Calls for a public inquiry into mental health inpatient facilities in Essex began after the deaths of two young men at the Linden Centre in Chelmsford.
Bereaved families outside the inquiry in Chelmsford. Pic: PA
The deaths of more than 2,000 people at mental health units in Essex are being investigated by a new inquiry.
Baroness Kate Lampard CBE will hear evidence from former patients, bereaved families, experts, and staff about deaths that occurred at inpatient facilities in the county – and within three months of discharge – between 2000 and 2023.
What is the scope of the inquiry?
The Lampard Inquiry has statutory status, which means those called to give evidence are legally obliged to appear. Not doing so is a criminal offence.
A previous attempt in 2021 – the Essex Mental Health Independent Inquiry – did not have statutory powers and was abandoned after only 11 members of staff agreed to give evidence of the 14,000 contacted.
In her opening statements, Baroness Lampard said “we may never have a definitive number of deaths” and although 2,000 were considered for investigation by the 2021 probe, the true figure will likely “be significantly in excess” of that.
It will look at the deaths of inpatients at the Essex Partnership University Foundation NHS Trust (EPUT), North East London Foundation Trust (NELFT), and organisations that existed previously in those areas.
People who died within three months of discharge from one of the units, who were refused, or waiting for a bed also fall under the inquiry’s remit.
Deaths that occurred while patients were receiving NHS care in the private sector are also included.
What happened in Essex?
The mothers of two young men who died at mental health units in Essex have long campaigned for justice and led calls for a public inquiry.
Lisa Morris’s son Ben died aged 20 in 2008 while he was an inpatient at the Linden Centre, previously run by the North Essex Partnership NHS Trust (NEP) – but now managed by EPUT.
He had a diagnosis of ADHD and took his own life 20 days after he arrived at the unit in Chelmsford. Ms Morris says he called her 30 minutes before he was found dead saying he wanted to leave. In 2011, an inquest found he died by suicide.
Matthew Leahy also died at the Linden Centre at the age of 20.
He had been sectioned and detained under the Mental Health Act and was under the care of the Early Intervention in Psychosis team when he died in November 2012.
His mother Melanie Leahy claims he called his father to say he had been raped days before he was found dead. Police were called but no crimes were recorded.
At his 2015 inquest, the coroner raised concerns about some aspects of Mr Leahy’s care but found it adequate on the whole – and that he died by suicide.
His subsequent report raised issues about staffing issues at the Linden Centre and urged NEP to consider an independent inquiry.
NEP bosses decided not to launch an inquiry, saying the inquest and other investigations had provided a “comprehensive airing” of the issues.
In April 2017, police said records of Mr Leahy’s care plan had been falsified, but ultimately no action was taken.
That year, they launched a corporate manslaughter investigation into the deaths of 25 patients at nine mental health units in Essex, including Mr Leahy’s and Mr Morris’s, but the cases failed to meet evidence thresholds.
In 2019, the Parliamentary and Health Service Ombudsman published a report into the two men’s deaths. It said there had been a “systemic failure to tackle repeated and critical failings” at the trust.
In 2020, the state of mental healthcare in Essex was debated in parliament after Ms Leahy and other bereaved relatives received more than 100,000 signatures on their petition.
Following an investigation by the Health and Safety Executive (HSE), in 2021 EPUT was fined £1.5m for failings that led to the deaths of 11 of its patients.
That year the Essex mental health independent inquiry began, but was soon shelved after witnesses failed to come forward.
What have the families said?
Speaking to Sky News, Melanie Leahy says she thinks the inquiry is going to find “there’s a lot, lot more” deaths.
“I believe it’s a cull,” she said. “It’s a cull of our most vulnerable, our most gentle, our most needy.”
As the inquiry began she also warned of ongoing risks.
“I and many families, we’re not just looking for answers, we’re fighting for future patients, hoping to prevent more tragedies,” she said.
What has the NHS said?
EPUT’s chief executive Paul Scott has said: “We welcome The Lampard Inquiry and will continue to do all we can to support Baroness Lampard and her team to provide the answers that patients, families and carers deserve.”
He has disputed the 2,000 deaths figure, however, claiming some have been from natural causes.
NELFT said in a statement: “We will continue to work with the inquiry to help families understand the circumstances surrounding the loss of their loved ones.
“Patient safety is our absolute priority and we are committed to learning from the work of the inquiry.”
What will the inquiry look at specifically?
The inquiry will look at the following key points:
• serious failings related to the delivery of safe and therapeutic inpatient treatment and care, which may include consideration of circumstances where serious harm short of death occurred;
• how and the extent to which patients were engaged with and involved in decisions in relation to their care;
• how and the extent to which families, carers, or other members of a patient’s support network were engaged with and involved in decisions in relation to the patient’s care, including any engagement after the patient’s death;
• matters relating to physical and sexual safety within mental health inpatient units at the Trust(s);
• the actions, practices and behaviours of permanent, temporary and agency staff providing mental health inpatient care at the Trust(s);
• the approach to staffing, training and working conditions of permanent, temporary and agency staff providing mental health inpatient care at the Trust(s); including the support provided to and the supervision of such staff;
• the actions, practices and behaviours of leadership in relation to mental health inpatient care at the Trust(s);
• the culture and the wider governance of and at the Trust(s);
• the quality of investigations undertaken or commissioned by the Trust(s) in relation to mental health inpatient care;
• the quality, timeliness, openness and adequacy of any response by or on behalf of the Trust(s) in relation to concerns, complaints, whistleblowing, investigations, inspections, and reports (both internal and external); and
• the interaction between the Trust(s) and other public bodies, (including, but not limited, to commissioners, coroners, professional regulators, and the Care Quality Commission).
How long will it take?
The inquiry began with opening statements on 9 September at the Civic Centre in Chelmsford. Bereaved relatives will give their impact statements until 25 September.
Proceedings will start then pause until November.
Next year, the inquiry will start taking evidence and move to Arundel House in London. Some 56 relatives and staff from 10 organisations will be questioned.
After retiring to analyse the evidence, conclusions are expected in 2026.
