The chair of England’s first public inquiry into mental health-related deaths has promised to “seek out the truth” despite encountering significant challenges in obtaining necessary documents from the NHS.
The Lampard Inquiry, which is investigating more than 2,000 deaths at NHS inpatient units in Essex between 2000 and 2023, has begun its first major evidence sessions in London.
Baroness Lampard, leading the inquiry, stated that although the process was “breaking new ground,” 21 legal notices had already been issued to NHS organizations to compel them to submit evidence. She emphasized that she would fully use her legal powers to obtain any missing documents.
“This inquiry is of national significance,” Baroness Lampard said. “We are focused on understanding what went wrong over nearly 25 years.”
Nicholas Griffin KC, the counsel for the inquiry, expressed frustration with the lack of cooperation from many providers. He noted delays in submitting documents and issues with the condition of paper records, including missing files. Griffin also pointed out that some providers, including private organizations, had sent information late.
He reminded those involved that suppressing, altering, or destroying evidence is a criminal offense and that providers should be sufficiently resourced to respond to the inquiry. Despite these setbacks, Griffin insisted the inquiry would continue without delay.
A previous government investigation into these deaths failed after only 11 out of 14,000 staff members agreed to participate. Griffin confirmed that the inquiry still faced obstacles in obtaining information. The inquiry team had requested assurances that no action would be taken against staff who provided information, but many providers, including major ones, refused to offer such guarantees.
Over the next three weeks, Baroness Lampard will hear from care regulators, experts, and Paul Scott, the chief executive of Essex Partnership NHS University Trust (EPUT). She pledged to tackle difficult issues directly and ensure that the experiences of those affected remain at the forefront of the inquiry. Her goal is to make “lasting, positive recommendations” for mental healthcare improvements across England.
Outside the hearing, Melanie Leahy, who has campaigned for years following her 20-year-old son Matthew’s death under NHS care, expressed her hopes for the inquiry. “It’s been years of heartbreak and unanswered questions,” she said. “This is our chance to get the truth.”
Leahy also criticized EPUT for its handling of her son’s inquest, claiming that staff walked out without speaking to anyone. Campaigners, along with lawyers representing bereaved families, have raised concerns that mental health services remain unsafe.
The inquiry team is investigating ongoing concerns and will review recent inquests and deaths to assess if the problems in Essex have been addressed. Dr. Emma Ireton, an associate professor at Nottingham Law School, will also produce a report on the implementation of the inquiry’s final recommendations.
In response to the ongoing investigation, EPUT chief executive Paul Scott has apologized for the deaths under his trust’s care. “As the inquiry progresses, we will hear many heart-wrenching accounts, and I want to express my sincere apologies for the losses,” he said.
The evidence hearings will continue until May 15 and will resume in July. Baroness Lampard is expected to issue her final recommendations for change in 2027.
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