Today marks the beginning of the public hearings of the ‘Lampard Inquiry’, a statutory inquiry investigating the deaths of over 2,000 mental health patients in NHS Trusts in Essex (‘the Trusts’).

Steven Snowden KC leads Dr Achas Burin, Rebecca Henshaw-Keene, and Jake Loomes all of 12 King’s Bench Walk (instructed by Nina Ali and Priya Singh of Hodge Jones & Allen), representing over 100 affected families.

Background

The start of these public hearings is one step in what has been a long and arduous road for patients of the Essex Trusts and the families of those patients who have tragically died.

The call for an inquiry followed repeated serious concerns which were raised about the standards of care in Essex NHS Trusts mental health services by (amongst others) Coroners, the Care Quality Commission, and the Parliamentary and Health Service Ombudsman.

In January 2021, the ‘Essex Mental Health Independent Inquiry’ was established. This was a non-statutory inquiry. As such, the then-chair (Dr Geraldine Strathdee CBE) had no legal powers to compel witnesses to attend.

In June 2021, the Health and Safety Executive prosecuted the North Essex Partnership NHS Trust (now Essex Partnership University NHS Foundation Trust) for what was described as a litany of failings which led to the Trust’s failure to prevent deaths of inpatients in their care. The Trust pleaded guilty and was fined £1.5 million.

In October 2022, a Channel 4 Dispatches documentary “Hospital Undercover Are They Safe” aired. The documentary showed undercover filming of an Essex Trust’s inpatient mental health ward, further highlighting serious concerns about the quality of care still being provided. Campaigning families made further pleas that a statutory inquiry was necessary to find out what happened and prevent a repeat of similar failings in the future.

In an open letter of 12 January 2023, Dr Strathdee stated that as a result of poor levels of witness engagement (only 11 mental health staff out of 14,000 who were contacted came forward to give evidence), it would not be possible for her inquiry to carry out its functions properly and meet its Terms of Reference.

In June 2023, Steve Barclay (then Secretary of State for Health and Social Care) announced that the independent inquiry would be granted statutory status under the Inquiries Act 2005. Baroness Kate Lampard replaced Dr Strathdee as the new chair from September 2023.

The scope of the present inquiry

As with all inquiries, the scope of the Lampard Inquiry is dictated by the Terms of Reference (‘ToR’). The Lampard Inquiry’s ToR can be found here.

The inquiry will investigate the circumstances surrounding the deaths of over 2,000 inpatients who received mental health care in NHS Trusts within Essex in the period between 1 January 2000 and 31 December 2023.

In so doing, the inquiry will consider, amongst other things:

  • Serious failings in the provision of safe and therapeutic inpatient care (including instances falling short of death).
  • Patient involvement in care decisions.
  • Family and carer engagement in patient care, including engagement after the patient’s death.
  • Issues of physical and sexual safety in mental health units.
  • Staff actions, practices, and behaviours.
  • Staffing, training, and working conditions for staff.
  • Leadership’s role in mental health inpatient care.
  • Culture and governance at the Trust(s).
  • Quality of the Trust(s) investigations into care.
  • Quality, timeliness, openness and adequacy of response to concerns, complaints, investigations etc.
  • Interaction with other public bodies.

Put shortly, the Inquiry will consider what happened to those patients and the care they received, why it happened, and make recommendations to try to prevent what went wrong from happening again.

Opening hearings

The initial hearings starting from today will take place in Chelmsford Civic Centre. The first day of hearings will see opening statements from the Chair, Counsel to the Inquiry, and Steven Snowden KC on behalf of patients and bereaved families represented by HJA. The opening statements can be watched here. Steven Snowden KC’s opening statement can be read here. His statement has been widely covered in the media including, The Times, ITV, The Telegraph and The Daily Mail.

The first tranche of hearings will run from 9 September 2024 to 25 September 2024 and will include: (1) opening statements from the Chair, counsel to the inquiry, and Counsel for Core Participants; and (2) impact evidence from friends and families of those who have died as well as evidence from former patients.

The Chair, Baroness Lampard, has expressed that the experiences of family and friends of those who have died as well as experiences of former patients will be at the forefront of the inquiry.

The start of these public hearings marks an important milestone for all those who have tirelessly campaigned for a statutory inquiry.