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The Lampard Enquiry is the first statutory public investigation into deaths in NHS mental health inpatient care, examining more than 2,000 cases in Essex. In this blog, Dr Richard Dune explores how its findings are reshaping the national conversation on patient safety, governance, and accountability across the NHS. He highlights how systemic failures in leadership, culture, and oversight have driven the need for reform, and why the enquiry’s lessons must translate into lasting change through stronger governance frameworks, digital compliance systems, and compassionate, learning-driven leadership.

When the Lampard Enquiry was formally announced in 2023, few anticipated just how far-reaching its findings would become. Now, as evidence continues to unfold, it is increasingly evident that this enquiry, examining more than 2,000 patient deaths across mental health services in Essex, will stand alongside the Francis Report and...

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By Dr Richard Dune

DNACPR mistakes in care: Governance, training and compliance - How poor DNACPR and resuscitation decisions highlight the urgent need for robust governance, digital compliance systems, and statutory training in care settings. "Action should be taken." - Coroner Darren Stewart OBE The recent BBC report into the tragic death of 74-year-old...

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By Dr Richard Dune

Is abolishing NHS England the reform we need? - The Mandatory Training Group UK -  On 13 March 2025, the UK government made a historic announcement: NHS England will be abolished and its functions reintegrated into the Department of Health and Social Care (DHSC). Framed as the largest governance overhaul...

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By Dr Richard Dune
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