Eight months after its 25-month schedule, Lampard's inquiry began revealing deep-rooted problems in the NHS Mental Health Service in Essex.

More than 2,000 deaths in hospitalized units between 2000 and the end of 2023, the investigation not only failed locally, but also examined whether these issues reflect a broader national problem. This is what has appeared so far.

The inquiry was named after its chairman, Baroness Kate Lampard.

She is a former barrister who oversees the NHS investigation into the abuse of former TV show host Jimmy Savile.

It mainly focuses on the Essex Partnership Trust (EPUT), which was merged in 2017 by the North Essex Partnership Trust.

It is also looking at deaths of patients in Essex, which are operated by 215 facilities operated by private providers and other NHS organizations, such as the NHS NHS Foundation Trust in London.

Former Health Ombudsman Sir Rob Behrens said on average that between 2011 and 2023, 5% of all mental health cases his team received were related to Essex.

He called the failure of nursing “the worst national health agency.”

In the testimony of relatives and friends of the deceased, they appeared individuals from various backgrounds, including chefs, bus drivers, heating engineers, former head teacher and parish councillor.

The survey heard evidence of a long-term decrease in registered mental health nurses and was increasingly relying on healthcare support workers across England. This shift is associated with reduced patient engagement and increased risk.

Former chief nurse Maria Nelligan told the investigation that this is because healthcare support workers are "cheaper" and said the shift has hurt therapeutic care.

Consultant psychiatrist Dr. Paul Davidson describes how employees across England “tick their feet” contribute to workplace culture, with professionals worried about being blamed for “any decision they make”.

EPUT CEO Paul Scott said the trust reduced its use of agents by 30%.

The query also highlights the issues of data collection and transparency.

Deborah Cole of the Charity Survey describes how “full statistics related to people who die in mental health detention”.

"There is good information about suicide deaths, but it is not a useful tool for evaluating the overall way of providing psychological services."

Baroness Lampard warned that the investigation may never find all deaths related to the failure of Essex mental health services.

She said that while the numbers will be published, it is likely to be approximate due to incomplete or inconsistent data.

The investigation examines the complexity of the regulatory system that oversees NHS trusts.

Mr Scott described the number of regulators issued the recommendations -19 total number of -19. This makes it difficult to implement consistent changes, he said.

The Health Minister said in his October 2024 stay away from the investigation that the government intends to reform the regulatory system.

This is a response to the way the trust is checked by the Quality of Care (CQC), called Penny Dash Review, which commented that the framework is too complex.

The Lampard query will consider the role of CQC related to the Essex event.

The three systemic questions asked - staff shortage, poor data and regulatory complexity - have long been worried.

Royal College of Nursing, CQC and the 2023 Public Accounts Commission report all marked staff shortages and burnout.

The 2023 review found that Norfolk and the NHS Foundation Trust lost their impact on patient death data, while the 2025 Health Service Safety Survey Agency (HSSIB) report requires a unified national data set.

After many critical reviews, regulatory reforms are also underway.

While Baroness Lampard is expected to refer to the reports, the investigation is also under pressure to discover new evidence.

Some families have expressed concern about its pace, and so far, there has been limited attention to cultural change.

They also pointed out that protection issues, such as the issue of patients withdrawing from the unit, have received little attention – in view of the recent inquiry about the death of an 18-year-old man, which died while accompanying the EPUT unit.

During the early non-practice stage of the inquiry, only 11 out of 14,000 employees were present.

Baroness Lampard said she would use her legal power to force evidence when necessary.

Mr Scott acknowledged that there was a "closed culture" in EPUT, but said the trust was encouraging openness.

In a recent inquiry about the death of a 16-year-old patient, a manager testified that staff members were reluctant to raise safety issues.

"There are real concerns about the safety of the ward and the staff are too worried about anything," said Brian O'Donnell, clinical director of the Colchester St Aubyn Center.

The family has also raised concerns about delays in the disclosure of evidence, including postponing the investigation meeting on Oxevision, due to the late submission of information by EPUT, an infrared monitoring system.

But Baroness Lampard said she decided to delay the hearing “eput should not be viewed in any way to avoid answering questions about its use of Oxevision.”

In July, the investigation will focus on the two former trusts that constitute the merger of EPUT.

Mr. Scott once said that when he arrived at the Trust in 2000, the combined legacy was “over-focused on governance and management, and insufficient safety for patients”.

Families call for a detailed review of individual deaths, but investigations are more likely to use selected cases to illustrate a broader range of systemic issues such as governance and culture.

Mr Scott apologized for the death in the trust’s care and said he believed EPUT should be a provider of Essex mental health services.