Why must the Lampard Inquiry investigate the impact of structural racism on deaths in mental health services?

The Lampard Inquiry, chaired by Baroness Kate Lampard CBE, is a statutory public inquiry, set up to investigate the deaths of mental health inpatients in Essex between 2000 and 2023. It is the first public inquiry into mental health services that has ever been held in England and established by a Minister.

What has happened so far?

The Inquiry opened on 9 September 2024, and the first hearings, in which opening statements and impact evidence were heard, took place in September and November 2024. Hearings continued in April 2025, with evidence from experts and relevant contextual evidence. In July 2025, the Inquiry heard evidence from bereaved families.

The focus of the Inquiry’s investigation is on NHS Trusts in Essex. However, the Chair has indicated that recommendations may be made on a national scale where appropriate. This means that the investigation may be informed by evidence from individuals, Trusts or other organisations who can provide insight into the provision of mental health care more widely.

Who are the Core Participants?

Individuals and organisations designated as Core Participant (“CPs”) have a formal status in the Inquiry that allows them to access disclosure, make legal submissions and question witnesses. It is a status typically granted to those who have a significant interest in the Inquiry's subject matter.

Applications for CP status remain open. Current CPs include Essex healthcare providers, other organisations which play a role in the delivery and regulation of mental healthcare, and nine separate groups of families/patients. INQUEST has also been granted CP status, as a charity providing expertise on state related deaths and their investigation (see the full list here).

What are the key issues for the Inquiry to investigate?

The Inquiry’s Terms of Reference permit the examination of all deaths of mental health inpatients under the care of NHS Trusts in Essex. This includes individuals who died while on leave from an inpatient unit, as well as those who died within three months of transfer, discharge, going absent without leave or absconding from an inpatient unit. It also includes those who died while waiting for a bed in an inpatient unit following clinical assessment of need and/or those awaiting assessment under the Mental Health Act.

The Inquiry has published a list of issues to help guide its investigative work. Key issues include, but are not limited to, the following:

• The quality of care provided to patients who died, including decisions about assessments, admission and treatment.
• Planning and management of discharge, continuity of care and treatment in the community.
• Engagement with patients, including involvement of families, carers and other members of their support network.
• Practices for safeguarding patients from harming themselves or others, including crisis and emergency management systems, and the use of restrictive treatment practices.
• Methods of data collection and sharing, and the adequacy of these systems.
• Barriers to accessing timely and appropriate care, including in relation to staffing constraints and the adequacy of training for staff.
• Management, leadership and whether providers’ systems were inhibited by aspects of governance and culture.
• The quality of any previous investigations by providers in relation to inpatient care and treatment, including whether conclusions and recommendations resulted in change.
• The extent to which providers’ interactions with external bodies were appropriate and effective

Issues that have already been examined include staff shortages, poor data collection systems and transparency, and the complexity of the framework for the regulation of Trusts.

The list of issues also includes the extent to which patients’ protected characteristics were associated with any differences in the treatment they received, whether structural racism and/or discrimination was an issue, and if so, whether it was identified as an issue by providers. In their opening statement, Lead Counsel to the Inquiry (“CTI”) also added that the Inquiry team were minded to add further matters to the list of issues, including the demographics of Essex and whether a person’s ethnicity influenced the treatment they received.

The Inquiry has therefore explicitly committed to examining the impact of racial disparities in the provision of mental healthcare, though there is currently no organisation with CP status whose specific focus is to bring to light issues of racial inequality in mental health settings.

Why is it so important for the Inquiry to examine racial inequalities and discrimination?

In investigating the provision of mental health inpatient care in Essex, evidence about whether there were systemic issues will provide important context. As part of this evidence, an evaluation of the impact of structural racism will be crucial.

There is currently no complete, published set of data which breaks down inpatient deaths by ethnicity across the Essex mental health Trusts. However, it is well known that a wealth of racial disparities exists within mental healthcare. Evidence, including an Independent Review of the Mental Health Act in 2018, has highlighted disparities in detention rates, with some ethnic minority groups more likely to be detained under the Act. In addition, ethnic minority patients often experience negative treatment outcomes (despite evidence suggesting higher prevalence of mental ill-health), and are more likely to be subject to violence and mistreatment while detained.

INQUEST, in their opening statement, highlighted that racial stereotyping is a serious issue across inpatient settings, which can lead to disproportionately punitive treatment and bring about a “culture of disbelief” when concerns are raised by individuals. The limited publicly available information suggests that this may be reflected in lower rates of reporting of complaints by patients from Black and ethnic minority backgrounds, signalling that systemic barriers are limiting access to justice.

On the whole, people from ethic minority communities experience profound inequalities when accessing mental health treatment, which is sadly reflective of broader structural racism. A rapid evidence review by the NHS Race & Health Observatory confirmed persistent inequalities in healthcare, including mental health care, “rooted in experiences of structural, institutional, and interpersonal racism.”  These issues have been reiterated in evidence to the UK Covid-19 Inquiry, which has brought to light the impacts of structural racism in exacerbating pre-existing health and socio-economic inequalities.

Looking forward

One of the key functions of a public inquiry is to learn lessons. Examining the impact of structural racism and discrimination will be key to understanding the full picture of deaths in Essex mental health services. It will be crucial to ensure targeted analysis into the relationship between race or ethnicity and patient outcomes. This understanding will be vital in shaping the Inquiry’s recommendations to avoid similar injustice in future.

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