Background to the Inquiry & why it matters
The Lampard Inquiry is looking at the deaths of in-patients who were being treated by Mental Health Services at Essex Partnership University NHS Foundation Trust (EPUT).
It started as the non-statutory Essex Mental Health Independent Inquiry in January 2021, but there were concerns about non-co-operation and inability to satisfy the remit of the Inquiry, so in June 2023 the Inquiry was backed by the government and was elevated to statutory status. Baroness Kate Lampard CBE was made Chair.
The Inquiry is looking at the deaths of inpatients who were in NHS mental health care in Essex between 2000 – 2023. It includes patients who were on adult wards, child & adolescent units, older adult units, secure/forensic wards and other specialist units.
The Inquiry has confirmed that is likely dealing with more than 2000 deaths at EPUT and its predecessor trusts. This figure may rise as the investigation progresses.
As a specialist medical negligence law firm, we are closely monitoring the Lampard Inquiry and the profound implications it holds for patients, families and healthcare providers in Essex and the rest of the UK.
In this article, we look at the Inquiry’s work with EPUT and its predecessors, the scope and significance of the investigation, and what it means for the patients, and / or the families of patients, who received unsafe mental health care.
Scope of the Inquiry – What does it hope to achieve?
The Inquiry covers a broad period: between 1 January 2000 to 31 December 2023. Earlier years may be harder to investigate because of limitations with data or documents.
The primary focus of the Inquiry is EPUT and its predecessor organisations, which merged to form EPUT in April 2017 (South Essex Partnership University NHS Foundation Trust and North Essex Partnership University NHS Foundation Trust).
The Inquiry is looking at in-patient deaths at EPUT. The detailed definitions of what constitutes an inpatient death for the remit of the Inquiry are:
- Deaths occurring on an NHS mental health inpatient unit or while receiving NHS-funded inpatient care in the independent sector.
- Deaths during or within 3 months of transfer from one of those units.
- Deaths occurring while awaiting a bed in a mental health inpatient unit, or within 3 months of a clinical assessment of need that did not result in admission.
- Deaths while on leave (including supervised leave) from such a unit, or within 3 months of absconding from a unit.
There is more information about the scope of the investigation here.
The key areas that the Inquiry is investigating are:
- Patterns of avoidable harm, neglect, unsafe care planning, inadequate supervision and therapeutic failure.
- Failure of governance, leadership, escalation of risk, staffing levels and training.
- Culture: including lack of candour with patients and families, failure to learn lessons, institutional defensiveness.
- Regulatory oversight: looking out how bodies such as the Care Quality Commission (CQC), NHS England and integrated care boards (ICBs) engaged with known risks at EPUT.
- Family and patient voice: how were families’ concerns handled, were whistleblowers supported, were lessons learned and implemented?
- Care after discharge or in the community within 3 months of leaving inpatient services: this is crucial to the Inquiry because many deaths of EPUT’s patients occurred shortly after discharge.
Why is EPUT at the centre of the Inquiry?
- There have been several investigations into EPUT in recent years, and the Trust has also been subject formal regulatory action, including a prosecution in 2021 for health & safety failuings relating to ligature risks and patient suicides, which resulted in a significant fine.
- The volume of deaths under EPUT’s care, and concerns raised by families and inquests, have made EPUT a central focus. Baroness Lampard has indicated that the Inquiry will include “more than 2,000 deaths”, but that this figure is a “conservative estimate”.
- The detailed and wide-ranging definition of inpatient death includes not only deaths that occurred on wards but also after the patient was discharged, during transfers and during other vulnerable periods — many of which involved EPUT’s services.
As a specialist medical negligence law firm, we recognise that these types of trust-wide failings, and multiple individual failings, are precisely the context in which claims for accountability, and also compensation, often arise.
The Inquiry is a necessary step because without intervention at EPUT, there will be no accountability for previous mental health negligence and the failures will continue.
Implications for Patients, Families & Legal Claims
For Families:
The Inquiry provides a platform for families bereaved or harmed by EPUT services to share their stories and have their voice heard. This is the only way for there to be transparency and to seek systemic change.
Families have been designated a “Core Participant” in the Inquiry, which means that they are allowed legal representation, access to evidence, and can have a say in the process.
For Victims of Negligence:
If someone’s loved one died (or was severely harmed) under EPUT’s care during the period covered by the Inquiry, there may be multiple legal routes. The Inquiry investigation is separate from a civil medical negligence claim, but evidence gathered by the Inquiry may support mental health negligence claim.
For Trusts & Healthcare Providers:
The outcome of the Inquiry will hopefully lead to recommendations and reforms in mental health inpatient care — including staffing, risk management, governance and culture. There is likely to be increased scrutiny following the Inquiry’s conclusion, as we have seen resulting from the maternity reviews and investigations in Shrewsbury & Telford, East Kent, Morcambe Bay and currently in Nottingham.
For Regulators & Legal Practice:
The Inquiry highlights the importance of responding to, and learning from, historic failings. In legal practice, we know that institutional failures often underpin claims where someone or their loved one has been harmed. At the root of the systemic failures is someone or a family whose life has been forever changed by the harm caused.
Our Role & Support
MDS is a specialist medical negligence law firm. We specialise in claims that involve mental health negligence.We can help you with:
- Assessing whether your case falls within the period and scope of the Inquiry (EPUT inpatient care 2000-2023).
- Applying for Core Participant status if you or your loved one’s case is eligible.
- Obtaining and preserving evidence (medical records, coroner’s reports, witness statements) — especially crucial given the age of many cases. In EPUT cases, the period of care is broad and some records may be missing (especially early 2000s), so timely legal action and preservation of materials is advisable.
- Advising on civil claims (compensation for death or injury) at the same time as or following the Inquiry process. We are experienced in claims involving mental health negligence. Click here to read the story of Miss Halliday, who died by suicide due to failures by the mental health services who were supposed to be supporting her. We supported Miss Halliday’s family at the Inquest into her death and then with a mental health negligence claim afterwards.
- Communicating sensitively with families and supporting their legal, emotional and practical needs.
If you or your loved one was not treated at EPUT, but you believe that you may have a claim, please contact us for a no-obligation consultation. We will listen to your concerns and will confirm if we can help you.
Next Steps & Timeline Considerations
- The Inquiry is ongoing and is holding public hearings (in London & live-streamed) and is still gathering evidence.
- The date for the final report has not been confirmed, but it has been suggested that there will be recommendations once the hearings conclude, which may be in 2026 or later.
- Any evidence from the Lampard Inquiry may strengthen a mental health negligence claim, especially if it demonstrates that there were patterns of neglect, a culture of non-reporting or systemic failures.
If you or a family member were cared for by EPUT (or a predecessor trust) in an inpatient mental health unit in Essex between 2000 and 2023, and you believe that failings in care contributed to serious harm or death, please do not hesitate to contact us for a confidential no-obligation consultation, so that you can tell us what happened. We will consider whether we can assist you and will inform you regarding the legal options available.
If you or a loved one believe that failings in mental health care or services contributed to serious harm or death in relation to another NHS Trust, please contact us for a confidential no-obligation consultation, so that you can tell us what happened. We will consider whether we can assist you and will inform you regarding the legal options available.
