “treatment-resistant depression” that led to repeated attempts at suicide and self-harm. He was admitted as an informal patient to Rochford Hospital run by Essex Partnership University NHS Foundation Trust (EPUT) on December 16, 2021 for planned Electro Convulsive Therapy (ECT).
Before that he had been under the care of the Older Adult Community Mental Health Team (OACMHT). An Associate Specialist Psychiatrist (ASP), undertook Stephen’s clinical review on December 17.
However, she was unaware that Stephen had been prescribed daily Lorazepam – used to treat anxiety and sleeping problems that are related to anxiety- in the community for some 14 months alongside antidepressant medication. This critical information had not been communicated to her by the OACMHT and neither had she reviewed, as she accepted she could and should have, the available medical records to obtain this information.
The coroner opened the inquest into his death on January 5, 2022. The investigation concluded at the end of the 9-day non-jury inquest on October 23, 2025.
In his prevention of future deaths report coroner Sean Horstead said: “The conclusion of the inquest was a short form conclusion of ‘suicide contributed to by neglect’ in conjunction with an expanded narrative conclusion which identified a series of serious failings cumulatively amounting to a gross failure to provide Stephen Neville, a person in a dependent position, with basic medical care.”
He added that the doctor conducting the medical review on December 17 failed to read and review readily available medical records and therefore failed to consider the likely impact on subsequent risk of such a sudden change to medication.
The reviewing doctor also failed to discuss and explain the abrupt medication changes to Mr Neville. The reviewing doctor failed to ensure that the nursing – and therefore support worker – staff were made aware of the abrupt medication changes and the potential impact on Stephen’s risk.
There was also a failure to appropriately manage the unlocked shower room, in which Stephen died, by “failing to attempt to mitigate the clear risks that his unsupervised access to this room represented”.
He added: “There was a failure to mitigate that risk by failing to implement any ‘individualised’ measures relevant to managing Stephen’s specific risk, for example by increasing his observation levels and/or removing the cord from his tracksuit bottoms that he had been allowed to retain, including after the abrupt changes to his medication.”
Paul Scott, CEO of Essex Partnership University NHS Foundation Trust (EPUT), said: “My deepest sympathies remain with Stephen’s family, friends and loved ones and I would like to apologise for the failings in his care.”
