Inquests & Public Inquiries

Why we need a public inquiry into the deaths of mental health patients in the care of NHS services

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Iftikhar Manzoor

Team Leader

5 min read time
31 Mar 2022

The first inquiry of its kind in England is investigating the deaths of 1,500 mental health patients who were being cared for by NHS services across Essex between 2000 and 2020.

The circumstances of their deaths were “unexpected, unexplained or self-inflicted”.

They included adults, young people and children. They were all highly vulnerable and died while they were inpatients or within months of being discharged.

The Essex Mental Health Independent Inquiry will hear evidence from families, carers, and friends of those who died; as well as staff, former-staff, relevant professionals, and organisations.

The Inquiry is independent of government and the health care system and aims to ‘inform change’.

The initial findings from the inquiry are deeply concerning. Already it has been established that families suffered “unimaginable pain and heartache” and major changes are needed. It has identified:

  • Patients and families were given too little information about treatment, likely length of stay and chances of recovery
  • There were serious concerns about patients’ physical, mental and sexual safety while on a ward
  • There were big differences in the quality of care patients received

The independent inquiry is welcome, but in my experience of representing families where a loved one has died in NHS care I know these same findings in Essex are a reflection of similar circumstances across the UK – that’s very concerning – and that’s why a public inquiry, not an independent one, is needed.

What is a public Inquiry?

Public inquiries are major investigations – convened by a government minister – that can have special powers to compel testimony and the release of evidence.

The justification required for a public inquiry is the existence of “public concern” about a particular event or set of events.

What is the purpose of a public inquiry?

The Government considers “preventing recurrence” to be the primary purpose of public inquiries, where these three main questions need answering:

  • What happened?
  • Why did it happen and what went wrong?
  • What can be done to prevent this happening again?

Inquiries then often draw on experts and policy professionals to help them form recommendations. These are intended to guide the Government and others to make the changes which will prevent recurrence.

Mental health hospital found to provide ‘insufficient care’ following death of teenage girl

Chelsea Blue Mooney with her dad Stephen.
Chelsea Blue Mooney with her dad Stephen.

What families in Essex have experienced is being repeated across the UK with many others suffering and coming to terms with loss and heartbreak.

The family of Chelsea Blue Mooney is just one of them.

Chelsea Blue from Bridlington in East Yorkshire was 17 when she died in the care of Cygnet Hospital in Sheffield.

Her Inquest was held in March this year and the jury heard that she had made over 200 ligature attempts on herself in the 18 months she was a patient during 2019 to 2021. She had also self-harmed through head-banging and swallowing objects.

Her family knew little of what was going on.

She died after a check on her was delayed by two-and-a-half minutes which “contributed to her death” and hospital staff “did not summon help with sufficient urgency”.

The jury concluded Chelsea Blue’s death was partly due to ‘insufficient care, and delays in the emergency response”.

The Coroner has now asked Cygnet Hospital, which provides Child and Adolescent Mental Health Services, to provide detailed information on the total number of ligature attempts for all patients over the same 18 month period to determine if the teenager’s death was an isolated incident or whether a culture of highly vulnerable patients using ligatures is more widespread at the hospital.

The outcome could result in The Coroner issuing a Preventing Future Deaths report to ensure wider lessons are learned with regards to the provision of children and young people’s mental health services.

Chelsea Blue’s family believe the service provided to Chelsea Blue was “underfunded and understaffed”.

The hospital also appeared to have a ‘culture of acceptance of ligatures’ but the family had no idea how many times their daughter was self-harming.

There was no real plan by the hospital to get to the root cause of such behaviour. There are now quite rightly serious questions being asked as to how this hospital ensures the safety of young people placed into its care.

Read more: Mental health hospital found to provide ‘insufficient care’ and ‘inadequate observations’ following the death of a teenage girl

Our team of dedicated inquest solicitors understand that trying to come to terms with the sudden loss of a loved one can be a deeply distressing experience. This is especially true when the exact circumstances of their death is unknown or unclear.

Our expert inquest lawyers are experienced at helping families find out the truth. Not only will we look to obtain answers about the circumstances of how your loved one died, we will try to highlight any failings or acts of negligence which may have contributed to their death. You can start your claim here.


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Why we need a public inquiry into the deaths of mental health patients in the care of NHS services

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