Essex mental health inquiry pointless without legal powers, say families

Call for review to have statutory powers to make witnesses give evidence after only 11 of 14,000 come forwar

Bereaved relatives have said an independent inquiry into the death of almost 2,000 mental health patients across NHS trusts in Essex is not “fit for purpose” in the absence of legal powers to compel witnesses to give evidence.

The call for a statutory inquiry by 83 families comes after the chair of the review, Dr Geraldine Strathdee, published an open letter saying it would “not be able to meet its terms of reference with a non-statutory status”.

In the same letter she said the inquiry team had written to 14,000 former or current members of staff at Essex Partnership University NHS trust (EPUT) or its successors and only 11 had replied saying they would give oral evidence.

The 83 families, represented by Hodge, Jones and Allen (HJA), are refusing to engage with the inquiry, because they believe there can be no accountability for the deaths of loved ones without greater powers, as evidenced by Strathdee’s letter.

Allegations include sexual assault against patients, staff taunting or neglect of patients, improper use of restraint, and patients absconding or being discharged with insufficient care in place. HJA says it has evidence of what would appear to be criminal liability.

Lisa Wolff, 51, the mother of Abbigail Smith, who killed herself, aged 26, in February 2021, the day after being discharged from the Linden centre, in Chelmsford, said: “There has to be transparency in these mental health services that are failing. I work in health, I want to welcome the thought that these places can be beacons of hope, that they can be a light in the dark for those people who are like Abbi – who are troubled, who need support – and for families to think: ‘Thank God they’ve gone in, they’re going to get the help they need,’ because right now, we can’t do that. Right now, we’re thinking: ‘Oh my God, they’ve gone in there. What’s going to happen to them?’”

She said less than a fortnight before her release and subsequent death, her daughter, who was first sectioned when she was 15, was downgraded from constant observation by two members of staff to no observation.

The inquiry, set up in 2021, was originally investigating 1,500 deaths of highly vulnerable people, including children, either while they were inpatients or within three months of discharge. The number has since risesn to almost 2,000.

Alan Oxton’s father, Steve, killed himself, aged 53, at the Lakes mental health hospital in Colchester. He said the inquest found failings with respect to not removing a belt from his father on admission, reducing the frequency that he was checked on by staff, and placing him in a room where a ligature could be suspended.

Oxton, who has been on antidepressants since his father’s death, said he believed the staff who had come forward were likely to be those with nothing to hide. “Without it being a statutory inquiry it’s pointless, and I’ve never engaged [with it]. The [number of] people they’ve got coming forward is so low, it’s pointless and not fit for purpose.”

More staff are said to have come forward since a plea by Strathdee but the number has not been revealed.

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There are also concerns that failings have not been addressed and suicides have continued. Daisy Simpson, 34, who has been under the care of EPUT since 2009, said: “This is bigger than just one person and the 80 families. There are people on a daily basis that are repeatedly failed and there are no lessons learned. I fear that if I ever ended up back in their inpatient service they would kill me.”

The former cabinet ministers John Whittingdale and Priti Patel have called for a statutory inquiry and were among a delegation of six Essex MPs who went to see the health secretary, Steve Barclay, last week to make the case. Whittingdale said Barclay was “very sympathetic” and the government seemed to be moving from a position where it was “very reluctant” to make the inquiry statutory, to acceptance that it “may need to be”.

An EPUT spokesperson said: “We are absolutely committed to learning lessons and improving the care and support offered to those who rely on us in often challenging circumstances. Our sincere apologies go out for the shortfall in care identified here and we continue to fully support the independent inquiry to provide the answers families rightly deserve. We continue to encourage staff to come forward and give evidence as part of this.”

The Department of Health and Social Care said the progress of the inquiry was being “carefully considered”, adding: “It is disappointing that current and former staff have not engaged to the extent expected nor that the inquiry has been able to access all the information it has requested.”

Source: The Guardian, 7th April 2023

Soteria Network AGM with Special Guests

Saturday, 13 May 2023 12:00 – 16:00
Birchcliffe Centre, Birchcliffe Road, Hebden Bridge, HX7 8DG

If Only There’d Been A Soteria House – Stories of Struggle, Hope and Survival – A Day to Advance Our Cause

with Horatio Clare, Tanya Frank and Rufus May

Book your place on Eventbrite here

The Soteria Network is an international movement fighting for more humane, non-coercive mental health care.

A pay-as-you-feel lunch will be available on the day. A bookstore will also be available to buy books and a stall selling homemade crafts and produce for donations on the day.

Horatio Clare, Travel Writer

Horatio lives locally and will talk about his experiences of psychosis and writing his book Heavy Light.

Horatio Clare’s books include – Running for the Hills (Somerset Maugham Award), A Single Swallow, Down to the Sea in Ships (Stanford Dolman Travel Book of the Year), Aubrey and the Terrible Yoot (Branford Boase Award), The Light in the Dark, Orison for a Curlew and Something of his Art: Walking to Lubeck with J S Bach. 

His latest book is Heavy Light: a story of madness, mania and healing.

Horatio broadcasts regularly on BBC Radio 4, notably for From Our Own Correspondent, and presents Radio 3’s acclaimed annual Sound Walks series at Christmas. His latest series for Radio 4 and BBC Sounds is Is Psychiatry Working?

He writes for the Financial Times, the Spectator, Conde Nast Traveller (where he is a contributing editor), and many other papers, websites and magazines. Horatio lectures in non-fiction at the University of Manchester.

Tanya Frank, Author of Zig Zag Boy

Tanya recently moved back to her native England. Prior to her return home, she lived in California, where she worked as a docent at an elephant seal sanctuary. Her writing has been featured in the New York Times, The Washington Post, The Guardian and numerous literary journals.

Psychologist Rufus May

Rufus May works as a clinical psychologist in in-patient wards in Bolton. He is passionate about holistic, social and emotional approaches to powerful states of mind. His interest is rooted in his own experiences of being treated for psychosis when he was 18 and his subsequent recovery. For more info see and

“Do it for Dan” Long Distance Walk : Jeff Evans Fundraiser for CHARM

Support Jeff as he commences his long distance walk along the length of the pilgrim route, Camino Frances (from St. Pied de Port in France to Compestela, Spain) to raise funds for CHARM from the 1st April until Early May
You can support Jeff and CHARM by sponsoring his fundraising walk at JustGiving here

We are delighted to have Jeff’s support again this year through your Do itf or Dan long distance hike fundraiser.

Jeff is supporting CHARM as a grass roots organisation campaigning for better and more compassionate mental health services in Manchester.

We believe, as Jeff does, that we need a whole new system.

We are doing this through raising awareness and concerns about the failure of services, as well as highlighting and calling for compassionate, holistic and human rights based services which we believe would have better support Dan and many others.

We hope all our supporters and all those concerned to build a service that we support all the communities of Manchester will support Geff

Message from Jeff:

“On Saturday 1st April 2023 I will commence the 3rd Do it for Dan Long-Distance Hike, this time along the Camino Santiago di Compostela (Frances), a journey of approx. 500 miles or 780 kilometres. The walk in Dan’s name seeks to promote a number of urgent issues concerning dangerous underfunding, and what has been proved to be appalling mismanagement, of our NHS Mental Health Services. Please see inside this card for further information on these defects in our mental health services, and on campaigns to halt and reverse those failings.

You will be able to keep regularly updated on my progress along the Camino, which hopefully will be relatively easy and painless, via the various social media ‘platforms’ advertised. This will include the Do it for Dan Facebook page & twitter account – fingers crossed that there are few technical glitches!

Messages of support are always welcome along the way and do help keep up morale, especially on challenging days. If you are able to sponsor the walk via the Do it for Dan Just Giving account that would also be lovely (please note that you can reduce or remove the ‘recommended fee’ the site invites you to pay). Previous events have together raised over £5,000 for mental health charities and for campaigning for a decent and professional NHS Mental Health Service. This year the beneficiary is again the long-established voluntary organisation CHARM whose record of care and campaigning for better mental health services is exemplary.

Many thanks to all those who have kindly supported the previous Do it for Dan and You & Yours events, and I look forward to your support for the Camino.

Very best wishes,


Children’s mental health service in Wigan ‘struggling with staffing’

“We are not fully staffed, I don’t know about anywhere in mental health that is fully staffed.”

Aerial view of Wigan Town Centre
Aerial view of Wigan Town Centre (Image: Copyright Unknown)

Mental health services for children and young people are struggling with recruiting and maintaining staff in Wigan, a meeting heard.

Child and Adolescent Mental Health Services (CAHMS) in the borough was taken over by Greater Manchester Mental Health NHS Foundation Trust back in 2021 and they are now operating out of a base on Manchester Road, Ince. Rachel Green, associate director of operations, GMMH, was in attendance at the Children and Young People Scrutiny Committee on March 28 where she explained that there is still reliance on agency staff in the sector.

Responding to a query about staffing levels from Coun Barry Taylor, Ms Green told Wigan Town Hall: “We are not fully staffed, I don’t know about anywhere in mental health that is fully staffed.

READ MORE: ‘He was a concerned citizen and shouted to ask if all was well – you each took grave exception to that’

“It’s not an excuse but that is the context, I have been in this sector for 30 years and there have always been challenges (for staffing). We have vacancies, the work we really need to do is around staff retention. 

“We sometimes need to use agency staff in some cases. It is a costly solution but that is where we are unfortunately.”

She went on to say that fluctuating demand, increased urgent referrals and the lack of sustainable funding streams are challenges going forward that they would focus on. “In the next 12-18 months we will be where we need to be”, the committee was told.

Despite this, there have been achievements for CAMHS. The committee heard of successes including rolling out a new community model, the mobilisation of new services, the refurbishment of Manchester Road CAMHS building (£370,000 rejuvenation), improved joint working with Wigan and Leigh Teaching Hospitals NHS Foundation Trust (WWL). 

Additionally there was also the transfer of the clinical record system from RIO (WWL’s system) to Paris (GMMH’s system) which took 18 months of planning to achieve.

Coun Gena Merrett, vice-chair of the committee, admitted that taking over the service would always come with challenges, but she wanted to know whether it was worth it. She asked: “Since you moved to GMMH has it improved?

“It is well documented for young people to access mental health services – it was difficult. Have referral times got quicker and young people are getting access?”

In response to the question, Ms Green explained: “I think there has been an improvement but there is still a lot to do. The workforce for example is not where it needs to be at the moment. 

“There are improvements in waiting times and access for young people. The transfer to PARIS has messed things up.”

The team at CAMHS are looking to create an all encompassing approach to mental health where everyone has a responsibility, the committee heard. The support of young people up to the age of 18 who have emotional, behavioural or mental health difficulties which are causing difficulties in their school, family or social life, is ‘up to everyone’, Shelley Bunting – Service Manager Wigan CAMHS, said.

GPs, health visitors, school health advisors, social workers or paediatricians are all able to make referrals to the CAMHS team.

Source: Manchester Evening News, 29th March 2023

Edenfield Centre: Patients and staff put at risk, report finds

Aerial view of the Edenfield Centre
The Edenfield Centre holds patients who are at serious risk of harming themselves or others

An NHS mental health trust exposed in an undercover BBC report on patient abuse put those in its care and staff at “undue risk”, a review has found.

Panorama found a “toxic culture of humiliation, verbal abuse and bullying” at the Edenfield Centre in Prestwich near Manchester last year. 

The Good Governance Institute (GGI) found pivotal staff members were not sufficiently trained and “lower than acceptable standards were normalised”.

The trust apologised “unreservedly”.

The BBC investigation, broadcast in September, unearthed extensive evidence of patient maltreatment and triggered the review of Greater Manchester Mental Health NHS Foundation Trust (GMMH).

A number of staff members were sacked or suspended following the programme. 

Workers were filmed using restraint inappropriately, swearing at patients and slapping them, while some of those being cared for endured long seclusions in small, bare rooms.

The GGI’s independent review, held between October and March, found:

  • Board and executive service visits were minimal and almost entirely absent during the pandemic
  • Staffing issues were critically low, exposing users, staff and the trust to undue risk and putting a “burden” on other staff
  • There were examples of rapid career progression through supervisory and managerial roles without adequate experience, training and support
  • The board “took on trust much of what they were told” and was “not clear about what was going on at the shop floor”
  • Internal communication “was poor”
  • The substandard physical environment and low staffing levels became normalised and accepted as “just the way things were”
  • There was little participation in external training, events and networks

It said there was “significant work to do” for GMMH to become “effective and trusted” and set a series of recommendations to improve.

However, the report stated the issues “should not be surprising given the speed the trust had grown and the expectations placed on the leadership to sort out complex, long-standing issues in Greater Manchester”.

The GGI said services were “bit-by-bit coming under significant pressures” from national financial challenges, recruitment difficulties and the pandemic.

The findings were “not as exceptional as the public may think,” it said, adding “this is a national issue and not unique to this trust”.

It concluded Edenfield should be seen as “a collective failure, not just of the trust or of specific individuals, but of a system of governance and assurance which had not kept pace with change”. 

A trust spokesperson said it accepted the findings and apologised “unreservedly” for its failings.

“We owe it to all our service users, their families, carers, and our hard-working staff to put things right,” they said. 

“Our draft improvement plan, published in February, spearheads our improvement journey. We have already begun to make progress to improve patient safety, create a better working environment for our staff, and strengthen our leadership and governance. 

“Following this report, and using the feedback we have gathered during the engagement period, we will be updating the plan to reflect these further changes and recommendations.” 

Source: BBC News, 29th March 2023

‘I feel the most stable’: supported housing for people with mental illness in Bolton

A case study from Bolton at Home shows how housing associations can support young people with severe mental illness and avoid inpatient re-admittance. Many housing associations are working in partnership with healthcare providers and we believe that every decision about care should be a decision about housing.

Bolton at Home provides both housing and support to maintain a tenancy for at-risk patients.

A young woman who had experienced sexual trauma had been repeatedly detained under the Mental Health Act, resulting in long-term admissions which negatively impacted her ability to live independently. She did not meet the criteria for young person housing provisions due to risk and described feeling unwanted and uncared for. The lack of stability also left her lacking trust in professionals and vulnerability to extortion.

While she was still in hospital, the Bolton at Home service assessed her and agreed a plan for discharge, as they felt her distress and risk were increasing whilst being an inpatient. They collectively agreed contingency plans to structure the transition from a clinical to community setting and these were reviewed regularly. Partnership working here was key to the success of the transition, from internal teams, tradespeople and clinical professionals.

Bolton at Home identified a suitable area and home, which was decorated, carpeted, and furnished with essential items.

On sign-up day the client was anxious and the team reassured her by talking through the steps and reminding her that the property would be a safe space for her. The team also helped the client to remember to check ID of visiting professionals, and that she could choose whether to invite people in.

Bolton at Home provide support under delayed transfer of care, community mental health teams and Greater Manchester mental health and as a result she has successfully maintained the tenancy and her finances. Having a home with responsive and structured support provided an alternative to compulsory admission which increased chances of recovery and independence and reduced inpatient length of stay.

She said: “I feel the most stable I have ever been in my entire life. I feel grounded and proud. You believe in me and that makes me believe in myself.”

NHS England accused of ‘massive betrayal’ over police-led SIM scheme

A policy to protect patients from a controversial scheme has been indefinitely delayed. The SIM scheme sees police embedded in clinical teams to help manage patients who persistently call emergency services

A policy to protect patients from the controversial SIM scheme has been indefinitely delayed

NHS England has been accused by campaigners of a “massive betrayal” as it appeared to shelve a long-awaited policy to safeguard mental health patients accessing emergency care.

A policy to protect patients from the controversial Serenity Integrated Mentoring (SIM) scheme was signed off by senior figures at NHS England and the NPCC in January before its publication was delayed indefinitely last week with no explanation, according to campaigners spoken to by Liberty Investigates.

Users of mental health services have been working alongside clinicians with NHS England since December 2021 on a review of SIM, a programme that sees officers embedded with health teams to help manage patients who persistently call emergency services.

The scheme was rolled out six years ago but criticised by clinicians and patients, including the group StopSIM which voiced concerns police officers were helping draw up plans for patients, many at high risk of self-harm, instructing A&E, ambulance, mental health services and police not to treat them for fear of reinforcing “attention seeking” behaviours.

People will continue to be harmed if there isn’t robust action. People continue to suffer under these models

NHS England’s mental health lead Tim Kendall wrote in May 2021 that SIM appeared to have “no evidence base” and asked NHS Mental Health Trusts to submit reviews.

Some of the reviews, obtained by FOI last year by Liberty Investigates and the Observer, revealed serious misgivings within trusts, including one stating there was “no reasonable way to defend” it.

Yet other information, also obtained by FOI, suggested the model was still in use. In response to questions from reporters, three trusts and four police forces said they still had patients on SIM.

StopSIM said it began working with NHS England in December 2021 to create a policy designed to safeguard patients and reduce the risks of SIM-type models.

According to spokespeople from the group, the policy was agreed in January this year, along with an accompanying statement in which NHS England accepted responsibility for the roll-out of SIM.

StopSIM said NHS England’s refusal to publish either the policy or the statement is a “massive betrayal” and that they feared their cooperation had been used by NHS England as a shield from criticism.

“People will continue to be harmed if there isn’t robust action. People continue to suffer under these models. It’s devastating for service users,” a spokesperson said.

Amy Wells, communications manager at the National Survivor User Network (NSUN), said she hopes the policy and statement will still be published. “NSUN is incredibly disappointed by the decision not to publish this important policy that members of the StopSIM coalition have dedicated so much time and energy to, already facing significant delays and barriers along the way,” she added.

The SIM scheme sees police embedded in clinical teams to help manage patients who persistently call emergency services
Andy Bell, interim chief executive of the Centre for Mental Health, said: “It is vital that people experiencing acute distress get compassionate support without the use or threat of coercion.

“The SIM model was extended nationwide without adequate proof that it was safe, acceptable or effective. The NHS needs to ensure that it puts people’s safety and wellbeing first, and that it listens to the views and concerns of people who use services when making changes to the ways they work.”

StopSIM say they will not participate in further policy development with NHS England, but will reboot their campaign and continue to call for the publication of the policy and the implementation of reforms for the welfare of patients.

In response to the comments, NHS England told Liberty Investigates it will write to all NHS trusts making clear “SIM or similar models must no longer be used” and that it will work with trusts to ensure issues raised by StopSIM are “eradicated”.

“We are grateful to the StopSIM coalition for initially highlighting concerns about the SIM model, for giving these concerns a platform via their campaign and also for the time they have put into assessing the model and making constructive proposals for change,” said a spokesperson.

Source: Liberty Investigates, 13th March 2023

Launch event for SUSTAIN: Managing hunger side-effects of antipsychotics

Friday, 31 March 2023, 13:00 – 14:30 BST, Online

  • 1 hour 30 minutes
  • Mobile eTicket
  • You can book your place here

This study aims to co-develop (with service-users, carers, and mental health professionals), a feasible and acceptable non-pharmacological (non-medication) support package to enhance self-management of antipsychotic-induced hunger.

In 2015, as part of the NIHR CLAHRC GM funding award, the team ran a research prioritisation event with service users, carers, and health professionals which highlighted antipsychotic related hunger as an important issue for those taking the medications.

Whilst mental health professionals were largely focussed on weight-gain, service users identified the underlying issue of hunger side effects as their research priority, with most receiving little help and support in managing this issue.

Antipsychotic medications are the main way that mental health services treat conditions with features of psychosis. We know that about four out of every five people that start taking antipsychotics put weight on very quickly. People can gain two stone in the first 12 months of taking antipsychotic medication and continue to gain weight for at least another 3-4 years.

We also know that weight gain increases people’s risk of developing long-term physical health conditions such as diabetes and heart disease. People who gain weight from antipsychotic medication tell us that the hunger they experience is very different to usual hunger, with it being much harder to control. We therefore want to understand more about the experiences of antipsychotic related hunger and how it might be helpfully managed.

This event will introduce the SUSTAIN study, its aims and objectives, its different phases, and how you can be part of it – by taking part, or by helping to spread the word.

The event is open to anyone with an interest in this subject-area, including service users, family carers, mental health professionals, researchers, research administrators, third-sector organisations, and the general public.

You can book your place here

CQC tells Manchester mental health trust to make further improvement

The Care Quality Commission (CQC) has told Greater Manchester Mental Health NHS Foundation Trust it must make improvements following an inspection of their community-based mental health services for people of working age in October.

Greater Manchester Mental Health NHS Foundation Trust provides community mental health services for adults of a working age to people from Bolton, Wigan, Salford, Trafford and the City of Manchester. The services aim to provide recovery focused care and treatment for people with severe mental illnesses such as schizophrenia, severe affective disorders or complex personality disorders within the community. This inspection looked at services in Central West, Central East and South Mersey teams.

This unannounced focused inspection was carried out following information of concern about the safety and quality of the service, and to follow up on the previous inspection where CQC rated safety as inadequate. Inspectors looked at the areas of safe and responsive only.

Following the latest inspection, the rating for safe remained as inadequate, and responsive remained as requires improvement. Due to concerns found around patient safety, CQC issued the trust with a warning notice to focus the trust’s attention on rapidly making the necessary improvements to keep people safe.

Karen Knapton, CQC deputy director of operations in the North, said:

“When we inspected the community-based mental health services, we found staff were passionate about their work, but it was disappointing to find safety concerns still needed addressing across the service.

“Understaffing was a big concern, and while many NHS services and those in the wider care sector face staffing challenges, the trust must find ways to minimise the risk this poses to people in its care. Many staff told us they felt they were operating at unsafe levels which had a negative impact on people’s care and safety.

“Routine appointments were often postponed as staff prioritised crisis interventions, and staff reported that high vacancy rates made it difficult to respond to people’s needs.

“The service was unable to run its physical health clinic as no staff were available to run it, meaning people had delayed care or were redirected to their GP for the checks they would have had there.

“We continue to monitor the service closely and have carried out a recent inspection to check that the necessary improvements have been made to keep people safe. These inspection findings will be published in a report in due course”.

Inspectors found the following during this inspection:

  • Staff felt respected and supported in their teams.
  • Not everyone using the service had up to date care plans and risk assessments. This meant that any new issues were not being identified or monitored.
  • Not all areas were clean and there was no system or audit in place to oversee this.
  • The telephone system was not designed in a way that made it easy for people to get through to the service.
  • Not all teams were adequately equipped to safely deliver physical health care.
  • There was no system in place for the storage and administration of medication.

Full story here

Source: CQC, 9th March 2023