Individuals with mental health issues represent some of society’s most at-risk members, yet mental health services in England have faced immense pressure for over a decade, sometimes with tragic results. A government-supported public inquiry is currently investigating the circumstances surrounding deaths in Essex as an initial focus—what exactly is this inquiry, and what objectives does it aim to fulfill?

Legal representatives for a growing number of families mourning their lost loved ones assert that the Lampard Inquiry is as crucial as those concerning the Post Office and infected blood scandals.

The inquiry’s chairwoman indicates that it will consider over 2,000 deaths, with the team suggesting that the identified shortcomings are “of a magnitude that is profoundly alarming.”

The issues documented in Essex over the past 24 years may reflect similar situations elsewhere. By scrutinizing these failures closely, the inquiry hopes to enhance mental health care throughout England.

The Lampard Inquiry stands as the inaugural public investigation specifically addressing mental health-related deaths.

Its purpose is to investigate the circumstances leading to the deaths of patients at child and adult inpatient facilities under the care of the NHS in Essex, covering the period from 2000 through the end of 2023.

The focus will be on two organizations: Essex Partnership University Foundation NHS Trust (EPUT) and North East London Foundation Trust (NELFT), as well as earlier institutions that previously operated in this capacity.

The inquiry will not examine community deaths unless they occurred within three months following discharge from a mental health facility, when a patient was assessed and denied a bed, or if the individual was on a waiting list for a bed.

Public inquiries are financed by the government and led by an independent chair.

These inquiries can compel witnesses to testify, although this does not extend to bereaved families.

No one will be declared guilty or innocent; instead, the inquiry will generate recommendations that the government may choose to embrace or disregard.

The Department of Health stated: “Every patient should receive care in an environment which ensures high-quality treatment, along with dignity and respect.”

The inquiry bears the name of its chairwoman, Baroness Kate Lampard.

A former barrister, she previously oversaw NHS investigations into the abuses carried out by former television presenter Jimmy Savile.

Baroness Lampard is a member of the House of Lords, serving as a crossbench peer, which means she is not aligned with any political party.

She asserts that the inquiry holds national significance and will propose recommendations aimed at enacting “tangible change” across England.

The impetus for the inquiry was first expressed by two mothers, whose 20-year-old sons died at the Linden Centre, a mental health facility in Chelmsford.

In 2008, Ben Morris, the son of Lisa Morris, was found dead after calling his mother to express his desire to leave.

Four years later, Melanie Leahy’s son Matthew was discovered unresponsive by staff and was later pronounced dead in a hospital. He had reported a sexual assault just days prior to his death.

Essex Police conducted an investigation without resulting in any arrests, but the Parliamentary and Health Service Ombudsman (PHSO) later found that the mental health trust had neglected its own procedures regarding rape allegations.

Additionally, Matthew’s care plan was falsified.

Since that time, numerous failings have come to light within the county.

The Care Quality Commission (CQC), the health regulatory body, raised alarms regarding ward safety and staffing levels from 2014 to 2018, but its recommendations went unheeded.

In 2017, Essex Police initiated a corporate manslaughter investigation into the deaths of 25 patients across nine mental health facilities, yet no charges were filed due to the lack of sufficient evidence.

In 2019, the PHSO released a report concerning the incidents involving Mr. Leahy and Mr. Morris, highlighting “systemic failures” in addressing ongoing and critical concerns over an intolerable duration.

The following year, Melanie Leahy and 24 other families launched an online petition demanding an independent inquiry, which attracted around 105,000 signatures and prompted parliamentary debate.

In 2021, former Health Minister Nadine Dorries announced that a thorough independent inquiry would be conducted, although it would not possess full legal authority to compel staff testimony.

That same year, the Health and Safety Executive fined EPUT £1.5 million following the deaths of 11 patients, with a High Court judge noting a “chain of failures” that hindered suicide prevention.

In 2023, an undercover Channel 4 investigation revealed that the CQC had rated two female wards as “inadequate” after exposing staff sleeping during patient observation.

In the same year, full legal powers were granted to the inquiry at the request of its previous chair, Dr. Geraldine Strathdee, who resigned for personal reasons. This development led to more deaths being incorporated into the investigation.

Like the COVID-19 inquiry, this investigation will be structured into various thematic areas, including:

Priya Singh from Hodge Jones and Allen, representing 126 families, commented: “The occurrence of deaths among patients in psychiatric institutions cannot persist in the UK.

“This represents a significant opportunity for the reform of mental healthcare in England. I hope we can uncover the root causes of the existing shortcomings.”

In a statement addressed to the inquiry, EPUT expressed sorrow towards all those who have been let down by mental health services in Essex.

They recognized that “each death represented a tragedy” and conceded that over the past decade, responses to learning from these deaths were inconsistent at best.

The trust acknowledged serious reports regarding patient sexual abuse and instances where staff had fallen asleep on duty, admitting that some wards were understaffed compared to the levels authorized by the trust and recognizing a national shortage of mental health professionals.

EPUT’s CEO, Paul Scott, reaffirmed, “We will endeavor to support Baroness Lampard and her team in delivering the answers that families, patients, and caregivers seek.”

Counsel to the inquiry, Nicholas Griffin KC, remarked on the disappointing levels of staff participation, noting that testimony from staff witnesses has been “scant.”

He pledged that the inquiry would utilize its powers to gather evidence from crucial staff responsible for patient care and management.

NELFT, which provides mental health services for children and adolescents in parts of Essex, assured the inquiry of its strong commitment to thorough support.

NHS England, tasked with overseeing certain specialized services, acknowledged its own shortcomings in specific areas.

Baroness Lampard delivered her initial address on September 9, 2024.

The inquiry is currently reviewing over 6,000 documents from health service providers and other relevant organizations.

Five rounds of evidence sessions have occurred thus far, with 100 families sharing their stories, and barristers interrogating the trusts and associated parties.

These sessions are taking place at Arundel House in London and are scheduled to continue until October 2026, with live streams available on YouTube.

The Health Service Journal (HSJ) has reported the inquiry’s expenses have already reached £5 million.

The final report and its recommendations are not expected to be released until 2027, almost seven years after the inquiry’s announcement.