“I vomit blood and I am terrified” — bereaved mum calls for mental health staff in Essex to be ordered to give evidence in inquiry into death of 2,000 people

Niamh Mc Dermott
10 min readApr 20


Families of victims who died in unusual circumstances are calling for answers.

Parents whose children didn’t get the help they need in Essex mental health services are calling for a statutory public inquiry. They feel undermined but believe if they are given the statutory footing that they seek, then staff would be compelled to give them answers.

The Essex mental health independent inquiry, the first of its kind in England is being held up by the unwillingness of staff to participate in the process and the trust failing to produce evidence requested by the chair.

The inquiry was established in January 2021 as a non-statutory inquiry to investigate the circumstances around the deaths of mental health inpatients and those who died within three months of discharge in Essex between January 2000 and December 2020.

‘Non-statutory’ means that it is not regulated by law and not set out in legislation. It also means that it cannot compel witnesses to give evidence under oath.

The inquiry is the UK’s largest-ever investigation. It is investigating the death of 2,000 people under the care of Essex mental health services over the 20 year period. It has been undermined by thousands of current and former staff refusing to give evidence.

Bereaved families, MP’s, and even the inquiry’s chair, now believe it can’t fulfil its purpose without powers to compel staff to give evidence. This has led to nationwide campaigning for a statutory public inquiry which would provide legal powers to compel a witness to give evidence.

Priya Singh is one of the senior associates at Hodge, Jones & Allen solicitors working pro-bono on this case. She is one of the lawyers representing 84 families who believe they have been failed by Essex mental health services.

Priya is a Senior Associate at Hodge Jones & Allen who is representing the families pro-bono

Ms. Singh represents patients, ex-patients, and bereaved families.

“These families have been through multiple processes to try to get an answer as to why their loved ones have died or failed. They’ve had inquests, investigation by the trust, and yet still families don’t even know the circumstances as to why their loved ones have died”, says Ms. Singh.

She believes they are “very, very, very close” to getting the statutory public inquiry.

Chris Nota, 19, from Southend, died after falling from the Queensway Bridge on 8 July 2020. He was under the care of The Essex Partnership University NHS Foundation Trust (EPUT) in the months before his death following a deterioration of his mental health.

Chris was autistic and an inquest into his death ruled that there had been multiple failures by the trust in Chris’ care, including a lack of support for his autism.

Chris Nota who died ages 19 under EPUT care

Recent studies have shown that the link between suicide ideation and autism in adults is strong. Up to 66% of autistic adults have thought about taking their own life, and 35% have attempted suicide according to a study done by The University of Nottingham and Cambridge in 2022.

An inquest into Chris’ death was initially opened on 12 September 2022 and was adjourned on 30 September as a result of a failure by EPUT to provide thousands of pages of correspondence between clinicians and other professionals about Chris and his care to independent investigators.

In an interview with Chris’s mother, Julia Hopper, she talked passionately as one of the campaigners for the inquiry to be put on a statutory footing. She has campaigned tiredlessly since her sons death. She believed no harm would come to her son.

“He was in a place of safety but was discharged unsafely”, she said.

The Coroner found that Chris’ death was contributed to by issues including the lack of an autism-focused approach to the assessment of his mental health, a failure to give sufficient consideration to detaining him under Section 3 of the Mental Health Act (MHA) 1983, insufficient consideration of the views and concerns of his family, inappropriate and unprofessional judgments on Chris’s mother, Julia Hopper, and “a serious failure” to include the level of concern of his safety expressed in emails exchanged by the Essex Support and Treatment for Early Psychosis (ESTEP) team. You can read more about it here:

During the inquiry, the Trust issued an apology expressing their “sincere apologies for the inadequate standard of care provided to Chris”.

Almost three years and after numerous details of failures she believes led to her sons death, she is not backing down in a call for a statutory public inquiry even though she knows it will come at a personal cost.

“I vomit blood and I’m terrified”, she says.

She believes that the families have no choice but to carry on this battle.

“What are you going to do? Kill my son. You’ve already done that”.

I’ve got nothing to lose, my sons dead”, she says.

Chris Nota with his mum Julia Hopper

Nobody for EPUT was available for an interview as the pre-election period for the local elections in May “restricted our external activity with press”.

However, in a statement, a spokesperson for EPUT said:

Matthew Leahy was just 20 when he died under the care of Essex Mental Health Services.

He was detained in November 2012 under the Mental Health Act at the Linden Centre in Broomfield, Chelmsford, and was found dead in his room just 7 days later.

Matthew’s mum, Melanie Leahy is leading the campaign for a statutory public inquiry.

Melanie made a complaint about North Essex Partnership University NHS Foundation Trust (NEP) to the Parliamentary and Health Service Ombudsman in 2015. In 2019, seven years after Matthew’s death, the ombudsman agreed with Melanie and found there was “significant failings” in areas of Matthew’s care.

Matthew and his mother Melanie

According to Melanie, three days before Matthew was found dead, he had rung his father and the police from Linden Centre claiming that he had been drugged and raped in the ward. The nurses assured Matthew’s mum that it was part of his delusion, she said.

No further action was taken by Essex Police, but the PHSO report confirmed that staff at the Linden Centre failed to take “adequate action” in response to Matthew’s claims.

Here is a timeline of the days prior to and post his death, according to his mother:

Melanie has been campaigning for a statutory public inquiry for over ten years and believes “a public inquiry, through which members of staff can be questioned under oath, is the only way to get the answers we desperately need”.

Melanie campaigning for a statutory public inquiry

A spokesperson for EPUT offered condolences for Matthew’s family at the time and said they “fully accepted all the recommendations in the Ombudsman’s Missed Opportunities report” relating to EPUT, including making sure they work with every patient to create a personalised care plan when they are admitted.

They also introduced several new safety measures at the Linden Centre, like increasing CCTV, anti-barricade doors, and improving the safety of our bathrooms and bedrooms.

Melanie Leahy and Julia Hopper met Members of Parliament- John Whittingdale, Priti Patel, and Vicky Ford in March. All of these MPS are behind calls for the inquiry to be put on a statutory footing.

In March 2023, Melanie and Ms. Hopper wrote a letter to the chair of the inquiry, Dr. Geraldine Strathdee on behalf of “multiple Essex families”. The letter outlines the concerns of the family and their calls for a statutory inquiry.

You can read the letter here:

Mental health charities, like SANE, are at the forefront of the campaigning and have been supporting the families during these tough times.

Marjorie Wallace, founder and chief executive of mental health charity SANE, has written an open letter to Steve Barclay, Secretary of State for Health and Social Care, backing families’ calls to convert the Essex Mental Health Independent Inquiry into a statutory public inquiry.

They believe this call will not only provide answers to the families, but it “should enable change in the provision of mental health services that could save future lives”.

You can read the letter here:

The treatment of Chris, Matthew and the other 2,000 patients are not isolated cases.

Mental Health Charity, MIND, have been calling for a full national statutory public inquiry.

Paul Spencer, Head of Health, Policy and Campaigns at MIND, mental health charity believes what is happening is part of a further problem nationwide.

“We know that, tragically, the many incidents at EPUT are not isolated cases, but feed into a wider national picture of systemic poor treatment, abuse and neglect stretching back many year”, he says.

Campaign supporter and mother, Emma Dalmayne believes that if there hadn’t of been intervention from her organistation, then her son might not be alive because he was refused mental health care.

Her son, Damien Dalmayne, 15, was refused care from the Children and Adolescent Mental Health Service, CAMHS in Greenwich.

Damien is autistic and his mother, Emma, believes that her sons life was put at risk by the lack of proper care that was given when he was first referred to CAMHS in 2020.

Damien was referred to CAMHS by his mum in 2020 and again by his paediatrician in December 2022. The referral letter said: “I would be grateful if you could see this 15 year old boy urgently. He was seen in a clinic and expressed having low moods and thoughts of self-harm”.

He was one of 4,524 Children and Adolescents that were referred to CAMHS in 2022 in the Oxleas NHS Foundation Trust. In a Freedom of Information request provided by the Trust in March 2023, it revealed that 30.81% of these referrals were referred back to a GP, or it was suggested to the parent(s)/guardian of the referred child/adolescent to seek help from another agency and that their Mental Health service would not be accepting the child/adolescent referral before an assessment was carried out or immediately after.

Damien Dalmayne

On 21 December 2022, Damien’s referral letter was refused. CAMHS Greenwich sent a letter stating: “We would agree that Damien experiences emotional difficulties. However, we consider that a Specialist Mental Health Service is not the most appropriate service to address Damien’s difficulties”.

They also noted his ASD diagnosis and said a more appropriate service would be through the Children and Disabilities Team.

In the National Autistic Society, it states that “CAMHS is a multi-disciplinary service providing specialist mental health services for children and young people with varying mental health issues. This includes children and young people on the autism spectrum, where there are concerns about the existence of additional mental health needs.”

Damien’s letter of referral and refusal

Emma received the letter of refusal the day after she was with Julia Hopper at her son’s inquest and was adamant that they were not doing the same to her son. This led to her to start a petition on change.org called ‘Stop Children and Adolescent Mental Health Services Denying Support for Autistic Kids’ which currently has over 180,000 signatures.

Damien and his mum Emma at change.org

Hundreds of people have shared their experiences in the petition comments.

Some reasons for people signing the petition

Emma set up ‘Autistic Inclusive Meets’ (AIM), the organisation that saved her sons life.

It is a non-for-profit organisation created by autistic people to enable families with autistic children, and autistic individuals to go out into the community and socialise in an accepting, inclusive environment with like-minded peers.

Damien believes that if AIM didn’t exist then his life would be very different.

“I would be very very very depressed”, he said.

AIM gave him the confidence to ask for support and if it wasn’t for AIM then he “probably wouldn’t be here to ask for help”, he claims.

But Damien also feels let down in his treatment from mental health services and believes he still needs therapy from CAMHS.

“I don’t understand why they choose to target special needs kids and choose not to do anything to assist because it feels like they are basically saying to us that we don’t speak your language and we don’t understand what you want so it just feels like either they don’t care, or they just don’t want to help or they just don’t understand. It’s one of those 3 things. I think it’s the first — We don’t care”, he said disappointedly.

António Ferreira is a mental health activist in Essex who wants to “reassure people to still access support when needed” despite the current bad publicity in the news.

He said: “I’m a true believer that friends and family are the best therapists.

If it’s not friends and families then charities and if it’s not charities, then contact your GP”.

If you have been affected by any of the issues mentioned in this article, please go to MIND where they provide a list of contacts if you are feeling suicidal.