A MENTAL health trust “ignored national guidance” in the days before the tragic death of a 22-year-old from Southend, it has been revealed.

Phephisa Mabuza, from Southend, was found dead at the base of the white cliffs of Dover on March 14 last year just days after his mum pleaded for a nurse to see him over his worsening condition.

Earlier this year, coroner Patricia Harding delivered a narrative verdict, highlighting she “can’t be satisfied” the care delivered by the Essex Partnership University Trust contributed to his death.

Now a prevention of future deaths report, published this week, has revealed that the trust “departed from the national guidance”.

The report stated: “A memo has been sent to all staff to notify them that the operational policy has been wrongly coded but a decision had not yet been taken as to whether and how the trust intended to move forward in respect of the departure from the national guidance.

“Action should be taken to prevent future deaths.”

The 22-year-old, known as Jazz by friends and loved ones, was diagnosed with “psychosis induced by drug use” in 2021 while an informal patient at a mental health facility in Colchester.

Following his diagnosis, he was moved to the EPUT first response team’s care, before being put into supported accommodation in July 2022 in Leigh.

In October 2022, Jazz returned home to live with his mother, Xolile Ngcobo, in Southend.

But Xolile discovered Jazz’s medication had run out and tried to contact EPUT on several occasions to discuss his worsening mental health, “hearing voices”, and need for medication.

She subsequently contacted the trust crisis team out of fear her son’s condition was worsening.

The nurse explained Jazz was not an immediate threat to himself or others and therefore, would be referred to the first response team so he could be restarted on his medication.

After not hearing from Jazz for 48 hours after the call with EPUT, Xolile reported him missing to the police on March 14, 2023.

But 24 hours later, Xolile was informed that Jazz had been found dead.

Following his death, and after the inquest, his mother, Xolile Ngcobo, said: “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.”“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.”

Paul Scott, CEO of Essex Partnership University NHS Trust said: “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.”