The Lampard Inquiry is investigating deaths of mental health inpatients in Essex between 2000 and 2023

Counsel to the inquiry, Nicholas Griffin KC, said: ‘It's clear that serious issues with mental health care in Essex continue, which underlines the significance and urgency of the work of the inquiry.'

Griffin said the inquiry was aware of deaths occurring in 2024 and highlighted a case in April which appeared to raise similar issues.

The counsel said 46 organisations in England and Wales had been asked to provide evidence.

Griffin said in 2023, over a third of deaths that occurred in England and Wales were referred to the coroner with 20% deemed to require an inquest, equivalent to almost 37,000, 492 of which occurred in state detention.

He said recordkeeping was an ongoing theme in the inquiry, adding ‘logging and retaining reports that were written and issued with the sole purpose of preventing future deaths does not at the moment appear to have been a priority for some providers'.

Griffin said: ‘The Inquiry is concerned that not enough was being done to monitor PFD reports, the concerns raised and the changes required, both within the providers  concerned and more widely. This may again point to a gap in the regulatory framework.'