Lampard Inquiry: Five things we've learned so far

After nearly two years of evidence, the Lampard Inquiry is uncovering serious and long-standing failures in Essex mental health services - failures which the inquiry chair says are also being identified in other parts of the country.

More than 2,000 deaths over 24 years are under scrutiny, but the inquiry says it may never know the true total.

Originally due to finish this year, it has been extended by at least 12 months because of the scale of the issues.

So what are five key things the latest evidence has revealed?

The inquiry heard emotional testimony from the mothers of two autistic young women who spent time at the St Aubyn Centre in Colchester.

Lisa Wolff said placing her daughter, Abbigail Smith, in the unit was like trying to "fit a square peg in a round hole" and that her autism was "ignored". She said staff denied Smith was autistic despite a diagnosis.

It heard Elise Sebastian and Smith were bullied by other patients. Victoria Sebastian said her daughter was punched for wanting to get better.

The inquiry also heard how other patients were failed. Channel Four's undercover Dispatches reporter Dawn Lowe described a woman with MS who remained in a mental health unit because suitable ground-floor accommodation in the community could not be found.

Witnesses described a culture at Essex Partnership University NHS Foundation Trust (EPUT) in which some staff were disengaged from patients. Former nurse Stuart Ayris called staff apathy "astonishing".

He said ward staff often remained in offices with doors closed because "it felt safer for them". He later said he became "ashamed" of the lack of engagement with patients.

Sebastian said doctors dismissed her daughter's physical health problems as being "in her head" and failed to investigate them.

Lowe said she was employed as a bank healthcare assistant without an interview, needing only a Covid vaccine and DBS check. She said she completed three in-person courses before starting, while agency staff completed fewer.

She added that she witnessed agency staff falling asleep, although some were sent home for doing so. Ward manager at Basildon Mental Health Unit, Chloe Cawston, said staff sleeping at work had been "a feature throughout her whole career", although it was less common now.

Lowe also said she saw agency staff on mobile phones and some who could "barely communicate in English". She said they failed to engage with patients, staff communication was sometimes "combative and unhelpful", and agency workers failed to immediately raise an alarm during one emergency.

She described it as "one of the most difficult jobs I have done", with understaffed wards in "chaos" and staff often unable to take breaks.

Several staff who spoke up said their concerns were ignored or that they faced repercussions.

Cawston said safety issues she raised before the death of Bethany Lilley in 2019 were not acted on.

Ayris said writing a critical report after a patient's death in the mid-to-late 2000s affected his career and led to him being moved into an administrative role.

Current clinical manager Brian O'Donnell said he was treated as a "trouble-maker" and had IT privileges removed, after raising concerns about low staffing levels at an inquest.

He also said he was told 4,000 staff safety reports needed to be "gone" while the inquiry was under way.

EPUT told the BBC that "all incidents and concerns are taken seriously" and investigated, and that a "huge amount of work had taken place" to build a culture where staff are "encouraged" to report concerns.

More on the Lampard Inquiry

• What is the Lampard mental health Inquiry?
• NHS manager says trust wanted 4,000 reports 'gone'
• 'Don't let blood be on your hands', mother tells inquiry

Whether cameras should be allowed to record where patients sleep has been another focus of the inquiry.

Oxevision, an infrared monitoring system used by 40% of NHS trusts including EPUT, tracks changes in behaviour and vital signs. Baroness Lampard examined its use as she considers whether interim recommendations are needed in October.

Cawston said the technology was "good in terms of the monitoring of physical health".

However, consultant nurse and expert witness Jill Archibald said she had found no direct link between Oxevision and improved care in cases she reviewed. The inquiry also heard it had sometimes been used as a substitute for patient observations, despite that not being its intended purpose.

Healthcare assistant Beverley Switzer said some patients covered cameras with paper or stickers.

Two University of Oxford statisticians said studies used to justify bringing in the technology did "not provide strong independent evidence of improved patient safety, acceptability or cost effectiveness".

LIO Health, which runs Oxevision, recently said: "Technology has a vital role to play in supporting safer inpatient mental health care, an area without any medical device technology until Oxevision."

It added its impact had been "significant".

"In one trust alone, the technology has helped staff in responding to 1,453 safety incidents over a four-year period," the company added.

Baroness Lampard said there had been delays in EPUT producing documents.

The inquiry heard one collection had been stored by a predecessor organisation in a building contaminated with asbestos, meaning the records had to be destroyed.

Former chief executive Paul Scott admitted the trust had "under-estimated" the work involved in meeting the inquiry's demands, but said EPUT was now expected to spend £30m on the process.

Baroness Lampard said Essex was not alone, adding that "systemic failings in mental health inpatient care were being identified in other parts of the country". She said she was monitoring developments at Tees, Esk and Wear Valleys NHS Foundation Trust, which has been told it must face a public inquiry.

EPUT chief executive Trevor Smith said: "As the inquiry progresses, there will be many accounts of people who were much loved and missed over the past 24 years, and I want to say how sorry I am for their loss.

"All of us across healthcare have a responsibility to work together to improve care and treatment for all... and to build on the improvements that have already been made over the last 24 years."

The inquiry will continue in October, with further hearings until the autumn of 2027.

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