Statement by Dr Geraldine Strathdee, Chair to the Inquiry, 28 March 2022

On 28 March 2022, the Chair to the Inquiry made a statement to media, appealing for the families and loved ones of those who died to come forward.

“I am Dr Geraldine Strathdee, and I am the Chair of the Essex Mental Health Independent Inquiry. This is an independent public Inquiry investigating the deaths of mental health inpatients in Essex between 2000 and 2020.

So far, the Inquiry has kept a relatively low profile. We have concentrated our efforts on getting the Inquiry up and running and gathering evidence. Now we are putting resources into reaching out to anyone affected by mental health inpatient deaths in Essex. It is one of the main reasons I’m talking to you today: to ask for your help in spreading information about the Inquiry and inviting people to give evidence.

I am committed to making sure everyone who wants to participate in the Inquiry can. So, through you, I am extending an invitation to anyone with evidence or anyone who wants to tell the Inquiry about their experience or that of their loved one.

My team will supply you with the Inquiry’s contact and twitter details – please do pass these on.

Until now the Inquiry has not used social media, but we are today launching a Twitter account to help us reach a wider audience. I’d be grateful if you all could flag it in your copy and on broadcast materials.

We know that people may well have moved on from Essex and that given we are covering a twenty-one-year period there are likely many people out there with evidence who haven’t yet heard of us or know how to contact us.

I will also give you an update on the Inquiry’s work and want to make you aware of some of our early findings.

So, first, a bit of background.

This Inquiry is the first public inquiry into mental health that has ever been held in England and which has been commissioned by a Minister. Last August we published our Terms of Reference, which set out the scope of what we are investigating. We held a consultation, and we had a good response. Since then, we have been gathering information about the scale and nature of issues surrounding mental health deaths in Essex.

We have been made aware of some 1,500 individuals who died while they were a patient on a mental health ward in Essex or within three months of being discharged. That’s 1,500 individuals who have lost their lives and countless others who will have been affected by these tragedies.

My team and I will be looking at how Essex compares to other areas in England to see if the issues identified are unique to Essex or evident elsewhere.

Right now, we have very limited information on the 1,500 deaths we’ve been made aware of. Our investigations are ongoing, and we expect to be able to provide a fuller breakdown of this number in the future. But as it stands, for example, we have only been given the cause of death for around 40% of these deaths.

In December last year we began taking evidence from families of those who’ve died, as well as former patients who have received care as inpatients themselves. These families and former patients have shared personal and detailed accounts of their experiences. Meeting with and hearing from them has been intensely moving.

They have told the Inquiry about the care provided to them or their loved one, the journey that led to their loved one becoming an inpatient, the deaths of their loved ones, and their experiences as family members. Most mental health care is provided in the community, so it is important that we understand the full journey of individuals through the system – not just the time they spend on an inpatient ward.

So far, we have heard from 14 families of those who’ve died and people who have been inpatients themselves. And more people are coming forward and booking evidence sessions. These stories will form the backbone of our evidence and will help inform change to how mental health inpatients are cared for.          

While each family’s story, and patient experience, is unique, there are some areas of concern that I have consistently heard:

– A lack of basic information being shared with patients and their families about their care and treatment, their choices, and the plans to get them better.

– Patients and their families have serious concerns about patients’ physical, mental, and sexual safety on the ward

Major differences in the quality of care patients receive both in staff attitudes and in the use of effective treatments

In our evidence we’ve heard details of compassionate, effective care that has transformed patients’ lives and we’ve heard unacceptable examples of dispassionate behaviour that families believe contributed to the death of their loved ones.

I am so very grateful to those who have shared their stories with us. One thing that is so clear to me in listening to families is that while every story is different, everyone I’ve spoken to has had a resolve that in telling theirs they want to help stop any other family from enduring the unimaginable pain and heartache they have.

I would like to invite anyone else who has been affected by a mental health inpatient death in Essex to get in touch with the Inquiry. Anyone wishing to talk to the Inquiry or find out more about evidence sessions can visit our website or contact the Inquiry team. Anyone who comes forward will be treated with respect and have the opportunity to talk with my highly skilled team in a way that feels right for them.  

Over the coming months we also will be inviting staff and professionals who work in mental health inpatient care in Essex to come forward and share their experiences. We will also be taking evidence from organisations who work within the health and care field.

We are offering private and confidential evidence sessions to families, patients, and staff. We will also give people the opportunity to give their evidence in public, should they wish.

Following that I will be making recommendations to the Government on what changes must be made to keep patients safe in mental health inpatient care and to improve the experiences of their families and loved ones. While the focus of this Inquiry is on Essex, many of these recommendations will require improvements at a national level.

It is an unusual event to have a mental health condition so serious that inpatient care is required. Anyone who does need it has the right to be treated with care, compassion, and dignity, and receive quality, evidence-based treatment.

I took on the role as Chair because I want to see real and lasting improvement in mental health inpatient care.

I started my career as a medical practitioner wanting to be a GP. My very first training placement was in a psychiatric institution. I remember walking down the corridor and smelling the awful smells, feeling the despair, seeing people walking like zombies, sometimes shoeless. My very first patient was a young woman, and I was warned not to go into her room because she was violent. But I did go into her room. And she told me why she was violent. She had been physically, sexually, and emotionally abused by family members since she was 10 years old. Now 19, she was in hospital. Her violence occurred when she was physically held down to be given medication, it reminded her of the abuse. She changed my life. I spent the rest of my career dedicated to making practical improvements for people like her.

We all know people who are affected by mental ill health at some stage in their lives and this needs to be treated with the importance and urgency of any critical health condition. It is essential that we get this right and I am grateful to everyone who takes this opportunity to improve mental health inpatient care now and in the future.”

You can read more here: EMHII Press Release

Inquiry Call for Evidence Press Release 10 November 2021

Independent Public Inquiry into deaths of mental health inpatients launches call for evidence.

Families, carers, and friends of inpatients in Essex who died between 2000 and 2020 are invited to give evidence to the independent Inquiry about what happened to their loved one. Anyone else with experience of mental health inpatient services in Essex during the 21 year period are also invited to give evidence to the Inquiry.

10 November 2021: The Essex Mental Health Independent Inquiry has today launched a call for evidence from families and carers of inpatients who died across NHS Trusts in Essex between 2000-2020, as well as anyone else with experience of mental health inpatient services across Essex during this 21 year period.

This is a chance for anyone with experience of mental health inpatient services in Essex to have their story heard and in doing so inform change in the provision of mental health services in the future.  

Dr Geraldine Strathdee, Chair of the Independent Inquiry, said: “I took the job as the Chair of the Essex Mental Health Independent Inquiry because I firmly believe that mental health care can and should do better for those who need it. I know that to improve mental health care we need to listen to those who have experienced it. This is why, hearing directly from families and carers who best knew those that were tragically lost, and patients who have experienced care themselves, is at the heart of this Inquiry. We will then develop clear recommendations for the Essex Trust, and the wider system, so that current and future inpatients receive safe, compassionate, and therapeutic care.

The Inquiry is ready to listen to anyone who would like to speak to us. Anyone who does speak to the Inquiry will be supported, and treated with dignity, care, and respect.”

As well as patients, families and carers, there will also be the opportunity over the coming weeks and months for staff and organisations, as well as anyone else who would like to, to provide evidence. The Inquiry will similarly launch a call to evidence for other groups related to the Inquiry in due course.

The Inquiry intends to publish its findings and recommendations in spring 2023. These recommendations will be essential to taking forward lessons learned to improve mental health services and prevent inpatient deaths in the future, not only in Essex but across the NHS and wider system.

Anyone who wishes to give evidence can contact the Inquiry team by emailing, calling 0207 972 3500 or filling out this webform. The Inquiry team will respond as soon as they can to arrange a session. Sessions will be held in Chelmsford (Essex) and in London and you will be invited to speak to two members of the Inquiry team.

We know that for many people, sharing information about those that have died, or your own experience as an inpatient, will be hugely difficult. The Inquiry team have set out further information on what you can expect from the evidence process in these FAQs and this video. The team will support you throughout and you will have access to specialist emotional support.

Today’s call for evidence follows publication of the Inquiry’s Terms of Reference in August. These were publicly consulted on for 10 weeks from 26th May 2021 and can be found here. After all evidence has been heard, the Inquiry team will begin their preliminary analysis and consider whether further evidence is required to meet its Terms of Reference and enable development of their recommendations for improving patient safety and mental health care.

If you have any questions or would like to discuss the process around giving evidence, or any other aspect of the Inquiry, please email or call us on 0207 972 3500.

You can find more information on the call for evidence here.

Terms of Reference Publication 24 August 2021

The Inquiry has now published its Terms of Reference, which can be found here, along with an Explanatory Note which explains in more detail what the Inquiry will investigate.

The Terms of Reference are based on a 10-week public consultation. The Chair, Dr Geraldine Strathdee, considered all the views expressed throughout the consultation, as well as documentary evidence and feedback on the draft Terms of Reference. Further detail on the process can be found in the Explanatory Note.

Now that the Terms of Reference are set, the Inquiry will move onto gathering evidence. We will shortly be publishing a call for witnesses with full details on how individuals can come forward to tell the Inquiry about their experiences. The team will be hearing from a range of witnesses including families, patients, and others affected by mental health inpatient treatment and deaths in Essex. More details will be available in due course.

Inquiry Press Release 26 May 2021

Independent Inquiry launches consultation with families into Essex mental health deaths
26 May 2021: The families of people who died while receiving inpatient mental health treatment at three Essex hospital trusts are being invited to get in touch with the independent inquiry set up to look into the circumstances of their deaths.

The families and others affected by the deaths are being urged to give their views on the issues to be considered by the Essex Mental Health Independent Inquiry, announced by the Government on 21 January 2021, as part of a consultation exercise launched today. In its announcement earlier this year, the Government said the Inquiry would investigate the circumstances of mental health inpatient deaths which occurred over a 21-year period between 1 January 2000 and 31 December 2020 at the former North Essex Partnership University NHS Foundation Trust (NEPT), the former South Essex Partnership University Trust (SEPT) and the Essex Partnership University NHS Foundation Trust (EPUT), which took over the provision of mental health services in Essex from 2017.

The Inquiry Chair, Dr. Geraldine Strathdee, now wants to hear the views of families and others affected by these events on the issues to be considered by the non-statutory independent Inquiry, as set out by the Government in January. The public will also have the opportunity to shape how the Inquiry obtains its evidence, including whether evidence should be heard in public or private hearings and whether it should be given anonymously or confidentially.

The Inquiry team has begun to reach out to families to invite them to share their views. At the end of the six-week consultation period, the Inquiry will publish its draft terms of reference, and there will be a further opportunity to comment on these terms before they are finalised.

Dr. Strathdee said: “I cannot imagine the intolerable pain and loss that the families of those who died have experienced. I am committed to putting their interests and the interests of those affected by these tragic events at the heart of this Inquiry and I urge them to get in touch with us.

In holding this Inquiry, our aim is to get to the truth about what happened and ultimately to improve care for people experiencing mental ill health and ensure their families have the support they need, at the right time. We want the families and those affected by these events to tell us the issues they want to see included in the terms of reference to ensure it is as robust as possible. It is vital that we understand the course of events and what has gone wrong if we are to improve the system and services and prevent deaths in future.”

The Inquiry’s findings, expected to be published in spring 2023, will be essential to taking forward the lessons learned from these events to improve mental health services and prevent inpatient deaths in the future, not only in Essex but across the NHS and wider system.

In establishing the Inquiry, Nadine Dorries, former Minister for Patient Safety, Suicide Prevention and Mental Health, said she had listened carefully to arguments for a more formal, statutory inquiry but considered that a non-statutory, independent inquiry was the best way to deliver a robust and independent process which will get to the truth and identify improvements in the timeliest way. Accordingly, the format of the Inquiry is not part of this consultation.
Those wishing to share their views on what the Inquiry should consider can do so either via an online survey on its website, by writing to the Inquiry or through a virtual or face-to-face meeting. Anyone wishing to request a meeting or find out more should email the Inquiry at or they can call 0207 972 3500.

After the terms of reference have been finalised, the Inquiry will move on to the next stage in which it will take detailed evidence from families and others affected.

For further information please contact or 0207 972 3500.

Written Statement 21 January 2021

Written Statement to Parliament 21st January 2021