The first statutory inquiry into mental health will uncover hundreds more preventable deaths than previously estimated, the chairman said on the opening day.
The Essex Mental Health Inquiry was initially due to look into around 2,000 deaths between 2000 and 2023. Speaking at the opening of proceedings in Chelmsford on Monday, chair Kate Lampard said she expected to uncover “significantly more” than this number.
Problems in collecting patient data are one of many shortcomings highlighted in the research into Essex Partnership University NHS Trust (EPUT), North East London NHS Foundation Trust (Nelft) and their predecessors.
Lady Lampard said: “I find it shocking that we may never be able to say with certainty how many people have died within the framework of this inquiry.”
Nicholas Griffin KC, counsel for the inquiry, said: “Further investigation has already shown that the previously quoted figure of 2,000 deaths will rise significantly.”
He said an updated figure would be provided in November.
The statutory inquiry will investigate incidents of serious patient harm, including suicide attempts and physical and sexual assaults. It will focus on deaths and injuries of inpatients, 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 are investigating alleged failings in mental health care on a scale that is deeply shocking.”
Some of these were ongoing and had national implications, she added. “A number of the issues that have been identified remain current and I need to address them as quickly as possible.”
The inquiry was put on a statutory footing after previous appeals for evidence and witnesses, by an earlier independent inquiry led by Dr Geraldine Strathdee, were ignored. Griffen said: “The response to this (appeal for evidence) was extremely poor.”
In a warning to service providers, Lampard said: “Where relevant evidence is not provided, or is not provided appropriately and promptly, I will not hesitate to use my legal powers to the fullest extent possible.”
After a minute’s silence for the victims, Lampard paid tribute to the families who have campaigned for years for a statutory inquiry. “I once again acknowledge the instrumental role of the families in setting up this independent statutory inquiry. Without their dedicated and tireless campaigning, it is unlikely we would be here today.”
Priya Singh, partner at Hodge Jones & Allen (HJA), which represents more than 120 victims and families, said: “It is shocking to hear that the inquiry expects to reveal many more deaths. There is no time to wait, people are still dying, not just in Essex but potentially nationwide.”
In its opening submission to the inquiry on behalf of the families, HJA criticised Essex trusts for obstructing the previous inquiry. It said that fewer than 30% of those considered by Strathdee to be essential witnesses agreed to attend evidence sessions.
The foundation was also accused of failing to change despite numerous damning reports from regulators, the parliamentary ombudsman, the health ombudsman, coroners and a criminal prosecution in 2021 over the suicide of 11 patients.
The statement said it was worrying that some healthcare professionals involved in patient abuse were still working in the NHS.
It listed 21 recurring problems that it expects the investigation to uncover. These include: inappropriate discharge of patients; failure to admit patients who urgently need help; inappropriate use of force and coercion; rapid staff changes; unsubstantiated accusations against families; and poor record keeping.
It added: “Given their experience of being fobbed off when they demanded a legal investigation, our clients are asking that the government take them seriously.”
A number of relatives and friends gathered outside the Chelmsford research site and placed posters on the pavement with photographs of loved ones who had died.
One banner read: “We demand truth, justice, accountability and change,” and another read: “Failed by Essex Mental Health Services.”
The hearings are expected to last until 2026.