The first inquiry of its kind held in England is investigating the deaths of 1,500 people who died while being cared for as patients of NHS mental health services in Essex.
They died in circumstances that were “unexpected, unexplained or self-inflicted” between 2000 and 2020 and while they were receiving treatment from NHS mental health trusts that for years had faced persistent complaints of providing poor care.
The 1,500 cases include children and young people as well as adults. All 1,500 were highly vulnerable after experiencing a serious deterioration in their mental health and died either while they were an inpatient in a mental health facility or within three months of being discharged.
Dr Geraldine Strathdee, who is leading the inquiry, said some of the evidence she and her team had collected so far was distressing and included “unacceptable examples of dispassionate behaviours that families believe contributed to the death of their loved ones”.
Unveiling initial findings from her inquiries so far, Strathdee said families had suffered “unimaginable pain and heartache” and major changes were needed.
She has so far identified three recurring failings at the now-defunct North Essex and South Essex mental health trusts and at Essex Partnership University NHS trust. This was formed in 2017 by a merger of the previous trusts and supplied the details of the 1,500 cases now being looked into. They are:
Serious concerns about patients’ physical, mental and sexual safety while on a ward, including claims of sexual harassment and sexual assault.
Big differences in the quality of care patients received, “both in staff attitudes and in the use of effective treatments”.
Patients and their families being given too little information about their treatment, likely length of stay and chances of recovery.
Strathdee, a leading psychiatrist and former national clinical director of mental health care at NHS England, is looking into 21 key areas of care. They include trusts’ management of patients’ risk of self-harm and suicide, use of restraint, deployment of drugs and management of drug regimes, and how well they dealt with patients’ physical health needs.
The inquiry was established in January 2021 by Nadine Dorries, the then minister for mental health, as a non-statutory independent inquiry. She acted amid ongoing concern about the quality and safety of mental health in Essex and after an investigation in 2019 by Rob Behrens, the parliamentary and health service ombudsman, which found numerous failings in the events surrounding the deaths of 20-year-old Matthew Leahy and another young man named only as Mr R.
Inquest, which investigates deaths in custody and residential mental health care, said the deaths amounted to “a national scandal”.
Selen Cavcav, a senior caseworker at the charity, said: “Sadly we are not shocked by the findings because we have long known how unsafe these services are, and the huge number of people who have been impacted by that.
“The scale of this problem and the details of many deaths of people under the care of Essex mental health services are nothing short of a national scandal.”
Some families with a relative who died while or after receiving mental health care in Essex have refused to participate in Strathdee’s inquiry because it is not a full public inquiry.
Cavcav said: “We continue to believe that only an inquiry with more teeth, namely a statutory public inquiry, will restore trust and ensure the broad-ranging scrutiny needed to tackle the unacceptable death toll of people under the care of Essex mental health services.”
But, she added: “Essex is not alone in having high numbers of preventable deaths of mental health patients, in a country whose mental health system has long been failing countless people in need.”
In a brief statement, Paul Scott, the chief executive of the merged Essex trust, did not apologise for failings or lives lost. He said only that “we continue to support the ongoing inquiry and encourage service users, family, carers and staff to share their experiences with the inquiry team so they have a full picture to draw on to make their recommendations.”
Strathdee is appealing for former patients and for relatives of those who died to talk to the inquiry, which has set up a Twitter account to encourage people to share their experiences.
In the UK and Ireland, Samaritans can be contacted on 116 123 or email jo@samaritans.org or jo@samaritans.ie. In the US, the National Suicide Prevention Lifeline is 1-800-273-8255. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at www.befrienders.org.
