Determining Core Participant Applications – Statement of Approach

I am very grateful indeed for the large number of applications received from individuals, family groups and organisations wanting to become Core Participants in the Lampard Inquiry. In this Statement I refer to a Core Participant as a “CP”. I include below some relevant statistics. I also set out the approach I have taken concerning certain issues that have arisen from the applications.

CP APPLICATIONS

The CP application window opened on 22 April and closed on 20 May 2024. The Inquiry notified applicants who applied within that window whether they had been successful during the week of 24 June 2024. I received over 100 applications, of which I have granted 66, falling into the following broad categories: bereaved family/friends; living current and former patients; health bodies and other organisations; and staff members.

I have granted CP status to the following health bodies and other organisations: Department of Health and Social Care; NHS England; Essex Partnership University NHS Foundation Trust; North East London NHS Foundation Trust; Care Quality Commission; Hertfordshire and West Essex Integrated Care Board; Suffolk and North East Essex Integrated Care Board; Mid and South Essex Integrated Care Board; Royal College of Psychiatrists; and INQUEST.

It is not appropriate to provide a fuller list of CPs at the moment. This is for various reasons, including outstanding applications to protect the identities of certain family members and (former) patients. A full list of CPs (containing cyphers instead of names in certain instances) will be posted on the Inquiry website in due course.

APPROACH

I have considered all applications with great care. In considering them, I have also paid particular attention to:

• the Inquiries Act 2005, including section 17(3) which requires me to act both with fairness and with regard to the need to avoid unnecessary cost;
• the Inquiry Rules 2006, including rule 5 which sets out criteria I must consider for the designation of core participants in the exercise of my discretion; and including rules 6 and 7 covering the designation of “recognised legal representatives”. A number of CPs have sought legal representation, although this is not necessary to engage with the Inquiry. Rule 7 makes clear that I must direct that two or more CPs shall be represented by a single legal representative in certain circumstances, namely where I consider that their interests in the outcome of the inquiry are similar; the facts they are likely to rely on in the course of the Inquiry are similar; and it is fair and proper for them to be jointly represented;
• the Inquiry’s Terms of Reference, which set out the matters to which the Inquiry relates, and accompanying Explanatory Note;
• the Inquiry’s Protocol on Core Participants, the contents of which I do not repeat here but provide an explanation of what a CP is and the process for making an application to become one; and
• the extent to which an individual or organisation will or is likely to be able to engage with the Inquiry and to advance its work.

The Protocol on Core Participants also makes the important points that it is not necessary to be a CP to engage meaningfully with the Inquiry; and that a person’s evidence carries no greater weight in the Inquiry’s eyes simply because they are a CP (see paragraphs 2-3).

The applications have helpfully illustrated certain issues arising from the Terms of Reference where further explanation of the approach I have taken may be helpful.

“Serious harm short of death”

The Terms of Reference state that the Inquiry will consider serious failings related to the delivery of safe and therapeutic inpatient treatment and care and that this may include “consideration of circumstances where serious harm short of death occurred” (at 2(a)).

I have defined “serious harm short of death” to apply to incidents and events that are serious in nature and which had a reasonable prospect of leading to death. They include, but are not limited to: attempted suicide, serious physical and/or sexual assault, and serious failure to look after a patient’s physical wellbeing. Where sufficient evidence of such events was provided within a Core Participant application, I have generally concluded that the individual has a sufficient interest in the matters which the Inquiry is investigating to be granted Core Participant status.

“Inpatient death”

The Explanatory Note sets out the Inquiry’s definition of “inpatient death” to include at (g) “those who died within 3 months of any mental health assessment provided by the Trust(s) where the decision was not to admit as an inpatient (this includes but is not limited to any death following a review in A&E, or an assessment under section 135 and 136 of the Mental Health Act)”.

I have generally concluded that applications in relation to the following fell within the Terms of Reference and also met the CP application threshold, subject to the exercise of my discretion and consideration of matters such as the last bullet point above:

• those who had an assessment with a psychiatrist, crisis team, or someone who had the expertise and power to refer the patient to an inpatient facility, and where the decision was made not to admit the person as an inpatient; and also
• those who were waiting for such an assessment, where the clinical need for one had been identified, but it had not yet taken place.

I received further applications where no assessment had taken place, nor had the clinical need for one been identified at the time. Such applications needed to be decided on a case-by-case basis, having regard to factors such as (but not limited to) whether the individual concerned had previously been an inpatient; whether they were in crisis at the time; and whether attempts had been made to seek inpatient admission or an assessment prior to the death, for example by family members.

Essex

The Terms of Reference require the Inquiry to investigate the circumstances surrounding the deaths of mental health inpatients under the care of NHS Trust(s) in Essex. For the avoidance of doubt, I consider “Essex” to be defined in accordance with Schedule 1 of the Lieutenancies Act 1997, as being comprised of the local government areas of Essex, Southend-on-Sea and Thurrock. This is the administrative county of Essex and does not include areas of Greater London.

However, I have determined that the Inquiry’s definition of “inpatient” includes mental health inpatients who were under the care of NHS providers in Essex, but who were placed outside Essex either because there was not enough bed space in Essex, or due to needing specialist services that were not at the relevant time available in Essex.

Time Limits

The Explanatory Note to the Terms of Reference confirms my approach that I will consider deaths which took place within three months of a mental health inpatient admission. I have applied that time limit when considering applications for CP status. A number of applications which I considered related to deaths which had taken place beyond three months of an inpatient admission. In my view, these applications primarily raised concerns about community mental health care and therefore could properly be categorised as deaths in the community. The Inquiry has been established to investigate mental health inpatient deaths and that accordingly must be the focus of the work of the Inquiry.

WORKING WITH CPs

This Inquiry is investigating matters of great importance and concern. Once again, I am grateful to all those who took the time to apply to become a CP. The Inquiry has already commenced engaging with some of its CPs and looks forward to engaging with others. CPs will play a helpful and meaningful role within the Inquiry and I look forward to receiving their contributions to assist me in meeting my Terms of Reference and delivering a thorough and robust report.