Speaking at the Lampard Inquiry, Sir Rob Behrens described the Essex Partnership University NHS Foundation Trust’s (EPUT) handling of two vulnerable young men as “the NHS at its worst”, a damning statement that should deeply concern anyone who believes in a compassionate, effective health service.

The inquiry, which is examining over 2,000 deaths in Essex mental health services over the past 24 years, is revealing a tragedy of staggering scale.

Among the most distressing cases are those of Matthew Leahy and ‘Mr R’. Matthew died in 2012 after reporting being raped while in care. His care plan was later found to have been falsified. ‘Mr R’ died in 2008 after some clinicians dismissed him as simply homeless, rather than recognising his mental health needs. Sir Rob identified 19 instances of maladministration in Matthew’s case alone.

These are not just statistics. These were young lives cut short. Families left devastated. A system that betrayed the very people it was supposed to protect.

Sir Rob’s evidence points to deep, systemic failures that require urgent and lasting change if mental health services are to genuinely serve those in need.

What needs to change

Leadership and accountability

 The “near-complete failure of the leadership” in the trust that preceded EPUT is a stark warning. Strong, transparent, and accountable leadership is essential. We need clear lines of responsibility and a culture where failures are acknowledged and corrected, not buried or excused.

Respect, dignity, and listening

 Mr R’s treatment, described as “patronising”, showed how easily people’s struggles can be dismissed. Services must listen to patients, treat them with dignity, and involve them in their care. The falsification of Matthew Leahy’s care plan shows how dangerously broken the system can become when trust is lost.

Safe environments

Sir Rob raised serious concerns about unsafe physical environments, including ligature points. At the most basic level, mental health facilities must be physically safe. This is a fundamental duty of care.

Staff training and support

Too often, there is a lack of training and development. Mental health staff must have the skills, understanding, and compassion needed to support people in crisis. This includes trauma awareness, de-escalation techniques, and building therapeutic relationships.

Read our guide to the mental health challenges often faced by healthcare staff.

A simpler complaints system

The current complaints process is “confusing”, and serious issues can easily fall through the cracks. Many grieving families do not have the energy or clarity to navigate it. Sir Rob suggested giving the ombudsman powers to start investigations without needing a complaint—an essential step forward.

Better communication

Patients and their families must be kept informed, involved in decisions, and treated as partners in care. Communication should build trust, not erode it.

A shared responsibility

While NHS trusts, regulators, and government agencies bear much of the responsibility, these events, described by Sir Rob as “not exceptional,” should also prompt wider reflection.

Here’s what we can do as a society:

Challenge stigma

 Mr R’s experience reflects the deep-rooted stigma surrounding mental illness. We must challenge these attitudes. Open, honest conversations about mental health, in our homes, workplaces, and communities, are vital.

Speak up and offer support

Melanie Leahy’s decade-long campaign for a public inquiry, praised by Sir Rob as “exemplary”, shows the power of persistence. While not everyone can lead such a campaign, we can all be more aware. If we see someone struggling or hear about poor care, we have a moral duty to speak up and offer help.

Push for better services

We must advocate for better funding, staffing, and prioritisation of mental health services. This includes supporting mental health charities, contacting local health authorities, and making our views known to MPs and decision-makers.

Lead with empathy

The people affected by these failures are not case numbers. They are sons, daughters, friends, and neighbours. A more compassionate society starts with empathy, not fear or judgment.

The Lampard Inquiry’s final report, due in 2027, will likely contain critical recommendations. But we cannot wait until then to act. The recent apology from EPUT’s chief executive is a start—but it must be followed by meaningful, lasting change.

The harrowing stories coming out of Essex should not only drive reforms in our mental health system. They should remind each of us that care is a collective responsibility, and we all have a role to play.

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