HOW MANY PREVENTION OF FUTURE DEATHS REPORTS DOES IT TAKE BEFORE “LEARNING” BECOMES ACTION? Since the Essex Mental Health Independent Inquiry began in 2021, coroners have continued issuing Prevention of Future Deaths — Regulation 28 — reports involving EPUT. These are not campaign claims. They are formal coronial warnings issued where a coroner believes there is a risk that future deaths could occur unless action is taken. And when you read through the reports, the same themes keep appearing: Risk assessment. Care planning. Record keeping. Communication. Discharge planning. Training and supervision. Failure to escalate deterioration. Lack of inpatient beds. Families raising concerns and not being heard. What makes this even more concerning is that EPUT itself carried out a thematic review of earlier Prevention of Future Deaths reports and identified recurring themes including communication, training and supervision, record keeping, discharge planning, care planning and risk assessment. Yet subsequent coronial reports continued to identify similar concerns. In the Darren Turner case, the coroner concluded that action taken to address previously recognised failures remained “inadequate and incomplete.” Then came further deaths. Jack Peatling was assessed as being at such high risk that he could not safely be managed in the community — yet no inpatient bed was available. Stuart Berry had repeated contact with mental health services before his death, with later findings that failures in his care probably contributed. Martin Bryant repeatedly attended Basildon’s Mental Health Urgent Care Department, with further concerns raised about patients waiting for admission and the availability of mental health beds. And these are only some of the cases. The most troubling part is this: These are not simply historic failings from years ago. Some of these deaths, inquests and formal coronial warnings occurred while the Essex mental health inquiry process was already under way. A Prevention of Future Deaths report is supposed to do exactly what its name says: Help prevent another death. So when the same concerns continue to appear, we have to ask: What happened to the learning? How many warnings does one organisation need? How many reviews? How many action plans? How many families have to be told that lessons will be learned? And most importantly: How many more people have to die before those lessons translate into demonstrably safer care? The Lampard Inquiry now has the opportunity to look beyond individual incidents and examine whether these repeated coronial warnings reveal something deeper about learning, accountability and whether failures were genuinely prevented from happening again. Families deserve more than assurances. They deserve evidence that lessons were actually learned. #LampardInquiry #EPUT #MentalHealth #PatientSafety #PreventionOfFutureDeaths #Regulation28 #Accountability #ListenToFamilies #MatthewsCampaign