Hundreds more avoidable deaths than previously estimated will be uncovered in the first statutory inquiry into mental health services, its chair said on the opening day.
The inquiry into mental health services in Essex was initially expected to examine about 2,000 deaths between 2000 and 2023. While opening proceedings in Chelmsford on Monday, its chair, Kate Lampard, said she expected to uncover “significantly in excess” of this number.
Problems collecting data on patients is one of a series of failures to be examined by the inquiry into Essex Partnership university NHS trust (Eput), North East London NHS foundation trust (Nelft) and predecessor organisations.
Lady Lampard said: “I find it shocking that we may never be able to say for sure how many people died within the remit of this inquiry.”
Nicholas Griffin KC, the counsel to the inquiry, said: “Further work done has already demonstrated that the figure previously given of 2,000 deaths will rise substantially.”
An updated figure would be provided in November, he said.
The statutory inquiry will examine incidents of serious patient harm, including attempted suicides and physical and sexual assaults. It will focus on inpatient deaths and injury, but will include incidents that occurred in the community three months after discharge or three months after a refusal to admit a patient.
Lampard said: “We’re investigating alleged failings in mental healthcare on a scale that is deeply shocking.”
Some of them were ongoing and had national implications, she added. “A number of the issues that have been identified remain of current concern and I need to address them as quickly as possible.”
The inquiry was put on a statutory footing after previous calls for evidence and witnesses, by a previous independent inquiry chaired by Dr Geraldine Strathdee, were ignored. Griffen said: “The response to this [call for evidence] was extremely poor.”
In a warning to service providers, Lampard said: “Where relevant evidence is not provided, or is not provided appropriately promptly, I will not hesitate to use my statutory powers to the fullest extent.”
After a minute’s silence for the victims, Lampard paid tribute to the families who have campaigned for years for a statutory inquiry. “I again acknowledge the instrumental role of the families in the creation of this independent statutory inquiry. Without their dedicated and tireless campaigning, it is unlikely that we would be here today.”
Priya Singh, a partner at Hodge Jones & Allen (HJA), which represents more than 120 victims and families, said: “It has been shocking to hear that the inquiry is expecting to uncover many more deaths. There is no time to wait, people are still dying, not just in Essex, but potentially, nationally.”
In its opening submission to the inquiry on behalf of the families, HJA criticised Essex trusts for thwarting the previous inquiry. It said less than 30% of those regarded as essential witnesses by Strathdee agreed to attend evidence sessions.
It also accused the trusts of failing to change despite numerous damning reports by regulators, the parliamentary and health service ombudsman, coroners and a criminal prosecution in 2021 over the death of 11 patients from suicide.
The submission said it was disturbing that some of the healthcare professionals involved in abusing patients were still working in the NHS.
It listed 21 recurring problems that it expects the inquiry to unearth. They include: inappropriate discharge of patients; failures to admit patients in desperate need; inappropriate use of force and restraint; rapid staff turnover; baseless accusations aimed at families, and poor record-keeping.
It added: “Given their experience of being fobbed off when calling for a statutory inquiry, our clients ask that government takes them seriously.”
A number of bereaved parents and families gathered outside the inquiry venue in Chelmsford and lay placards on the pavement with photos of loved ones who had died.
One banner said: “We demand truth, justice, accountability, change,” and another said: “Failed by Essex mental health services.”
The inquiry evidence sessions are expected to continue until 2026.
• In the UK and Ireland, Samaritans can be contacted on freephone 116 123, or email jo@samaritans.org or jo@samaritans.ie. In the US, the National Suicide Prevention Lifeline is at 988 or chat for support. You can also text HOME to 741741 to connect with a crisis text line counselor. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at befrienders.org
