“Lack of candour” prevalent following deaths at NHS mental health trusts in Essex, Lampard Inquiry hears
15 May 2025
Garden Court North’s Anna Morris KC and Lily Lewis represent INQUEST, whose Director Deborah Coles (pictured) gave evidence to the Lampard Inquiry on 12 May 2025. Credit: Lampard Inquiry / YouTube,
NHS Mental Health Trusts have repeatedly tried to prevent coroners from issuing Prevention of Future Deaths reports following the deaths of thousands of mental health patients in Essex, the Lampard Inquiry has heard.
In her evidence on the 12 May 2025, Deborah Coles, Director of INQUEST, said that a pattern of “reprehensible” behaviour which was “played out across the country” but “exemplified” in Essex, where the NHS mental health trusts’ “lack of candour” necessitated a statutory public inquiry.
Garden Court North’s Anna Morris KC and Lily Lewis (instructed by Bhatt Murphy Solicitors) are representing INQUEST, who have been designated Core Participants in the Inquiry.
The Lampard Inquiry, chaired by Baroness Kate Lampard CBE, is investigating the deaths of more than 2,000 people being treated by NHS mental health services in Essex between 2000 and 2023.
The Inquiry heard evidence from Essex Partnership University Foundation NHS Trust (EPUT) and other relevant organisations from 28 April until today (15 May 2025).
In 2021, EPUT was prosecuted in relation to health and safety failings concerning ligature points and fined £1,500,000.
Institutional defensiveness
Speaking to the BBC after giving evidence, Ms Coles said: “Trusts are more concerned with protecting their reputations than acknowledging the failings in their systems and processes and trying to do something meaningful about it”.
She pinpointed a “culture of defensiveness”, saying that “NHS trusts try and argue with coroners that [the Trusts have] already implemented changes and that a report is not necessary,” she said, adding that this approach undermined potential for local and national learning.
Concerns around the institutional defensiveness of Trust’s was also emphasised by Sir Robert Behrens CBE, former Parliamentary and Health Service Ombudsman (PHSO), in his evidence on 6 May 2025.
He said that the PHSO’s Broken Trust Report 2023 “found cases of serious failure and avoidable death” which were “very worrying”. He described the Trusts’ handling of mental health deaths as “the NHS at its worst”.
Sir Robert also drew attention to the difficulties in overseeing recommendations after an Inquiry’s conclusion, raising the PHSO’s reliance on Regulators such as the Care Quality Commission (CQC).
INQUEST has made repeated calls for a National Oversight Mechanism, which would ensure coroners’ Prevention of Future Death Reports and Public Inquiry recommendations are followed up on.
The Lampard Inquiry will resume its hearings at Arundel House, London, on 7 July 2025.
Anna and Lily are instructed by Charlotte Haworth Hird and Amy Ooi of Bhatt Murphy Solicitors.
Additional media
The Lampard Inquiry – April Public Hearings Running Order
BBC – Charity boss slams ‘reprehensible’ health trusts
ITVX – ‘Falsifying safety records well known at Essex mental health trust’, Lampard Inquiry told
BBC – ‘The NHS at its worst’, ex-ombudsman tells inquiry
For further information, please contact Alex Blair, Communications Manager at Garden Court North Chambers: ablair@gcnchambers.co.uk
