Lampard Inquiry: Irwin Mitchell supporting those affected by the death of a loved one while under the care of Essex mental health services
Irwin Mitchell is instructed by a bereaved relative with core participant status in the Lampard Inquiry.
Further to the death of her son in a mental health in-patient setting, the core participant has instructed Irwin Mitchell to help her participate in the Inquiry, provide evidence about her and her son’s experience with Essex mental health services, and uncover the truth about Essex mental health in-patient deaths.
What is the Lampard Inquiry?
The Lampard Inquiry is a statutory, public inquiry, investigating mental health deaths in Essex covering a period from 2000 – 2023.
The first public hearings began in September 2024, hearing opening statements as well as powerful and moving commemorative and impact statements from bereaved family core participants. Evidence has most recently been heard, from 13 to 28 October, 2025, in the fourth round of public hearings.
The hearings have so far heard evidence from core participant bereaved family members, explaining the harrowing events suffered by their loved ones leading to their tragic deaths whilst in-patients or recent in-patients of mental health Trusts in Essex.
What is a core participant?
A core participant is an individual or organisation granted special status in an Inquiry, with status to participate in the process. These public hearings have also heard evidence from independent experts, relevant stakeholders from organisations such as the charity INQUEST and the Parliamentary and Health Service Ombudsman, as well as senior management from Essex Partnership University Foundation Trust (‘EPUT’)
The recent October 2025 hearings have heard evidence about the use of the controversial, vision-based monitoring system, ‘Oxevision’, and further evidence from bereaved family member core participants.
Why is this Lampard Inquiry important?
The Lampard Inquiry is the first and only of its kind; an inquiry into mental health services. It's estimated that more than 2,000 people have died whilst mental heath inpatients in Essex between 2000 and 2023. Sadly, an exact number of the people who have died whilst under the care of Essex mental health services is unknown and is likely to never be known.
The Lampard Inquiry is a result of tireless and extensive campaigning by families to uncover what has gone wrong in provision of mental health services in Essex resulting in the most tragic outcomes.
The evidence so far
The evidence heard so far in public hearings has uncovered troubling and tragic trends in the issues faced repeatedly by patients and family members receiving mental health care.
This includes issues such as:
- A lack of family involvement in a patient’s care;
- A ‘revolving-door’ inpatient admissions;
- Rushed and unplanned discharges from admission;
- Worrying attitudes towards self-harm, neuro-divergency, and substance misuse.
Many bereaved family core participants have also described the sometimes re-traumatising and difficult impact of participating in inquest proceedings, sometimes without legal representation.
The April hearings heard Deborah Coles of INQUEST make powerful representations for a national oversight mechanism that would create independent and national oversight of Prevention of Future Death Reports to help spot trends, centrally record issues raised by coroners in these reports, and keep track of responses given by institutions.
What is next?
Counsel to the Inquiry (‘CTI’), the barrister who advises the Inquiry’s Chair and leads the questioning of witnesses, has updated the public that a further three weeks of hearings will be held in October 2026 to continue to hear key evidence, with closing submissions being pushed back to November 2026.
CTI also confirmed that the Lampard Inquiry’s ‘Investigative Strategy’ will soon be made available to core participants. This strategy will provide further information as to how the Lampard Inquiry intends to assess what ‘illustrative cases’ it will be focusing on, in order to identify key issues and themes to investigate further.
This Investigative Strategy will also provide further information as to how the Inquiry will seek to assess compliance with reviews and recommendations already made to Essex mental health services, following processes such as internal and independent investigations and inquests.
This is a key concern for many bereaved families, and lived experience core participants who have repeatedly raised concerns about Essex mental health services not learning lessons following tragic inpatient deaths.
Conclusion
Ultimately, the purpose of an inquiry is to understand what has gone wrong, and what changes can be implemented to avoid such tragedies in the future.
The Lampard Inquiry has committed to setting up a “Recommendations and Implementations Forum” to identify the best way to implement recommendations made by the Chair to ensure meaningful and lasting change to mental health services both locally and nationally.
The hope is that lives will be saved by such recommendations and that no family will have to go through what, unfortunately, so many families in Essex already have.
Find out more about Irwin Mitchell's expertise in supporting families through public inquiries at our dedicated proteting your rights section.
