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BBC News
20-05-2025
- Health
- BBC News
Lampard Inquiry: What has happened so far?
Eight months into its 25-month timeline, the Lampard Inquiry is beginning to expose deep-rooted issues in NHS mental health services in Essex. With more than 2,000 deaths in inpatient units between 2000 and the end of 2023, the inquiry is examining not only local failings but also whether these reflect wider national problems. Here is what has emerged so far. A system under scrutiny The inquiry is named after its chairwoman, Baroness Kate is a former barrister who oversaw the NHS investigations into abuse by former television presenter Jimmy is primarily focused on Essex Partnership University NHS Foundation Trust (EPUT), formed in 2017 from the merger of North and South Essex Partnership Trusts. It is also looking at the deaths of patients from Essex at inpatient units run by private providers and 215 facilities run by other NHS organisations, such as North East London NHS Foundation former health ombudsman Sir Rob Behrens said on average, 5% of all mental health cases received by his team between 2011 and 2023 were related to called the failures in care "the National Health Service at its worst".During testimony from the relatives and friends of those who died, it emerged that they were individuals from a range of backgrounds, including a chef, bus driver, heating engineer, former head teacher, and parish councillor. Lack of staff The inquiry has heard evidence of a long-term reduction in registered mental health nurses, with increased reliance on healthcare support workers across England. This shift has been linked to reduced patient engagement and increased chief nurse Maria Nelligan told the inquiry this was because healthcare support workers were "cheaper" and said the shift compromised therapeutic Paul Davidson, a consultant psychiatrist, described how staff across England were "rushed off their feet," contributing to a workplace culture where professionals feared being blamed "whatever decision they took". Paul Scott, chief executive of EPUT, stated the trust had reduced its use of agency staff by 30%. Poor data The inquiry has also highlighted issues with data collection and transparency. Deborah Cole, from the charity Inquest, described how there was no "complete set of statistics in relation to those who die in mental health detention". Dr Davidson added: "There is good information in relation to deaths by suicide, [but] this is not a helpful tool by which to assess how mental services are being provided overall."Baroness Lampard has warned that the inquiry may never uncover the full scale of deaths linked to failings in Essex mental health stated that while a figure would be published, it was likely to be approximate, due to incomplete or inconsistent data over the 24-year period under review Regulating trusts The inquiry has examined the complexity of the regulatory system overseeing NHS trusts. Mr Scott described being "overwhelmed" by the number of regulatory bodies -19 in total - each issuing recommendations. This, he said, made it difficult to implement consistent from the inquiry, in October 2024, the health secretary stated that the government intended to reform the regulatory was in response to a review of the way the Care Quality Commission (CQC) inspected trusts, called the Penny Dash Review, which said the framework was too Lampard Inquiry will consider the CQC's role in relation to events in Essex. Analysis Three systemic issues raised by the inquiry - staff shortages, poor data, and regulatory complexity - have been longstanding concerns. The Royal College of Nursing, the CQC and a 2023 Public Accounts Committee report all flagged staffing shortages and burnout. A 2023 review found Norfolk and Suffolk NHS Foundation Trust had lost track of patient death data, while a 2025 Health Services Safety Investigations Body (HSSIB) report called for a unified national dataset. Regulatory reform is also under way following multiple critical reviews. While Baroness Lampard is expected to reference these reports, the inquiry is also under pressure to uncover new families have expressed concern regarding its pace, and limited focus so far on cultural have also noted that safeguarding issues, such as patients absconding from units, have received little attention - a relevant issue given a recent inquest into the death of an 18-year-old who died while on escorted leave from an EPUT unit. Transparency and whistleblowing Only 11 out of 14,000 staff came forward during the earlier non-statutory phase of the inquiry. Baroness Lampard has said she will use statutory powers to compel evidence if necessary. Mr Scott acknowledged that "closed cultures" existed at EPUT but said the trust was encouraging openness. During a recent inquest into the death of a 16-year-old patient, a manager testified that staff were reluctant to raise safety concerns. Brian O'Donnell, clinical lead at the St Aubyn Centre in Colchester, said there was a "real concern about safety on the wards, and staff are too worried to say anything about it".Families have also raised concerns about delays in evidence disclosure, including a postponed inquiry session on a Oxevision, an infrared monitoring system, due to late submission of information by Baroness Lampard said her decision to delay the hearing "should not be viewed in any way as enabling EPUT to avoid answering questions about its use of Oxevision". What comes next? In July, the inquiry will focus on the two former trusts that merged to form EPUT. Mr Scott has said, when he arrived at the trust in 2000, the legacy of the merger was that "there was too much focus on governance and management and not enough on patient safety".Families are calling for detailed scrutiny of individual deaths, but the inquiry is more likely to use selected cases to illustrate broader systemic issues such as governance, and Scott has apologised for deaths under the trust's care and stated that he believes EPUT should remain the provider of mental health services in Essex. Follow Essex news on BBC Sounds, Facebook, Instagram and X.
ITV News
15-05-2025
- Health
- ITV News
Lampard Inquiry: Essex mental health trust boss 'sorry' over 'heartbreaking' failings to families
The chief executive of a mental health trust has admitted at an inquiry that listening to accounts from bereaved families was "extremely sobering and shocking", as he offered an apology. Paul Scott, chief executive officer of Essex Partnership University NHS Foundation Trust (EPUT), defended the organisation at the Lampard Inquiry on Thursday and said it should continue to deliver mental health services. The Lampard Inquiry is examining the deaths of more than 2,000 people at NHS-run inpatient units in Essex between 2000 and 2023. It includes those who died within three months of discharge, and those who died as inpatients receiving NHS-funded care in the independent sector. At a hearing in London, he said: 'I'd like to offer an apology and condolences to all families who have lost loved ones under the care of Essex mental health. 'I have listened when I first joined, I've met many families, at the Health and Safety Executive (HSE) prosecution (which saw the trust fined £1.5 million), I was in the court for that and I've heard testimonies through this inquiry as well. 'They've been brave, powerful and heartbreaking. 'These have deeply affected me and motivated me to make a real difference and I'm sorry for their enduring pain. 'Since joining the organisation I have given everything I have to try and improve safety and I will continue to do so.' Mr Scott became chief executive of EPUT in 2020 and described the HSE prosecution as 'extremely sobering and shocking to listen to very powerful testimonies of families in the courtroom, how they'd been failed, the impact it had on them'. 'The responsibility I felt to address that was very powerful with me,' he said. 'I still remember that every day, that day is probably one of the most profound days of my life.' Mr Scott referred to an opening statement that a barrister for EPUT gave in September last year 'where we were very clear about accepting the failings of the past'. He said: 'We admitted to failings around ligature points and other environmental risks; staff members' culture and conduct; sexual and physical abuse; absconding; discharge and assessment of patients; involvement of family and friends and staff engagement with investigations.' EPUT was formed in 2017 following a merger of the former North Essex Partnership University NHS Foundation Trust and the South Essex Partnership University NHS Foundation Trust. Nicholas Griffin KC, counsel to the inquiry, asked Mr Scott if 'financial pressures have adversely impacted patient safety since the merger.' Mr Scott said: 'Since I've joined there has been no financial constraints on our inpatient wards – the constraint is the supply of staff. 'I think prior to that there was very strict financial control, now whether you call that financial constraint or not… 'My view was we should have been investing more earlier.' Thursday's hearing marked the conclusion of an "introductory" three-week session before the next public hearings of the inquiry in July, which will focus on 'those who died while under the care of EPUT's predecessor trusts'. Some families have been left dissatisfied by the hearings so far, according to Hodge Jones & Allen solicitors, which is representing 126 families. Priya Singh, from Hodge Jones & Allen Solicitors, said: "I think a lot of the evidence given today is not going to mirror our families' experiences which happened whilst their loved ones were alive and when they passed away, so I think they're going to struggle with the evidence they heard today." Ralph Taylor's wife Carol died in 2023 after being admitted to the mental health unit at St Margaret's Hospital in Epping. Mr Taylor said: "I think there's a failure of culture, I really don't know what you do about it, but I don't think EPUT is the right organisation to do it because of the experience of families. "They've failed to look after so many patients in the past, how can you be confident they'll do that in the future? "I can't bring her back but if we can save at least one life by virtue of them changing how they treat people it's worth it." During the inquiry opening in Chelmsford last year, the chairwoman of the inquiry, Baroness Kate Lampard CBE, said "we may never know" the true number of people who died. But she warned it is expected to be "significantly in excess" of the 2,000 deaths previously reported.
Yahoo
15-05-2025
- Health
- Yahoo
Mental health trust boss offers apology to families at inquiry into deaths
The chief executive of a mental health trust has offered an apology to bereaved families at an inquiry into the deaths of more than 2,000 people. The Lampard Inquiry, chaired by Baroness Kate Lampard, is examining deaths at NHS-run inpatient units in Essex between 2000 and 2023. It will include those who died within three months of discharge, and those who died as inpatients receiving NHS-funded care in the independent sector. Paul Scott, chief executive officer of Essex Partnership University NHS Foundation Trust (EPUT), gave evidence to a hearing held at Arundel House in central London on Thursday. Early in his evidence, he said: 'I'd like to offer an apology and condolences to all families who have lost loved ones under the care of Essex mental health. 'I have listened when I first joined, I've met many families, at the HSE (Health and Safety Executive) prosecution (which saw the trust fined £1.5 million in 2021 over failures to remove ligature points) I was in the court for that and I've heard testimonies through this inquiry as well. 'They've been brave, powerful and heartbreaking. 'These have deeply affected me and motivated me to make a real difference and I'm sorry for their enduring pain. 'Since joining the organisation I have given everything I have to try and improve safety and I will continue to do so.' Mr Scott became chief executive of EPUT in 2020. EPUT was formed in 2017 following a merger of the former North Essex Partnership University NHS Foundation Trust and the South Essex Partnership University NHS Foundation Trust. Mr Scott described the HSE prosecution as 'extremely sobering and shocking to listen to very powerful testimonies of families in the courtroom, how they'd been failed, the impact it had on them'. 'The responsibility I felt to address that was very powerful with me,' he said. 'I still remember that every day, that day is probably one of the most profound days of my life.' He said that a 2022 Dispatches documentary, where an undercover reporter looked at conditions on wards, was 'equally very shocking, especially when it's our services and the services I'm responsible for'. Mr Scott referred to an opening statement that a barrister for EPUT gave in September last year 'where we were very clear about accepting the failings of the past'. Detailing these, he said: 'We admitted to failings around ligature points and other environmental risks; staff members' culture and conduct; sexual and physical abuse; absconding; discharge and assessment of patients; involvement of family and friends and staff engagement with investigations.' Nicholas Griffin KC, counsel to the inquiry, asked Mr Scott if 'financial pressures have adversely impacted patient safety since the merger' of the predecessor trusts to form EPUT. Mr Scott said: 'Since I've joined there has been no financial constraints on our inpatient wards – the constraint is the supply of staff. 'I think prior to that there was very strict financial control, now whether you call that financial constraint or not… 'My view was we should have been investing more earlier.' Mr Scott also apologised for the impact of a 'late submission' to the inquiry which he said was 'intended to update' the inquiry on work that had been done by EPUT. He acknowledged the 'delay and disruption to the inquiry as a result of our submission'. The inquiry continues.
Yahoo
01-05-2025
- Health
- Yahoo
'Appalling' inquest delays hurt families
Bereaved families have been traumatised by "distressing and appalling delays" to inquest proceedings, a landmark inquiry heard. The Lampard Inquiry is examining the deaths of more than 2,000 mental health patients who died under NHS care in Essex between 2000 and 2023. Fiona Murphy KC told the hearing "institutional defensiveness" by health providers was hindering inquests and preventing families from getting closure. Essex Partnership University NHS Foundation Trust (EPUT) has apologised to those affected. The public inquiry is England's first into mental health deaths, with evidence being heard in London after previous sessions in September and November. Ms Murphy told of the "horrendous" experiences that families she represented had during their loved ones' inquests. She said there had been an "extraordinary and shocking number of deaths" in inpatient units in Essex. "The families' experience has death of loved ones falling under the radar and of distressing and at times appalling delays," she said. The solicitor accused EPUT of knowingly disrupting inquest proceedings by being defensive. This included "unreasonably disputing" the relevance of an inquest, failing to provide evidence and delaying its disclosure. Ms Murphy said: "There has also been shameful misrepresentation that lessons have been learned when they have not. "These defensive behaviours cause real harm. "They cause the retraumatisation of grieving families, they obstruct the truth, they obstruct lesson learning and they act as a fundamental bar and barrier to change." Mum says son died in 'hell on Earth' facility Ex-footballer died after discharge, inquiry told Families mourn loved ones at Lampard Inquiry An inquest is a legal investigation into a death which appears to be due to unknown, violent or unnatural causes. Coroners can hold an Article 2 inquest when the person's death occurred while they were under state care. Ms Murphy said they had the potential to deliver "real meaning" for families, as well as change. However, she claimed a "systematic collapse of acceptable service delivery in Essex" was "undermining" this potential. EPUT chief executive Paul Scott has apologised for deaths under his trust's care. He said: "As the inquiry progresses, there will be many accounts of people who were much loved and missed over the past 24 years and I want to say how sorry I am for their loss." Follow Essex news on BBC Sounds, Facebook, Instagram and X. What is the Lampard Inquiry and what could it change? Mental health inquiry chair vows to 'seek out' truth Mum says son died in 'hell on Earth' facility The Lampard Inquiry
Yahoo
01-05-2025
- Health
- Yahoo
Alert muted before teen died at unit, inquest told
Staff muted a safety alarm before a teenager was found unconscious at an NHS mental health unit, an inquest heard. Elise Sebastian died in April 2021 after she was found unresponsive in her bedroom at the St Aubyn Centre in Colchester. The 16-year-old was supposed to receive one-to-one care but an inquest was told an alert system, linked with her bedroom, was muted and she was left alone for 28 minutes. The coroner was told changes had been made to the alert system. The unit is run by the Essex Partnership University NHS Foundation Trust (EPUT), which is the subject of an ongoing public inquiry. Elise, who was from Southminster near Maldon, was found unresponsive in her room on 17 April 2021. She died in hospital two days later. The alert system, called Oxyvision, was introduced in the ward two months beforehand. The inquest was told the system was designed to help staff monitor the safety of patients in their bedrooms and bathrooms by using infrared sensors, and to reduce the number of self-harming incidents. Essex area coroner Sonia Hayes read from a patient safety investigation conducted by EPUT following Elise's death. It said that "confidence had been weakened" in the system because the wi-fi was not reliable on the mobile tablets used by staff. An alarm would usually sound on the tablets if a patient was where they should not be. The report also found an alert on a desktop computer in the nurse's office was muted. It said this "led to a considerable reduction in the line of sight to Elise's bedroom". The coroner was told it was the trust's policy to raise a Datix safety report if the wi-fi was not working properly, but no report could be found. The inquest jury was told - that the day after she died - the trust changed its operating procedure, telling staff the volume on alerts must not be turned down or muted. Laura Cozens is head of patient safety and quality at Oxyhealth, which provides the Oxyvision system. She said the tablet software had since been tweaked, so that the volume of the alert automatically rose after 60 seconds of sounding. The system was an "additional supportive tool and it shouldn't replace staff", she added. Brian O'Donnell, clinical lead for EPUT, told the jury that signs had been placed around the main computer terminal asking staff not to turn down the alert volume. He said warnings and alerts should never be ignored, adding he "would absolutely not expect any staff member to mute the volume". Mr O'Donnell was asked if staff had muted it so they were not disturbed. "I wasn't there, so I don't know," he added. He admitted that since Oxyvision was installed, there had been some complacency. "We do rely too much on technology nowadays," he said. The inquest continues. Follow Essex news on BBC Sounds, Facebook, Instagram and X. NHS trust admits failures led to teenager's death Essex Coroner's Service
