Lampard Inquiry: Concerns raised before death were not acted on

A manager at the mental health trust at the centre of a public inquiry has said concerns she raised before the death of a patient were not acted on.

Chloe Cawston was giving evidence to the Lampard Inquiry, which is examining the deaths of more than 2,000 patients who received care from mental health services in Essex between 2000 and the end of 2023.

Cawston was a ward manager at Basildon Mental Health Unit when 28-year-old Bethany Lilley died in January 2019.

The inquiry heard she had raised concerns about patient transfer procedures before and after Bethany's death. Asked whether any action had been taken before she died, Cawston replied: "Not that I can recall."

Bethany was found unresponsive after being transferred to Basildon. The inquiry heard the ward did not receive all the relevant paperwork or case notes and there was not an appropriate handover between hospitals.

Cawston told the inquiry she had been a registered mental health nurse since 2011 and became a ward manager at Basildon in 2018.

During her evidence, she also accepted there had not always been enough beds for people in mental health crisis.

"Nationally there's been a shortage of mental health beds," she said.

She told the inquiry that if no bed was available, a plan would be put in place for a patient to attend A&E if they needed immediate help.

Cawston said if someone left A&E before a bed became available, staff would try to contact them and alert police if necessary.

Asked about ward culture, she said staff falling asleep at work had been "a feature throughout her whole career", although it was less common now.

She also accepted that risk assessments before patients went on leave had not always been carried out properly.

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Source: BBC News, 10 July 2026