Consultation on Terms of Reference

We have heard from former patients, families, and others affected by mental health inpatient treatments and mental health inpatient deaths in Essex. Based on these views and the issues set by the former Minister for Patient Safety, Suicide Prevention and Mental Health we have produced the  Terms of Reference. These are published below with an explanatory note.

The consultation ended at 5pm on Tuesday 3 August 2021.


Terms of Reference

The Essex Mental Health Independent Inquiry will review the care and treatment pathways and the circumstances and practices surrounding the deaths of mental health inpatients.

The Inquiry will investigate the deaths which took place in mental health inpatient facilities across NHS Trusts in Essex between 1 January 2000 and 31 December 2020. It will draw conclusions in relation to the safety and quality of care provided locally and nationally to mental health inpatients.

The Inquiry intends to publish a report in spring 2023. The Inquiry will provide regular updates on its progress and may highlight matters requiring urgent attention.

The issues the Inquiry will consider are:

  1. key factors that led to the deaths of mental health inpatients who were under the care of the Trust(s), including care and treatment pathways;
  2. the role, involvement, and communication with the patient and their families, carers, or other members of their support network in the patient’s care;
  3. the culture, leadership, and governance that may have impacted on the ability of the Trust(s) to improve inpatient safety, treatment, and care and reduce inpatient deaths;
  4. the quality of previous investigations into mental health inpatient deaths, the conclusions and recommendations of those investigations, and the response by the Trust(s) and the wider system;
  5. recommendations for the Trust(s) to ensure action is taken so that current and future mental health inpatients receive appropriate and safe treatment and care; and,
  6. further recommendations for the Trust(s), mental health services, the NHS, and the wider system.
Further detail and explanation is provided in the Explanatory Note.

Frequently Asked Questions (FAQs) can be found here.