The Lampard Mental Health Public Enquiry

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 the Mid Staffordshire enquiry as one of the most consequential investigations into healthcare governance in recent history.

It is the first statutory public enquiry in England to focus exclusively on deaths in mental health inpatient settings. Its scale, scope and emotional weight are unprecedented. And it has reignited the difficult but necessary conversations about leadership, regulatory compliance, culture and accountability in the NHS.

In this blog, Dr Richard Dune explores how the Lampard Enquiry is reshaping the national conversation on patient safety, governance, and trust within mental health services, and what its lessons mean for the future of NHS leadership and accountability.

Scope and significance

Chaired by Baroness Kate Lampard CBE, the enquiry is investigating systemic failings at the Essex Partnership University NHS Foundation Trust (EPUT) and its predecessor organisations.

Over the past two decades, families have repeatedly raised concerns about deaths, neglect, unsafe ward environments, poor communication and insufficient oversight, with little visible accountability or sustained change.

The enquiry’s remit is broad. It covers areas such as:

• The safety, quality and therapeutic culture of inpatient mental health units

• The use of restraint, seclusion and medication in those settings

• Staff training, workforce composition, leadership and governance

• Communication with families and carers

• The adequacy of regulation, oversight and system-learning

• The systemic factors behind preventable deaths and serious harms.

So far, more than 100 families have given evidence, describing experiences ranging from uninvestigated abuse to falsified records and ignored warnings. These testimonies are harrowing, not only for what they reveal about individual cases but for what they suggest about organisational culture across the wider system.

Notably, the Chair has highlighted that the 2,000 deaths figure is likely a minimum, and that the actual number may be “significantly in excess” of this.

In other words, what we are seeing in Essex may be the tip of a national iceberg.

Funding, parity and the long shadow of under-resourcing

In public statements, EPUT’s chief executive has acknowledged that the Trust has operated against a backdrop of “deep-rooted cultural failures” and two decades of underinvestment in mental health services.

On the funding front: in 2016, the UK Government introduced the Mental Health Investment Standard, a policy commitment to give mental health the same funding priority as physical health.

Yet, as EPUT and other witnesses to the enquiry have noted, parity of esteem remains elusive. Mental health spending accounted for just 8.8 % of the overall NHS budget in 2024-25, according to one advocacy body. The government has pledged additional funds and recruitment of thousands of mental-health-specific staff, but the question remains: Is this enough to meet the scale of the problem?

The enquiry’s emerging evidence suggests: not. Because cultural change, patient safety and workforce resilience cannot be achieved without the scaffolding of sustained investment in infrastructure, training, leadership development and governance systems.

Workforce: The human face of the crisis

The enquiry casts a harsh light on a workforce stretched to breaking point.

One of the most damaging trends has been the long-term decline in registered mental health nurses, and the increasing reliance on healthcare assistants and temporary staff. A former chief nurse told the enquiry that support workers were hired because they were “cheaper”, even though this move compromised standards of care.

EPUT has since taken steps. Over a recent three-year period, the Trust reported a 21% increase in nursing staff and recruited from some 90 different nationalities; nurse vacancy rates have fallen from 19% to 12%. But national professional bodies continue to warn that the NHS needs to increase training places for mental health nursing by 93% by 2031 to meet future demand.

From the enquiry’s perspective, the critical point is this: sustainable safety depends on more than numbers. It depends on continuity, competence, culture, and an environment in which staff feel valued, supported and safe to raise concerns.

Culture, compassion and the “care gap”

Possibly the most striking revelations emerging from the enquiry concern culture, how attitudes and values within organisations can either protect or endanger patients.

One relative described certain wards as “feeling more like prisons.” Others spoke of staff who seemed “too busy filling in forms to talk to patients.”

Evidence has pointed to recurring failures in compassionate care, in listening, and in meaningful communication, all of which sit at the heart of patient safety.

In response, EPUT has committed £14.4 million to improve ward environments, introducing activity coordinators, therapists and peer-support staff with lived experience of mental illness. The Chief Executive himself admitted the wards are “not like the Ritz Hotel,” but said the look, feel, and ethos had “changed dramatically since 2015.”

However, multiple coroners have issued formal warnings to EPUT this year alone, raising concerns that further deaths could occur if improvements are not rapid and embedded.

This tension, between visible progress and persistent risk, captures the complexity of reforming safety culture.

Leadership and governance: From reflection to reform

At its core, the Lampard Enquiry is a story of governance.

It asks fundamental questions about how systems are managed, how risks are escalated, how lessons are learned, and, importantly, how they are acted upon. It exposes the gulf that can exist between what Boards believe is happening and what patients, families and frontline staff actually experience.

The failures at EPUT and elsewhere are not simply a result of individual errors or understaffing. They are, the enquiry suggests, about systemic weaknesses in oversight, assurance and accountability. Weak governance means safety becomes an add-on, rather than an integral part; it means learning is episodic rather than continuous; it means leadership is reactive, not proactive.

Strong governance means more than just compliance with rules; it means fostering a culture of curiosity, transparency, and continuous improvement. As every major healthcare enquiry from Francis (2013) to Ockenden (2022) has emphasised, safety is everyone’s responsibility, but leadership sets the tone.

If history is any guide, the measure of success for the Lampard Enquiry will not just be the number of recommendations delivered, but whether they lead to structural reform that embeds learning into every layer of the NHS, not simply as a policy document, but as lived practice.

National priorities: Patient safety and the NHS learning system

The enquiry aligns closely with national priorities under NHS England’s Patient Safety Strategy and the Learning from Patient Safety Events (LFPSE) framework.
Both emphasise proactive learning, improved incident reporting, and the integration of safety data across systems. Yet these frameworks can only work if culture supports them.

At the national level, organisations such as the Care Quality Commission (CQC) and the Health Services Safety Investigations Body (HSSIB) have emphasised the importance of psychological safety within teams, enabling staff to raise concerns without fear of retribution.

The Lampard Enquiry, however, has already revealed that this ideal remains unevenly realised in mental health services. Deep-seated cultural and governance failures mean the system’s learning loops are weak, inconsistent, and too often reactive.

Turning an enquiry’s recommendations into a transformed learning system will require more than ambition. It will require investment, corporate commitment and regulatory will.

Beyond the enquiry: Building a safer future

While the Lampard Enquiry is rooted in Essex, its implications are national. The issues it highlights, the underfunding, workforce strain, weak governance, and unsafe culture, are not confined to one geographic area or one trust. They echo across mental health services, adult social care, community and inpatient settings.

The challenge now is not merely to complete the enquiry, but to turn the enquiry into improvement. That means:

• Sustained investment - Ensuring mental health services are funded proportionate to need, not just treated as “additional”.
• Integrated governance - Connecting quality, risk and workforce data across providers, commissioners and regulators.
• Education and accountability - Ensuring leaders are trained in clinical governance, human factors and systems thinking.
• Transparency and family involvement - Embedding the voices of patients and relatives into every review, every board meeting and every learning cycle.
• Technology-enabled learning - Using digital systems to track, analyse and share lessons in real time, enabling predictive analytics to target risks before harm occurs.

Patient safety cannot depend on individual heroism or reactive reviews. It must be built into the architecture of every healthcare organisation, from the front-line nurse to the boardroom.

The leadership imperative

Leadership will determine whether the Lampard Enquiry marks a turning point or another missed opportunity. The words spoken by EPUT’s CEO are right to emphasise improvement and hope, but optimism must be matched with measurable action.

Across the NHS (and for every regulated provider), the same applies: good intentions are not enough. Leaders must build teams that are resilient, inclusive, evidence-driven, and so well-supported that raising concerns is a regular part of the process. They must bridge the gap between policy and practice, not just by writing a strategic framework, but by ensuring that governance frameworks are living, breathing systems of accountability and learning.

In short, the future of patient safety in mental health rests on how well we lead and how well we listen.

Conclusion: From lessons to legacy

The Lampard Enquiry has already changed the national conversation about mental health care. It has laid bare the human cost of organisational failure, but it has also created an opportunity for transformation.

If the NHS and its partners act decisively, this enquiry could become the catalyst for a new era of mental health governance, one characterised by transparency, compassion and collaboration.

The measure of success will not just be in the number of recommendations written, but in the number of lives saved.

Key FAQs: What the Lampard Enquiry means

What is the Lampard Enquiry?

It is a statutory public enquiry investigating inpatient mental health deaths in Essex between 2000 and 2023 under the care of NHS trusts in the county.

Why is it called the Lampard Enquiry?

It is named after Baroness Kate Lampard, who was appointed Chair of the enquiry.

Why the focus on Essex?

The enquiry was prompted by campaigning from bereaved families in Essex whose loved ones died while in mental health inpatient care in the county, two of whom were young men, whose deaths triggered national attention.

What is its scope?

 Among other things, it will examine:

• Deaths of inpatients in NHS mental health units in Essex between 2000-2023;

• Deaths within three months of discharge in specific circumstances;

• The culture, governance, oversight and systemic factors behind those deaths.

How long will it take?

The enquiry opened public hearings from September 2024, and while there is no fixed final date, it is expected to continue into 2026 or beyond, with a report possibly published by 2027.

Why this matters to you

For regulated providers, governance professionals and compliance teams in health and social care, the Lampard Enquiry is more than an external event, but a warning and a roadmap. If the failures revealed had been outside your organisation, the root causes (leadership, culture, governance, workforce, safety systems) are exactly the ones you must be mastering internally.

The day when “we’ll learn from it next time” is long past. In the era of just culture, digital compliance systems and multi-agency regulation, organisations must turn the lessons into living systems. That means real-time workforce analytics, incident-to-learning loops, transparent boards, a compassionate culture, open reporting, and sustained investment in people and infrastructure.

Our work: Strengthening governance and compliance through ComplyPlus™

At The Mandatory Training Group, we support organisations to translate regulatory requirements into effective, evidence-based systems of governance, compliance and workforce learning.

Our flagship platform, ComplyPlus™ Software, is an all-in-one compliance and governance solution designed for CQC- and Ofsted-regulated providers. It integrates:

• Learning management (LMS) and training management (TMS) systems;

• Policy and document control for real-time version tracking;

• Incident and audit management for safer reporting and learning;

• Workforce analytics to monitor competence and staffing assurance.

ComplyPlus™ supports a culture of accountability and continuous improvement, helping health and social care organisations align with the CQC’s Single Assessment Framework and national patient safety priorities.

As inquiries like Lampard’s remind us: governance is not simply an administrative function, it’s a moral one.

Through ComplyPlus™, we help organisations move beyond mere compliance and build systems that protect, empower and learn, ensuring that “avoidable” never happens again.

Key references

• HM Government (2025). The Lampard Enquiry (formerly known as the Essex Mental Health Independent enquiry) will examine deaths of mental health inpatients in Essex between 2000 and 2023. 

• The Lampard Enquiry (2025). About the Lampart enquiry. Investigating mental health deaths in Essex.

• Essex Partnership University NHS Foundation Trust (2025). The Lampard Enquiry. 

• Tidman Z. (2025). £5m spent on deaths enquiry still years from completion.