What is the Essex Mental Health Inquiry?

Simon Edward • Feb 17, 2023

In this post, we explain the Essex Mental Health Inquiry – an investigation into the deaths of nearly 2,000 mental health patients between 2000 and 2021.

In this post, we explain the Essex Mental Health Inquiry – an investigation into the deaths of nearly 2,000 mental health patients between 2000 and 2021.

Between 2000 and 2021, close to 2,000 patients died in a mental health ward in Essex, or within three months of discharge.


An independent inquiry into these events was launched in 2020 – but now its chair, Dr Geraldine Strathdee, is urging the government to make it statutory.


Before we take a look at the scope of the inquiry, let's break down what these terms mean.


What is a public inquiry?

Public inquiries into events of major public concern or public policy issues are a frequent occurrence in public life, but they can often seem to drag on in the background. At the time of writing, there are 14 in progress. These look at topics ranging from the UK government's COVID-19 response to the Edinburgh Trams project.


Inquiries are often lengthy processes that involve years of information-gathering and analysis. Most famously, the
Bloody Sunday Inquiry took 12 years and cost somewhere in the region of £400 million.


They set out to establish what happened, who is responsible and what can be learned for the future. It's also been
argued that they provide catharsis for the people involved and reassurance to the public.


It's important to remember that public inquiries aren't court cases. While the findings of an inquiry can lead to criminal proceedings, the inquiry itself aims to establish responsibility – not guilt.


One of the biggest ramifications of this is that the inquiry's recommendations are in no way legally binding. The government or public body in question can implement the recommendations or not as they see fit.


What are the differences between statutory and non-statutory inquiries?


Statutory inquiries are usually held under the
Inquiries Act 2005. They have to be called by a government minister, who appoints a chair. The chair leads the inquiry and is responsible for writing up and publishing the inquiry's findings and recommendations.


A non-statutory inquiry such as the Essex Mental Health Inquiry has also been established by a government minister – in this case ex-Health Minister Nadine Dorries – but not under an Act of Parliament.


This may seem like a slight distinction, but it has two key implications for the running of an inquiry.


First, non-statutory public inquiry procedures are more flexible than statutory ones. This means it's easier to gather "sensitive" information – evidence relating to the intelligence services, police or military, for example.


Secondly – and most importantly for the Essex Mental Health Inquiry – non-statutory inquiries don't have the power to compel witnesses to give evidence under oath.


This is a stumbling block if core participants or witnesses aren't forthcoming – and this is exactly what's happening in the case of Essex.


What do we know so far?


The Essex Mental Health Inquiry was launched as a non-statutory inquiry in 2020 after a petition was signed by 100,000 people. But on Friday 13 January, Dr Strathdee published an open letter which revealed that only 11 out of 14,000 staff were willing to provide evidence.


Were the inquiry to be made statutory, the team would have the ability to compel people to give evidence under oath.


Strathdee has warned that the inquiry is currently unable to meet its own
Terms of Reference – its stated aim to "review the care and treatment pathways and the circumstances and practices surrounding the deaths of mental health inpatients". She argued that staff evidence was "fundamental to the inquiry".


The initial petition was set up by Melanie Leahy. Her son Matthew died in 2012 while an inpatient. She told the BBC: "I want to be able to say to Essex that your loved ones are safe when they come under the care of Essex mental health services. Give us our statutory public inquiry."


At the time of writing, Leahy and the inquiry have some support from Essex MPs – both John Whittingdale (Maldon) and Priti Patel (Witham) have asked to meet Steve Barclay, the current Health Secretary.


On top of this, 93 Essex families are campaigning for the inquiry to be upgraded to statutory status.

What is the inquiry seeking to find out?


The inquiry is aiming to uncover the key factors leading to the deaths of mental health inpatients. This is likely to include conclusions regarding the governance of the NHS bodies in question along with recommendations for both them and the NHS as a whole.


The scope of the inquiry is necessarily broad, given the sheer number of deaths being investigated. For this reason, it's hard to say when its findings and recommendations will be published – especially given that it's been pushed back from spring 2023.


Some bereaved families have gone public about their losses – these include Melanie Leahy and
Julia Hopper. Hopper's son Christopher Nota died in 2020 only a few days after being discharged from Essex mental health services. Hopper has said that "a million chances were squandered" to help her son.

Key points

  • The inquiry is investigating deaths in several settings: the former North Essex Partnership University NHS Foundation Trust, the former South Essex Partnership University NHS Foundation Trust and the Essex Partnership University NHS Foundation Trust.
  • It will cover a 21-year period – from 1 January 2000 to 31 December 2020.
  • Key members of the inquiry are Dr Geraldine Strathdee OBE (chair), Kate Ward (secretary) and Catherine Turtle (inquiry legal advisor).
  • At the time of writing, we don't know when the report will be published as it's been pushed back from spring 2023.


For more information visit
the inquiry website.


Have you been affected by the events in Essex? Do you want to give evidence at the inquiry but need legal guidance?


Please don't hesitate to
get in touch for a free, sensitive, no-obligation consultation. Our team of experienced public inquiry solicitors would be more than happy to help.

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