Man died after trust 'ignored national guidance'

A man who was "hearing voices" died after a mental health service ignored national guidance and failed to see him within 72 hours, a report said.

Phephisa Mabuza, from Southend-on-Sea, Essex, was found dead on 14 March 2023 after falling from height in Dover, Kent.

The 22-year-old's mother had called 111 the day before and pleaded with the Essex Partnership University Trust (EPUT) for a nurse to see him as his psychotic disorder was worsening, a prevention of future deaths report said.

EPUT said its policy on mental health triages had been "wrongly coded" at the time and staff had since been informed of the correct process.

The trust is currently the subject of an independent inquiry into the deaths of almost 2,000 mental health patients under its care.

National guidance dictated that Mr Mabuza, who was deemed a Category D patient, should have been seen face-to-face within 72 hours of the 111 call, Kent coroner Patricia Harding said.

However, the coroner said EPUT departed from the UK Mental Health Triage Scale by instead telling its staff they should act within seven days to Category D patients.

She implored the trust to inform her of changes it planned to make by 9 September.

Mr Mabuza, known as Jazz, was last seen walking alone towards the White Cliffs of Dover at 14:18 GMT on 13 March 2023, where he was found the next day.

Earlier that day he had travelled by train from Southend-on-Sea to Dover and withdrawn money on route.

He had not taken olanzapine, prescribed for psychosis, for a number of months and was "hearing voices in the days before his death", the report said.

Ms Harding said he died from "multiple injuries" he suffered in the fall, but stressed it was not clear how he fell or his intention at the time.

Her report outlined how, on 10 March, Mr Mabuza's mother, Xolile Ngcobo, dialled 111 and spoke to a mental health nurse who conducted a "very brief" telephone triage with the pair.

The nurse contacted EPUT's first response team to make a face-to-face appointment with Mr Mabuza and requested his GP reconsider prescribing olanzapine again.

However, a system failure meant the prescription request did not go through and it was not there when Ms Ngcobo went to collect it on 13 March.

Speaking after an inquest into his death in May, she said her son was "mistreated and failed by those who were there to protect him".

Ms Ngcobo added: "He meant so much to so many and he will forever live on in our memories."

EPUT chief executive, Paul Scott, said on Thursday: "My sincere condolences remain with Phephisa’s family, friends and loved ones following their very sad loss.

"We have responded to the coroner and taken steps to address the concerns raised to ensure people in crisis receive the right care at the right time."

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