Stuart Woodward/BBC
Sam Cook said her sister Paula Parretti had been “screaming from the rooftops” about her treatment, but “nobody would listen”
The first public inquiry in England to look solely at the deaths of mental health patients will resume in February, having passed its halfway stage. The Lampard Inquiry is examining more than 2,000 deaths of people under the care of NHS mental health services in Essex between 2000 and 2023. Dozens of bereaved families and friends have given evidence so far, but how do those participants feel about the inquiry’s progress?
Carol Taylor first met her husband Ralph when they worked at a solicitor’s firm, asking him out on a date in an unusual way.
“She actually sent me a bill for work done – the price of which was a whisky after work,” recalled Ralph.
“I couldn’t believe my luck.”
Ralph Taylor
Ralph and Carol Taylor were married for nearly 50 years
The couple moved in after just six months of dating, enjoying nearly 50 years of marriage together as Carol switched from being a legal secretary into teaching.
But Carol’s mental health declined in later years, diagnosed with recurrent depressive disorder.
Although this was kept in check by medication, her mental health became affected by her physical health which also began to deteriorate, most notably following a trip to Iceland where she was diagnosed with pneumonia and type 2 diabetes.
Ralph – from Buckhurst Hill – said he and the family sought psychiatric help for Carol, which was “not forthcoming”.
She was admitted to hospital in June 2023 after taking an overdose, described as “a cry for help” by her husband.
Eventually transferred to the St Margaret’s mental health unit in Epping, Carol stayed in hospital for the next five months, where she was resistant to treatment, becoming malnourished and dehydrated.
Coupled with a lack of mobility, it created the perfect conditions for a blood clot to form in her lung, from which she died on 21 November 2023, aged 75.
Ralph has criticised staff at the Essex Partnership University NHS Foundation Trust (EPUT) and their attempts to resuscitate Carol, which he referred to as “shambolic”.
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“They were trying to resuscitate her with her being on her side, not on her back, they hadn’t switched the oxygen on,” he told the BBC.
Staff tried to call 999 but did not know they had to press nine first to get an outside line, he explained.
Ralph – who has called for better staff training and more transparency towards families – also said opportunities had been missed by the inquiry itself to try getting answers from the trust.
“I was a bit frustrated because they weren’t being asked the hard questions,” he said, adding that the counsel to the inquiry “seems to adopt a sort of gentlemanly approach”.
“Although there were barristers there representing the families, they couldn’t ask the questions direct, they had to be fed through the counsel to the inquiry.”
Sam Cook
Paula Parretti was described by her sister as “larger than life” and “a lovely person”
Other core participants, such as Sam Cook, are still waiting to give their evidence to the Lampard Inquiry.
She will speak in February about her older sister Paula Parretti, who she described as “larger than life” and “a lovely person”.
Paula – who had battled borderline personality disorder and post-traumatic stress disorder since childhood – took her own life in 2022, after several previous attempts.
Sam, from Witham in Essex, said her sister was often discharged from hospital too early.
She said on one occasion, with Paula in the middle of a panic attack, her bags were “dumped” at Sam’s feet, with staff telling her “you’ve got to take her now, we need the bed”.
“That was the moment she gave up,” Sam told the BBC.
She said she told Paula – who was feeling suicidal at the time – that she would get her more help, but her sister responded: “What’s the point? Nobody cares”.
“She was screaming from the rooftops that she was being treated awful,” Sam said, adding that she believes EPUT considered her sister to be “an inconvenience”.
“Nobody would listen. This is my way of helping her get heard.”
‘Change has to happen’
EPUT has repeated its apology to bereaved families and said that lessons would be learned, but Sam said the trust needed “to be held accountable for their actions”.
“Their apology doesn’t really mean much,” she said.
“Where was their apology when people were going to them directly, saying you’ve failed our family member, you’ve failed our loved one.”
Sam said she had faith in Baroness Lampard’s inquiry, and remained optimistic that “some good will come of this”.
“Change has to happen because without it, we’re going to lose so many more people,” she told the BBC.
A spokesperson for the Lampard Inquiry told the BBC it had heard “compelling and heartbreaking evidence” from 30 family members and friends since it began in September 2024, as well as 71 commemorative oral statements.
“Much of this evidence has described the inadequate care and treatment that peoples’ loved ones were subjected to, and all of which raises serious concerns about provision of mental health inpatient services in Essex,” the spokesperson added.
Although the inquiry has already heard from EPUT representatives, the BBC understands that several senior managers at the trust will be called to give further evidence.
Paul Scott, chief executive of EPUT, said: “My thoughts are with the families and loved ones of Paula and Carol and I send my condolences both personally and on behalf of the trust.
“As the Inquiry progresses there will be many accounts of people who were much loved and missed over the past 24 years and I want to say how sorry I am for their loss.
“All of us across healthcare have a responsibility to work together to improve care and treatment for all and to build on the improvements that have already been made over the last 24 years.”
The Lampard Inquiry will resume on 2 February 2026.