Mother backs watchdog for inquiry findings

A mother who campaigned for the first public inquiry into mental health deaths in Essex is backing calls for an independent watchdog to ensure inquiry recommendations are acted upon.

Melanie Leahy, whose son Matthew died at the Linden Centre in Chelmsford in 2012, is supporting a petition by the charity Inquest for a body to monitor whether recommendations are acted upon.

The campaign comes as the Lampard Inquiry resumes hearings later.

There is currently no legal requirement for the government or public bodies to respond to inquiry recommendations, explain how they will act on them or report progress. A government spokesperson said it had made changes and it should be held accountable.

The inquiry is examining the deaths of more than 2,000 people under Essex NHS mental health services between 2000 and 2023.

Leahy said she did not want "Matthew's legacy to be another report sitting on a shelf".

Chaired by Baroness Kate Lampard, the inquiry is the first in the UK specifically focused on mental health care.

Under the Inquiries Act 2005, inquiry chairs can make recommendations, but those recommendations are not legally binding.

Leahy said she wanted to ensure the process, which has taken almost 14 years, resulted in lasting change.

"The true measure of any public inquiry is not the report it publishes, but the lives its recommendations go on to save.

"Recommendations don't save lives. Implementation does."

She is backing calls for an independent body to oversee recommendations after inquiries have ended, so any failure to act is publicly explained and scrutinised.

The Inquest charity says there is currently no system to ensure potentially life-saving recommendations from inquiries, inquests and investigations are implemented.

A briefing commissioned by the Lampard Inquiry said the lack of an independent system to check what happens to recommendations after inquiries end is "a significant weakness of the current public inquiry framework".

The report, by Dr Emma Ireton, Associate Professor at Nottingham Law School, said recommendations could be accepted initially but later delayed, watered down or forgotten, leaving bereaved families and survivors feeling let down.

The Lampard Inquiry has been hearing evidence since September 2024 and is due to conclude evidence sessions in autumn 2027.

Leahy said the long-running process had come at a personal cost.

"This is a journey I never chose, but one I have felt compelled to continue," she said.

"There have been times when I've felt overwhelmed, confused and emotionally exhausted."

Concerns about what happens after public inquiries have also been raised in Parliament.

A House of Lords committee reviewing the Inquiries Act 2005 warned that public inquiries were often criticised for their cost, length and the lack of follow-up to recommendations.

It proposed the creation of a parliamentary committee to oversee inquiries and hold governments to account for implementing recommendations.

In its response, the government said there had too often been "insufficient transparency and accountability" around the implementation of recommendations and agreed that the public inquiry system "must be improved".

The Cabinet Office has since launched an online tracker showing recommendations from major public inquiries, the government's response and updates on progress.

However, supporters of change argue that tracking progress is not the same as independently checking whether recommendations have actually been carried out.

In her opening statement, Baroness Lampard said her final recommendations would include expected timescales for implementation and how progress should be monitored.

She has also said she would not hesitate to make interim recommendations if the inquiry uncovered issues requiring urgent action.

A government spokesperson said: "When inquiry recommendations are accepted these become government policy.

"The government should be held to account to deliver on all of its commitments."

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