Inquiry into trusts’ care failures probes 1,500 deaths

Geraldine Strathdee, former national clinical director for mental health at NHS England, today announced that the Essex mental health independent inquiry has uncovered evidence of 1,500 individuals who died while a patient on a mental health ward or within three months of being discharged.

This figure is a huge leap from 25 deaths linked to inpatient mental health services in the county which were previously investigated by police in 2018.

The 1,500 deaths occurred over a 21-year period and the team has only established cause of death in approximately 40 per cent of cases – as the now merged Essex Partnership University FT has been “unable” to advise how hundreds of patients died.

The hugely increased number – which Dr Strathdee says is not final – has been identified through trust records, with around 1,376 thought to be directly relevant to the inquiry.

While the focus of the inquiry is on Essex deaths between 2000 and the end of 2020, Dr Strathdee said many of its recommendations will require national improvements and “hold systems’ feet to the fire”.  

It is a public inquiry, but is not a statutory inquiry, and several families are not engaging with it.  Dr Strathdee said if its non-statutory basis had a negative impact on the inquiry’s ability to complete its work, she would “waste no time in going to the minister and ask to be converted”.

Leadership, culture and governance within organisations will come under the spotlight alongside the wider system of care, not just the standards and care provided in inpatient settings, the inquiry’s terms of reference suggest.

Dr Strathdee revealed to HSJ that the inquiry team is keen to “talk to people at all levels” and encouraged former and current trust staff to come forward for sessions, which can be private. 

Evidence will also be collected from professional bodies responsible for oversight, governance, regulation and improvement of safety, quality of care and services, she added.

Announcing the update on the probe, launched last year and aiming to report in spring 2023, Dr Strathdee said: “This is a real opportunity to hold the systems’ feet to the fire and make real improvements in care and treatment for people experiencing mental ill health.”

Initial evidence to the inquiry so far suggests that themes over the two decades include concern over sexual and physical safety of patients, poor communication of patient choice and therapies, alongside “striking differences” in levels of compassion, use of restraints and attitudes of caregivers across the trust’s services.

EPUT formed in 2017 following the merger of two separate trusts providing mental health services in north and south Essex. Dr Strathdee told HSJ the inquiry team was aware “organisational change in particular can be a major period of risks”, with such a transition likely to be scrutinised as part of the probe.

She also did not rule out extending the investigation beyond the end of 2020, but said it would be down to ministers to decide “what they feel is relevant for the future”.

Since the beginning of 2022, there have been a series of prevention of future deaths reports relating to deaths at EPUT during the coronavirus pandemic.

And just this month “gross failures” were identified in the care of 28-year-old Bethany Lilley, who died in 2019, according to a ruling by a coroner who found her death had been contributed to by neglect.

Paul Scott, chief executive of EPUT, said: “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.”

Bosses said the trust has invested £40m in improvements to inpatient and community services in recent years, adding that the new leadership under Mr Scott has ”prioritised patient safety”.