Mental health deaths issue downplayed by those in heart of government – inquiry

An inquiry into mental health deaths in Essex has been told that the extent of the problem was “downplayed by those within the heart of government”.

The Lampard Inquiry will investigate the deaths of people who were receiving mental health inpatient care in Essex between 2000 and 2023.

Chairwoman Baroness Kate Lampard CBE said the number of deaths within the scope of the inquiry will be “significantly in excess of the 2,000” previously thought.

This will include people who died within three months of discharge, and those who died as inpatients receiving NHS-funded care in the independent sector.

Lily Lewis, representing the charity Inquest, told the second day of the inquiry on Tuesday that the “full scale of failings in Essex has yet to be fully uncovered”.

She said that Inquest, which carries out specialist casework around state-related deaths including when people die in mental health settings, has since 2008 worked on 49 cases that fall within Essex mental health services.

“It seems clear now that defensiveness flowed from the very top,” she told the inquiry, which is being heard in Chelmsford.

She said that in October 2019, then Conservative health minister Nadine Dorries was asked if the government would announce a public inquiry into failings by mental health services in Essex.

“She said that she had been advised by the Department for Health and Social Care that, and I quote, ‘public inquiries do not happen for individual cases’,” said Ms Lewis.

The barrister said that Ms Dorries said “they tend to happen where there is a systemic problem or there are multiple cases – in this case a public inquiry is not an appropriate response because we’re talking about two cases”.

Ms Lewis said: “By October 2019 it was patently clear that the problems in Essex were about more than two cases.

“By this date Inquest had already worked with at least 17 families whose loved ones had died as inpatients under the care of Essex mental health trusts.

“Multiple cases had been publicly reported and there was ample evidence of systemic failings at that stage.

“Yet the extent of the problem was not only being downplayed by those within the heart of government but it appears that the calls for a public inquiry were being actively resisted by those at the top of the Department for Health and Social Care.

“As we heard from Mr Snowden KC on behalf of families and patients yesterday we now know that in 2020 Ms Dorries sent appalling messages to then health secretary Matt Hancock informing him of her plans to isolate Melanie Leahy and undermine her calls for a public inquiry.

“Sadly these revelations are the latest in a pattern of defence and denial which has characterised the response of government to state-related deaths.”

She said the charity shares “horror and concern that despite countless investigations… preventable deaths have continued”.

The barrister said it “shouldn’t fall to bereaved families… to ensure such serious and repeated state failings are properly investigated”.

She said that the “default position of the relevant trusts appears to be defensiveness, denial and delay”.

Zeenat Islam, representing three integrated care boards (ICBs), said the boards would “listen carefully to the evidence”.

She said in an opening statement that Suffolk and North East Essex ICB, Mid and South Essex ICB and Hertfordshire and West Essex ICB were established in 2022 amid national reforms to the system.

ICBs replaced Clinical Commissioning Groups in the NHS in England from July 2022.

Ms Islam said that the ICBs she represents made a “firm commitment to supporting the inquiry in its investigation” and had a “willingness to reflect on key learning that emerges”.

Paul Scott, chief executive of Essex Partnership University NHS Foundation Trust (EPUT), said: “I want to say how sorry I am to anyone who has lost a loved one or whose care has not been of the standard it should have been.

“I welcome the Lampard Inquiry and we will do all we can to support Baroness Lampard and the team to deliver the answers that families and patients are seeking.”

The inquiry will continue with opening statements from 10am on Wednesday.