Lampard Inquiry: Mother describes ‘corrupt’ mental health system

The inquiry also heard from Dawn Johnson, whose mother Iris Scott was found hanging in her bedroom at the Crystal Centre, Chelmsford, in 2014.

Her death, aged 73, was one of those investigated by the Health and Safety Executive (HSE), which fined EPUT £1.5m for safety failings in 2021.

Describing her mother as the “life and soul of the party” who had put her family at the centre of everything, Ms Johnson said the lack of care she had received “humiliated her and her condition”.

“The failings of those entrusted to keep her safe not only led to the horrific and avoidable death, but also undermined and riddled her nearest and dearest of the right and the ability to grieve properly and wholly,” she said.

James Nolan described how his father Michael Nolan, 63, became depressed after his own mother died.

He was sectioned to a mental health ward in Essex, but took his life in 2022.

Mr Nolan said he had been shocked to learn at the subsequent inquest that staff had not observed his father, as they should have done.

“They didn’t give him the care, attention and treatment he so desperately needed,” said Mr Nolan, adding he could no longer “trust the NHS”.