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Statement by Dr Geraldine Strathdee, Chair to the Inquiry

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

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