What is the Lampard mental health inquiry?

It began as the relentless fight of two mothers whose sons were able to take their own lives on a mental health ward in Essex.

Matthew Leahy's mother, Melanie, and Ben Morris's mother, Lisa, wanted to know why, when their children were supposed to be in a place of safety, they were able to die.

More than a decade later, a public inquiry - the first of its kind into mental health - is underway, investigating "in excess" of 2,000 patient deaths, over the last 20 years.  

Over the next three weeks, the inquiry will hear its first factual evidence, including, for the first time, from the boss of the NHS Trust responsible for the majority of mental health services in Essex.

What is The Lampard Inquiry? 

Named after its Chair, Baroness Kate Lampard CBE, The Lampard Inquiry is a statutory inquiry, investigating the deaths of inpatients who died whilst they were living on adult and children mental health units run by the NHS in Essex, between the years 2000 and the end of 2023.

It will also look at deaths that happened within three months of patients being discharged from those units. 

Patients will also be included, if they were assessed and refused a bed on a mental health ward, or if they were waiting for assessment. 

The majority of NHS mental health services in Essex are provided by the Essex Partnership University NHS Foundation Trust, which runs 35 adult inpatient wards and three for children and teenagers across the county.

But the inquiry will also look at deaths that occurred while patients were receiving NHS care in the private sector. 

The inquiry opened in September 2024, with Baroness Lampard saying the number of deaths being looked into will likely be "significantly in excess" of 2,000.

What does it hope to achieve? 

The Lampard Inquiry has put services across Essex firmly in the spotlight.

But the repeated failures in Essex over the last two decades could be indicative of what is going on elsewhere in the UK, and this inquiry could have ramifications for all NHS mental health provision.  

Baroness Lampard has made it clear she wants the findings of this inquiry to help improve mental healthcare across the country, saying "we can make recommendations for real and lasting change in memory of those who have lost their lives as mental health patients in Essex".

What powers does the Lampard Inquiry have? 

The Lampard Inquiry, which is funded and backed by the government, is independent, as is the chair, Baroness Lampard.

She is a former barrister who, in 2015, led a report into the relationship between former broadcaster Jimmy Savile and NHS hospitals.

Baroness Lampard is also a member of the House of Lords, but is not affiliated to a political party.  

The Lampard Inquiry has statutory status, which means it can legally force witnesses to give evidence.

It is an important difference for some families and campaigners, who were unhappy with the original, non-statutory inquiry, the Essex Mental Health Independent Inquiry - which started in 2021, but had to be abandoned after only 11 members of staff, out of the 14,000 that were contacted, agreed to give evidence.  

During the inquiry, Baroness Lampard will hear evidence from bereaved families, former patients, experts and staff.

From this, she will draw up recommendations that the government can choose to accept or ignore.

The inquiry has no power to find anyone guilty or innocent, but if Baroness Lampard believes a crime has taken place, she will report this to the police.  

Why Essex?

In 2008, 20-year-old Ben Morris called his mum, Lisa, and said he wanted to leave the Linden Centre in Chelmsford.

Thirty minutes later, he was found dead. He had a diagnosis of attention deficit hyperactivity disorder (ADHD), and an inquest concluded he died by suicide.  

In 2012, days after reporting being raped on the unit, and only a week after he was admitted to the Linden Centre, 20-year-old Matthew Leahy was found unresponsive in his room.

He later died in hospital. He had been sectioned and detained under the Mental Health Act, and was suffering with psychosis.  

In 2017, police said records of Matthew's care plan had been falsified, but no action was taken.

Later that year, officers also launched a corporate manslaughter investigation into the deaths of 25 patients at nine mental health units in Essex - including the Linden Centre. But, they decided there was no case to answer, as the evidence threshold wasn't met.  

North Essex Partnership NHS Trust, which ran the Linden Centre, and the South Essex Partnership NHS Trust also merged in 2017, to form the Essex Partnership University NHS Foundation Trust (EPUT). 

In 2019, the Parliamentary and Health Ombudsman published a report into the deaths of Matthew Leahy and Ben Morris.

He found their mothers, Melanie and Lisa, had been badly let down, and opportunities to save their sons were missed, saying there had been a "systematic failure to tackle repeated and critical failings over an unacceptable period of time".

Melanie began petitioning for a public inquiry into the death of her son, and her campaign gained momentum, with many other bereaved families joining her.

By 2020, she had raised the more than 100,000 signatures needed to force a debate in Parliament.

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In November 2020, that debate, on the state of mental healthcare in Essex took place, where an independent inquiry into deaths at the Linden Centre was announced by the then MP and Health Minister Nadine Dorries. 

A few months later, in 2021, the Essex Mental Health Independent Inquiry was established, with Dr Geraldine Strathdee as its chair. 

Then, in June, EPUT pleaded guilty to failing to prevent patient suicides, following an investigation by the Health and Safety Executive into the deaths of 11 inpatients between 2004 and 2015.

Ben Morris and Matthew Leahy were included in that 11. 

The Trust accepted that its predecessor, the North Essex Trust, had failed to properly manage fixed ligature points in its units, at seven of its sites, and it was fined £1.5 million. The judge said there had been a "litany of failures".  

By 2022, the inquiry announced it was looking into some 1,500 unexpected, unexplained and self-inflicted deaths of Essex Partnership University Trust patients between 2000 and 2020.

This number was later updated to 2,000. But, despite repeated calls for staff members to come forward and give evidence, by 2023, the inquiry was abandoned, with the chair writing to the then health secretary Steve Barclay MP to say she will not be able to complete the work if the inquiry was not given legal powers to force witnesses.  

In June 2023, it was converted to a statutory inquiry, and Dr Strathdee stood down for personal reasons. Baroness Lampard was then appointed as the new chair.  

What concerns will the Lampard Inquiry examine?  

• Serious failings in the delivery of safe and therapeutic care;

• How much patients and their families were involved in decisions relating to their care;

• Physical and sexual safety on the wards;

• The practices of staff, both permanent and agency, in providing mental health care;

• Staffing numbers, training and working conditions on units, including support and supervision;

• The actions and behaviours of the leadership and management team;

• The culture and wider governance of the Trust(s);

• The quality of investigations carried out by the Trust(s);

• How the Trust(s) reacted to any concerns, complaints, investigations and inspections;

• The interactions between the Trust(s) and regulators, coroners and other public bodies

 What has the NHS said? 

In its opening statement to the inquiry, Essex Partnership University NHS Foundation Trust apologised to patients and families for "failing" them. 

Speaking on behalf of the Trust, Eleanor Grey KC acknowledged a series of failings, including allegations of sexual assault by staff. 

Ms Grey also outlined a number of steps already taken to improve safety on the wards, including 1,700 new staff, introducing new technology - like body worn cameras - and more than £6 million spent on removing fixed ligature risks. 

But she went on to question the number of deaths being looked into by the inquiry, saying the investigation would include patients who died of natural causes, such as a heart attack, while living on mental health wards. 

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How long will the Lampard Inquiry take? The chair opened the Lampard Inquiry on September 9 2024, at the Civic Centre in Chelmsford. Her opening statement was followed by impact statements from bereaved families. These finished in November.On April 28 2025, the inquiry will restart for three weeks at Arundel House in London. This will be the first substantive evidence heard in the inquiry and will involve evidence from historic inspections and prosecutions, as well as analysis of coroners' reports and the number of ligatures on wards and absconcions from wards. It will also be the first time we hear from the Chief Executive of Essex Partnership University NHS Foundation Trust (EPUT), Paul Scott. There are then more hearings scheduled throughout the year. After she has examined the evidence, Baroness Lampard is expected to publish her recommendations no earlier than the end of 2026.

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