Lord Darzi’s Warnings Realised: The Essex Mental Health Tragedy Unveiled at the Lampard Inquiry

Lord Darzi wrote that the NHS is in serious trouble¹. This was tragically shown by the commemorative statements read during the Lampard Inquiry.

On Monday 9th September 2024, oral testimony began at the Lampard Inquiry. This is the culmination of 12 years of work by Melanie Leahy, and all the bereaved families of inpatients who died under the care of the Essex Mental Health Trusts. They have campaigned tirelessly for a statutory inquiry in the face of lack of support from the government and, at times, their outright opposition. The families have been supported by Nina Ali, Priya Singh and the HJA Clinical Negligence throughout their journey.

Only 11 NHS staff members agreed to testify in the previous non-statutory Essex Inquiry. This was a scenario foreseen by HJA and the families they represent. Due to this lack of cooperation Dr Geraldine Strathdee CBE, Chair of the Essex Inquiry, requested that the Secretary of Health and Social Care grant the Inquiry statutory status.

The Essex Inquiry was then converted to the Lampard Inquiry² and given statutory powers³. The Lampard Inquiry now has the statutory power to compel much needed testimony from the staff involved. The Lampard Inquiry is investigating the deaths of mental health inpatients in Essex. HJA are representing 119 clients related to the Inquiry.

The HJA Medical Negligence team attended the hearings and heard bereaved family and friends share poignant and heart breaking commemorative statements about the impact of losing their loved ones to suicide. The bereaved called in no uncertain terms for the end of preventable deaths in the mental health service.

As outlined in Steven Snowden KC’s opening statement⁴ (on behalf of the patients and families represented by HJA) mental illness is not a terminal diagnosis. Those suffering ill-health expect to get better or recover entirely. This was not the case for patients under the care of the Essex Mental Health Trusts.

Lord Darzi, in his recent rapid investigation of the state of the NHS⁵, outlined that the NHS is in serious trouble. Nowhere was this more apparent than in the testimony of the core participants of the Lampard Inquiry. The details of this testimony as a whole highlighted that the failures of the Essex Mental Health trusts are exactly the serious trouble that Lord Darzi was referring to.

Lord Darzi highlighted the surge in waiting lists for mental health and community services. The Chair of the Inquiry has heard multiple stories of people attempting and succeeding to die by suicide as they waited for a bed. Their families spoke of the impact of being left to care for their loved ones with no support from the Essex Trusts and the life-changing, horrific scenario of finding their loved ones after an incident. The Chair heard from parents about the multiple young people that have lost their lives as they waited and the devastating effect this has had on the young person’s parents, siblings and extended family. Lord Darzi wrote in his report that long waits have been normalised. He stated that there were 345,000 referrals where people are waiting over a year for first contact with mental health services, 190,000 were people under the age of 18. The idea that waiting for services and the dire consequences of this is becoming normal is unimaginable to anyone present at the hearings over the past two weeks.

Lord Darzi wrote of concerns surrounding the quality of maternity care. Over the last two weeks the Chair has heard story after story of post-natal depression being the catalyst for suicidal and psychotic episodes which led to individuals becoming inpatients. These individuals then died due to failings in the care they received. The tragedy of these failings became ever more apparent as photos of the deceased and their children were shown on the big screens in the Inquiry room. This served to highlight the generational trauma and far-reaching impact of every preventable death that has occurred.

Lord Darzi wrote:

“The patient voice is not loud enough”

“The NHS should aspire to deliver high quality care for all, all of the time. That not only means care that is safe and effective but that treats people with dignity, compassion and respect”

The commemorative statements showed that the families and patients under the Essex Trusts were not listened to. Many spoke of their attempts to contact the professionals responsible for their loved one’s care being ignored or met with callous indifference. The families’ search for answers through inquests and investigations was unsuccessful and it took many years of campaigning for a statutory inquiry to be called. The fact that the bereaved have been left without a complete picture of how their loved ones died shows a lack of respect for families and patients, it shows a lack of a service that treats people with dignity, compassion and respect. Lord Darzi stated that there is a disengaged, disempowered NHS work force, facing challenges of low morale after the pandemic. The effect of this can be seen through the stories of mental health inpatients in Essex.

Lord Darzi wrote that the NHS is in critical condition but he also presented a plan for repair. In reference to mental health services he states that there needs to be more community care, a point that the families HJA represents have said will save lives. He pushes for a multidisciplinary approach, something that one bereaved sister spoke of as a change needed to support those dealing with dual diagnosis. This was also highlighted by the many families who lost a loved one with Autism. They lost their lives due to their specific needs not being met, understood, or in some cases, considered at all.

The families called again and again for systemic and lasting change in the care provided by the Essex Mental Health Trusts. The HJA team heard the story of a 13 year old child needlessly suffering and eventually losing their life. The bereaved families who spoke at the Inquiry showed unimaginable courage and resilience to relive what must be the most traumatic period in their lives. The poignant nature of their testimony is meant to highlight to the Chair just how serious and important her investigation is, and how many lives are relying on the proper implementation of her recommendations. The families continue to fight for the truth and meaningful change in memory of their loved ones, but they should not have to.

The Lord Darzi report and the Lampard Inquiry represent an opportunity to recommend and implement lasting systemic change in NHS mental health services both in Essex and Nationally.

HJA will continue to support those families who lost their loved ones due to failings in the mental health system, until the necessary change is implemented, and there are no more preventable deaths in the Essex Mental Health Trusts. If your loved one has died due to the failure of the EMHT and you would like to speak to our medical negligence team please call  0808 115 8150 or request a callback.