Coroner “Can’t Be Satisfied” Of EPUT’s Role In The Death Of 22-Year-Old Whose Body Was Found Off The Cliffs Of Dover

Phephisa Siphelele Mabuza from Southend suffered psychotic symptoms after his mother Xolile Ngcobo was unable to convince Essex Partnership University Trust to urgently assess her son, despite describing that he had not been taking his medication and had been “hearing noises in his head”, following his discharge from a mental health rehabilitation centre in Leigh-on-Sea operated by the Essex Partnership University Trust.

Coroner Patricia Harding today delivered a narrative verdict, highlighting that she “can’t be satisfied” that the care delivered by the Essex Partnership University Trust (EPUT) contributed to the death of 22-year-old Phephisa Siphelele Mabuza.

The verdict comes after his mother, Xolile Ngcobo, was unable to convince Essex Partnership University Trust to urgently assess her son, despite describing that he had not been taking his medication and had been “hearing noises in his head” following his discharge from a mental health rehabilitation centre in Leigh-On-Sea, where he had been living in assisted accommodation from July to October 2022.

Phephisa Siphelele Mabuza, who was known as ‘Jazz’ by his friends and loved ones, was diagnosed with ‘psychosis induced by drug use’ in 2021 whilst he was an informal patient at Ipswich Road mental health facility in Colchester, a facility run by the NHS and EPUT.

Following his diagnosis, Jazz was moved to the EPUT First Response Team’s (FRT) care and assigned two care coordinators, who were mental health practitioners tasked with ensuring he received the “treatment mapped out in his Care Plan; attended appointments, agreed to a plan of care in accordance with the Policies and Procedure protocols of FRT service” and to inform the “Multi-Disciplinary Team (MDT) of any changes in presentation and risk issues, to provide support towards wellbeing and obtaining quality of life during recovery for 6 months.”

While in the care of FRT, Jazz was moved into supported accommodation in July 2022 in Leigh-On-Sea and was meant to have regular fortnightly care coordination contact. In October 2022 Jazz returned home to live with his mother Xolile Ngcobo in Southend-On-Sea. Upon returning home, Xolile discovered that Jazz’s medication had run out. Xolile subsequently tried to contact EPUT on several occasions to discuss his worsening mental health and his need for medication.

After consistently failing to contact EPUT she was finally able to contact someone at his registered GP surgery. Xolile tried to explain to the practice that Jazz’s worsening symptoms were due to his lack of medication but was allegedly advised that he was ok; implying he did not need further anti-psychosis medication.

Xolile subsequently contacted the EPUT crisis team out of fear that her son’s condition was worsening. She was able to speak with a Mental Health Nurse, Olurotimi Dosumu. During the call, Xolile made it clear her son wasn’t taking his medication because it had run out and that his condition was serious. Furthermore, Xolile informed EPUT that Jazz had been “hearing voices in his head” and required an urgent assessment. After providing the mental health nurse with this information, Olurotimi explained to Xolile that Jazz was not an immediate threat to himself or others and therefore, would be referred to the FRT so that he could be restarted on his medication.

After not hearing from Jazz for 48 hours following the call with EPUT, Xolile reported him missing to the police on 14 March 2023. 24 hours later, Xolile was informed that Jazz had been found dead at the base of the white cliffs of Dover.

Jazz’s death is yet another addition to over 2,000 deaths in Essex to have taken place under the care of EPUT over the last two decades. The Lampard Inquiry was upgraded to statutory status in November 2023 and subsequently had its final terms of reference announced in April 2024. Following this, the inquiry will now be able to proceed into investigating patient deaths which took place in Essex wards between 1 January 2000 and 31 December 2023.

Jazz’s mother, Xolile Ngcobo said: “I am disappointed by today’s verdict. We want to ensure this doesn’t happen to anyone else’s loved ones – no parent should have to bury their child. Nothing can bring my dear son back. He meant so much to so many and he will forever live on in our memories. He was mistreated and failed by those who were there to protect him. My son should have been given the medication he needed, yet he was denied by the trust responsible for his wellbeing. I hope this case is a turning point for future practice. EPUT must change. It should provide patients with the support they need – not a death sentence.”

Hodge Jones & Allen Solicitor representing Xolile Ngcobo, Adefolaju Sanda said: “We are saddened by the verdict delivered by coroner Patricia Harding. This is such a vital case in the fight for justice against the Essex Partnership University Trust, which has been responsible for the deaths of so many young people in the mental health care system across Essex. Our thoughts are with Jazz’s family at this time as we continue to fight for his story to be heard so that we can learn from these failings and prevent future deaths in mental health wards.”