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19 Apr 2023

SANE backs families’ call for statutory public inquiry into patient deaths

Marjorie Wallace, founder and chief executive of SANE, has written an open letter to Steve Barclay, Secretary of State for Health and Social Care, backing families’ calls to convert the Essex Mental Health Independent Inquiry into a statutory public inquiry.

The ongoing inquiry, which is investigating up to 2000 deaths of inpatients across NHS trusts between 2000 and 2020, is already the country’s largest investigation into mental health services.

The upgrade would give the inquiry legal powers to compel witnesses to give evidence, providing the answers families have long campaigned for, and start the process of much-needed change to mental health services in Essex and across the country.

Significant failings

Established in 2021, the non-statutory, independent inquiry followed the Parliamentary and Health Service Ombudsman’s report “Missed opportunities: What lessons can be learned from failings at the North Essex Partnership University NHS Foundation Trust” in June 2019, which found that there were significant failings in the care and treatment of two vulnerable young men who died shortly after being admitted to North Essex Partnership University NHS Foundation Trust.

The Essex Mental Health Independent Inquiry is looking into the circumstances of in-patient deaths at the former North Essex Partnership University NHS Foundation Trust, the former South Essex Partnership University Trust and the Essex Partnership University NHS Foundation Trust, which took over responsibility for mental health services in Essex from 2017. It covers 1 January 2000 to 31 December 2020.

Areas of concern

The inquiry chair, Dr Geraldine Strathdee, has said the investigation has heard so far details of compassionate, effective care that had transformed patients’ lives – as well as unacceptable examples of dispassionate behaviour that families believed had contributed to the death of their loved one. She identified some common areas of concern:

  • A lack of basic information being shared with patients and their families about their care and treatment, their choices, and the plans to get them better.
  • Patients and their families voicing serious concerns about patients’ physical, mental  and sexual safety on the ward.
  • Major differences in the quality of care patients receive – in the attitude of staff and in the use of effective treatments.

In July 2022, Dr Strathdee, issued an urgent appeal to staff to come forward, to share their experiences and insights.

However, by January this year, she revealed that of the over 14,000 staff written to, the inquiry had received only 11 who have said they would attend an evidence session. Due to the poor staff engagement, it is her view that the inquiry will not be able to meet its terms of reference with a non-statutory status.

Open letter to Rt Hon Steve Barclay

Dear Secretary of State,

Essex Mental Health Independent Inquiry

I am writing to you to urge that you upgrade the current Essex Mental Health Independent Inquiry to a statutory public inquiry with the power to compel witnesses and have evidence given under oath.

Since its inception SANE has worked closely with the families of patients receiving psychiatric care, to support the vital part they play in such care. This has involved analysis of the reports of inquiries following tragedies, and we know how important such inquiries have been in bringing about change.

SANE has supported the call for a full inquiry into the deaths of patients under the care of Essex Partnership University Trust and its predecessors, deaths which have now been revealed to total up to 2,000 between 2000 and 2020 – a truly tragic and shocking number.

This is why we are very concerned that the Chair of the current inquiry has said that it does not have the powers to meet its terms of reference. This reflects the fact that, reportedly, only 11 out of 14,000 former or current members of staff have agreed to give oral evidence, effectively stalling the inquiry’s work.

We know that more than 80 bereaved families are refusing to engage with the inquiry because it is not statutory, and SANE understands their position. These families have been hugely frustrated by the absence of progress and saddened by the continuing deaths of mental health patients in the county of Essex.

We believe that the current inquiry must be put on a statutory footing. Without this, Melanie Leahy, whose son Matthew died in 2012 in a mental health unit in Essex, and all the other families who have lost sons, daughters, fathers and mothers will be denied answers that would be common courtesy and require minimal resources. Nor will it be possible to have an adequate picture of all the factors involved in such a large number of individual deaths.

A statutory public inquiry would not only provide answers for all the families but should enable change in the provision of mental health services that could save future lives.

It has been reported that you recognise that the current situation is unsustainable after meeting with Members of Parliament representing Essex constituencies, who back the call for a statutory public inquiry. I very much hope that you will accept the case for such an inquiry and take steps to establish one.

Yours sincerely,

Marjorie Wallace CBE

Further reading:

Essex mental health inquiry: Staff could be compelled to give evidence – BBC News

Essex Mental Health Independent Inquiry

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