The Lampard Inquiry highlights how fear of blame is harming care in Essex mental health services, affecting both staff and patients.
At England’s first mental health inquiry, expert witness Dr. Ian Davidson described a “culture of fear” among mental health staff. The inquiry examines the deaths of 2,000 patients in Essex from 2000 to 2023.
Dr. Davidson, a consultant psychiatrist with 23 years of experience, said staff feel blamed no matter what they do. He gave an example from a community mental health team managing long waiting lists. To see more patients, they have to discharge others. But if something goes wrong after discharge, staff get blamed. If they keep patients longer, their workload grows, and if a patient misses a visit, they are also blamed.
This cycle creates stress and reduces staff’s ability to provide care with empathy. “Every human being has a limited ability to be compassionate,” Dr. Davidson said. “The more stressed and rushed staff are, the less time they have for a kind and thoughtful response.”
He added that limited resources lead to a defensive approach. Staff spend more time documenting to protect themselves from blame instead of focusing on care.
Dr. Davidson also pointed to a severe shortage of registered mental health nurses in England. In 2023, there were 13,000 nurse vacancies and a 26% drop in new applications. On some wards, one or two nurses support many healthcare assistants. This imbalance causes “compassion fatigue,” where staff are tired and less engaged with patients.
This lack of proper care harms trust between patients, families, and staff. Former chief nurse Maria Nelligan said over the past 25 years, there were times when cost-cutting favored cheaper healthcare assistants over registered nurses. She said a good mental health ward should focus on respect, compassion, and meaningful activities.
Ms. Nelligan added that patients should have individual timetables for one-on-one sessions with nurses to support their recovery.
The government plans to introduce a new NHS staffing plan this summer. It aims to ensure the right workforce is in place through reforms and investments. A spokesperson expressed sympathy for families affected by these tragedies and said it is vital for everyone to share their stories.
The Lampard Inquiry will continue hearing evidence until October 2026. Baroness Lampard’s final report is expected in 2027.
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