Essex mental health inquiry hears of 'complete failure of leadership'
A former health ombudsman's told an inquiry into over 2,000 mental health patient deaths in Essex that failings in two young men's cases were a "disgrace".
A former health ombudsman has told an inquiry into the deaths of more than 2,000 mental health patients in Essex that failings in the cases of two vulnerable young men were a "disgrace".
Sir Rob Behrens, who was parliamentary and health service ombudsman (PHSO) from 2017 to 2024, said the two deaths involving North Essex Partnership Trust were "an indictment of the health service".
A PHSO report titled Missed Opportunities, published in 2019, details failings in the care of 20-year-old Matthew Leahy who died in 2012 and in the care of a 20-year-old man referred to as Mr R who died in 2008.
Sir Rob was asked about the report at the Lampard Inquiry, which is examining deaths at NHS-run inpatient units in Essex between 2000 and 2023.
He said in a statement to the inquiry that there was "in summary a near-complete failure of the leadership of this trust, certainly before it was merged" with South Essex Partnership Trust to become Essex Partnership University Trust.
"This was an indictment of the health service," he said.
Sir Rob said that a journalist had said to him, during an interview about the 2019 report: "You're very angry aren't you, I don't see that very often in public servants."
"I was a bit ashamed at the time that I showed that anger but actually reflecting on it this was a disgrace, this was the National Health Service at its worst and needed calling out," said the former ombudsman.
He said that in both cases covered by the report "there was a cavalier approach to communication which was disastrous for the survival of the two people involved".
The deaths in scope of the Lampard Inquiry will include those who died within three months of discharge, and those who died as inpatients receiving NHS-funded care in the independent sector.
Commemorative evidence from loved ones about those who died was given at a series of hearings last year, and a three-week block of introductory hearings is now under way.
At Tuesday's hearing, sitting at Arundel House in central London, Sir Rob described "shocking" record keeping he had seen in Essex.
"I did not expect the fabrication of documents to feature in my role as health service ombudsman and it has done," he said.
"And the failure to record what has happened both in Essex and outside Essex has been shocking."
Nicholas Griffin KC, counsel to the inquiry, asked Sir Rob: "Is shocking a word that you use regularly in relation to your work or does this really stand out?"
The former ombudsman replied: "I try not to be sensationalist but I think it's an appropriate term to use."
He said the Lampard Inquiry has "frankly taken far too long to come about because the government was extremely reluctant to create a public inquiry in these issues".
He said that "despite all the evidence to the contrary it wouldn't have an independent inquiry after our report".
Sir Rob said that the ombudsman could only investigate cases that were reported, and did not have "the power of own initiative".
"There were a small number of very significant and heart-breaking cases in Essex where the families of the people who died were brave enough to complain about what had happened and that was the focus of our investigations," he said.
"But we subsequently discovered that in the same institution there were a significant number of other deaths where for understandable reasons, because of bereavement or trauma or both, the families had not complained about and the ombudsman had no opportunity to investigate those cases.
"If we had had the power of own initiative then the resolution of these tragic issues could have been speeded up very dramatically."
The inquiry continues, with hearings until October 2026.