On 25 November 2024 the Lampard Inquiry will hear an Opening Statement delivered on behalf of two bereaved families whose loved ones died in the care of Essex mental health services.
The families of Sophie Alderman and Edwige Nsilu, represented by Bindmans LLP, will tell the Inquiry how they entrusted the care and safety of their loved ones to Essex mental health services but that the relevant services and providers failed to deliver on this, with devastating effect.
Amidst a catalogue of individual and potentially systemic failings, the families will call on the Inquiry to scrutinise concerns about the role of Oxevision cameras on wards, the safety and quality of independent providers of mental health services, and how structural and institutional racism and discrimination may impact the treatment and care delivered to black and racialised patients.
Among the all-too-common failings identified in the care their loved ones received in Essex mental health services, the families will also raise failings in care planning and management, record keeping, and family engagement; serious issues in staffing and training; failures to ensure physical and sexual safety of vulnerable patients; and failures in responding to serious incidents and deaths, and in learning lessons to prevent future deaths.
Sophie Alderman died in 2022 aged just 27 under the care of Essex Partnership University NHS Foundation Trust (EPUT) whilst detained on Willow Ward at Rochford Community Hospital. At the Inquest into Sophie’s death her family heard that repeated restraints and staff shortages were common on Willow Ward.
Sophie’s family will ask the Inquiry to consider their concerns that Oxevision cameras installed in Sophie’s bedrooms whilst under the care of EPUT may have caused her distress and harmed her mental health, yet it failed to keep her safe shortly before her death. They will urge the Inquiry to consider concerns the impact of sustained surveillance on vulnerable patients, patient’s consent and the safety and efficacy of Oxevision.
Edwige Nsilu died in 2020 aged only 20 while detained in the care of St Andrew’s Healthcare, an independent mental healthcare provider in Essex. During Edwige’s inquest her family heard evidence about staff failures to update her risk assessment and care plan and delays in the emergency response when Edwige was found unconscious. The two nurses who found her said that they believed that Edwige was ‘feigning unconsciousness’ and they left her on the floor. The Inquest concluded that Edwige’s death was contributed to by neglect.
The Nsilu family will urge the Inquiry to consider their concerns that structural and institutional racism impacted Edwige’s care, and her death, as with the care and treatment experienced by other black and racialised patients. Edwige’s family will also raise serious concerns about the quality and safety of independent mental health providers.
This is the first public inquiry into mental health services that has ever been held in England and established by a Minister and it is the product of sustained efforts by dedicated campaigners calling for truth and urgent changes to mental health services.
On calling for change, Tammy Smith, who is Sophie Alderman’s mother, said:
“I believe Sophie’s death was entirely avoidable – a fact that breaks my heart, and makes grieving harder – but there is an opportunity to ensure that Sophie’s death is not in vain, and that no family shares this pain. In order for that to happen, lessons must be learnt so that further deaths are prevented.”
Of her daughter Sophie, Mrs Smith said:
“She was such a funny person and developed cheeky sarcasms which always kept me on my toes. Sophie is hugely missed by so many of her loved ones.”
Of Oxevision, Mrs Smith said:
“It is difficult for me to comprehend how such an intrusive system which might have worsened Sophie’s paranoia and mistrust can be justified when it did not protect her. I also hope the Inquiry will consider the reliance on technology, like Oxevision, to keep patients safe.”
On calling for change, Joyce Nsilu, who is Edwige’s mother, said:
“We still hope for changes for all those under the care of Essex mental health services and their families. We want health services and providers to be open and transparent, not to keep secrets, and to communicate with the parents and families of patients.”
On Edwige, Mrs Nsilu said:
“Edwige was loving, warm, nurturing, gorgeous and strong. We called her the mother of all children because she had a deep love for every single person.”
On the role of racism in her daughter’s death, Mrs Nsilu said:
“I strongly believe that my daughter experienced mistreatment because she was black and because of racism.”
Rachel Harger of Bindmans LLP said:
“This public inquiry would not be happening without the powerful and tireless campaigning of bereaved families over many years for scrutiny of the deaths of not only their own loved ones, but of over 2,000 more vulnerable persons.
“The families of Sophie Alderman and Edwige Nsilu add their voices to those of many bereaved families calling for a rigorous investigation by this inquiry and recommendations which may lead to lasting change in mental health services, to ensure that vulnerable people receive the compassionate and safe care that they deserve and to break a cycle of failings which have led to so many avoidable deaths.”
NOTES TO EDITORS
The families are represented by Rachel Harger, Khariya Ali and Alfie Meadows of Bindmans LLP and by Brenda Campbell KC of Lincoln House Chambers and Tom Stoate of Doughty Street Chambers.
Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.
• Edwige Nsilu, 20, died on 5 February 2020 after being found unresponsive at St Andrew’s Healthcare Essex. An inquest concluded that neglect contributed to her death. Media release.
• Sophie Alderman, 27, died on 19 August 2022 under the care of Essex Partnership University NHS Foundation Trust (EPUT) whilst a detained inpatient on Willow Ward, Rochford Hospital, Essex. Media release.
Lampard Inquiry Background
The Lampard Inquiry is a re-launch of the work of the Essex Mental Health Independent Inquiry.
That earlier iteration was established in 2021 to investigate the deaths of at least 2,000 mental health inpatients who passed away either while patients on an Essex mental health ward, or within three months of being discharged, between 2000 and 2020. The then Essex Mental Health Independent Inquiry was established on a non-statutory basis and therefore lacked powers to compel witnesses to attend and to give evidence under oath.
In January 2023, the then-chair of the inquiry published an open letter stating that the inquiry would be unable to meet its terms of reference with a non-statutory status. In the letter (available here), Dr Strathdee detailed that despite writing to over 14,000 staff, only 11 agreed to attend an evidence session.
On 27 October 2023, the Department of Health and Social Care issued a formal notice of conversion, confirming the Inquiry’s new statutory status.
A revised Terms of Reference was published on 10 April 2024, which widened the time investigatory timeframe of deaths to between 1 January 2000 and 31 December 2023. It also confirmed that it would cover those who died as inpatients receiving NHS funded care within the independent sector, as well as those in NHS units.
The Lampard Inquiry held its first public hearing between 9 and 25 September 2024 which heard Opening Statements to the Inquiry and commemorative and impact evidence from Core Participants.
CP families were warned by Baroness Lampard at that hearing to expect that the Inquiry will uncover “significantly in excess” of 2,000 deaths and that the Inquiry may never be able to say for certain how many people within the remit of the Inquiry.
Lampard Inquiry – November Hearing
The Inquiry will now hold a virtual hearing from Monday 25 November to Wednesday 27 November 2024. The hearing will start at 10am each day. It will provide a further opportunity for the Inquiry to hear Opening Statements and impact and commemorative accounts from families and friends of those who have died. The running order (i.e. the timings and schedule) can be viewed here.
The Hearing can be watched on the Inquiry’s YouTube Channel where the broadcast will be subject to a 10-minute delay.