1. This is the first disclosure update, covering the period from the Inquiry’s inception to 6 March 2025.
Requests for Information
2. As at 6 March 2025, the Inquiry had sent a total of 293 requests for information, under either Rule 9 of the Inquiry Rules 2006 or Section 21of the Inquiries Act 2005. These requests have been directed to a range of individuals and organisations including:
- 58 requests to organisations which are Core Participants;
- 72 requests to organisations which are not Core Participants;
- 162 requests to individuals and families.
In some instances, where recipients were found to have no relevant involvement within the scope of the Inquiry’s Terms of Reference, they have been excluded from the total count of requests issued. A full list of organisations issued with Rule 9 requests is annexed to this Note.
Hearings and Evidence Gathered
3. To date, the Inquiry has held the following hearings, receiving a substantial volume of evidence from those affected and involved in mental health services:
- Opening Hearings (9 – 25 September 2024): These hearings provided an opportunity for Core Participants to deliver opening statements, and for bereaved families to share commemorative and impact evidence. During these hearings, the Inquiry received 10 opening statements, and 49 commemorative and impact statements from bereaved families and friends, which have been published on the Inquiry’s website.
- Second Commemorative and Impact Evidence Hearings (25 – 27 November 2024): Virtual hearings continued the collection of commemorative and impact evidence, with 3 additional opening statements and 29 statements received from bereaved families and friends, which have been published on the Inquiry’s website.
- First Substantive Evidence Hearings (28 April – 15 May 2025): The Inquiry will begin examining substantive evidence to establish the broader context for it its work and set the foundation for the evidence to follow. A significant number of Rule 9 requests have been sent to gather relevant material, and the Inquiry anticipates receiving a significant volume of additional documents by the end of March 2025. Based on current responses and outstanding requests, the Inquiry expects the total number of documents to be received, to reach 1,867. The Inquiry continues to actively engage with relevant organisations and individuals to secure the necessary evidence ahead of the hearings.
Key Themes of Rule 9 requests
4. The Inquiry’s information requests have focused on a broad range of critical issues affecting mental health inpatient services. These include, but are not limited to:
- Inpatient care and safety: The provision and oversight of mental health services in Essex and other areas, including pre-admission assessments, inpatient pathways, and incidents of harm.
- Patient monitoring and autonomy: A key area of focus is the use of Oxevision, a monitoring technology used in mental health inpatient units. The Inquiry is examining its deployment, effectiveness, and the perspectives of those subject to its use, including campaign groups opposing it, healthcare providers that procured Oxevision, and the company responsible for the technology itself.
- Autism and Mental Health Inpatients: The intersection of autism and inpatient mental health care, including the impact of co-morbidity alongside mental health conditions, and the adequacy of adjustments made to care.
- Regulatory oversight and accountability: The role of organisations such as the Care Quality Commission, Nursing and Midwifery Association, General Medical Council, Health and Care Professionals Council, National Health Service England, and the Parliamentary Health Service Ombudsman in monitoring mental health inpatient services, responding to incidents and addressing concerns raised by patients, families and staff.
- Investigations into serious incidents: Examination of whistleblowing reports, safety incidents including physical and sexual safety, ligature and absconsion data, as well as official investigations undertaken by Essex Police and prosecutions by the Health and Safety Executive.
- Staff and staffing matters: Examination of the approach to staffing, training, and working conditions for those providing inpatient mental health care. This includes staff support and supervision, as well as evidence relating to staff-related concerns and experiences shared by individuals.
Work is ongoing regarding future Rule 9 requests, which will extend beyond the themes currently highlighted, as relevant to the Inquiry’s Terms of Reference.
Ensuring Full Cooperation
5. Certain organisations and individuals have received multiple Rule 9 requests, reflecting the complexity and breadth of the Inquiry’s investigation. In instances where responses have not been forthcoming or do not include sufficient detail, and the information is deemed critical to the Inquiry’s progress, Section 21 notices have been issued to compel the submission of evidence, underscoring the Inquiry’s determination to obtain the necessary information to fulfil its Terms of Reference.
Next Steps
6. The Inquiry continues to receive and review documents, with a substantial number of additional responses expected in the coming weeks. A further disclosure update will provide details in June 2025.
ANNEXURE TO DISCLOSURE UPDATE OF MARCH 2025
Rule 9 recipient organisations
Autism Action (formerly Autism Centre of Excellence, Cambridge)
Barchester Healthcare Mental Health Hospitals
Battersea Bridge House Limited
Barnet, Enfield and Haringey
Mental Health NHS Trust (now North London NHS Foundation Trust)
Cambridge and Peterborough NHS Foundation Trust
Central and Northwest London NHS Foundation Trust
Care Quality Commission
Channel 4
Cygnet Healthcare
Deloitte
Department for Health and Social Care
East London NHS Foundation Trust
Ellern Mede
Elysium Healthcare
Essex County Council
Essex Country Council (for Essex Safeguarding Adults Board)
Essex Partnership University NHS Foundation Trust
East Suffolk and North Essex NHS Foundation Trust
Essex Police
General Medical Council
Great Ormond Street Hospital
Grove Park Healthcare Group
Harbar 8
Health and Care Professions Council
Healthwatch Essex
Hertfordshire and West Essex ICB
Hertfordshire Partnership
University NHS Foundation Trust
Health and Safety Executive
Humber Teaching NHS Foundation Trust
INQUEST
Kent and Medway NHS and Social Care Partnership Trust
Lewisham and Greenwich NHS Trust
Magna House
Midlands Partnership University NHS Foundation Trust
Mid and South Essex NHS Foundation Trust
MIND
Nest Healthcare
North East London NHS Foundation Trust
Newbridge Care Systems
Newmarket House Healthcare
NHS England
NHS Mid and South Essex Integrated Care Board
NHS Suffolk and North East Essex Integrated Care Board
Norfolk & Suffolk NHS Foundation Trust
Nottinghamshire Healthcare NHS Foundation Trust
Nouvita Healthcare
Nursing and Midwifery Council
Oldercare (Haslemere) Limited
Oxehealth
Parliamentary Health Service Ombudsman
Princess Alexandra Healthcare Trust
Priory Group
Rethink
Sheffield Children’s NHS Foundation Trust
Southend on Sea City Council
South London & Maudsley NHS Foundation Trust
Southend on Sea City Council
Southern Health NHS Foundation Trust
Southern Hill Hospital Norfolk
Southwest London and St George’s
Mental Health NHS Trust
St Andrew’s Healthcare
St Matthews Healthcare Ltd
Stop Oxevision
Suffolk and North East Essex ICB
Tees, Esk and Wear Valleys NHS Foundation Trust
The Salvation Army Social Work Trust
Thurrock Council
Vivre Care
Wedgewood House
West London NHS Trust
