Senior representatives from Ison Harrison joined families, patients and campaigners this week for a significant engagement meeting with the Department of Health and Social Care (DHSC), focused on the set-up phase of the Statutory Public Inquiry into failings within mental health services under Tees Esk and Wear Valley (TEWV) NHS Foundation Trust.

News of the inquiry has featured on mainstream media, including an ITV News interview with Jess Evison, mother of a man who died following mental health trust failings. In the report, in which we also hear from Ison Harrison’s Alistair Smith, she speaks openly about the impact of the care her son received and the urgent need for accountability as the statutory public inquiry begins.

Around 50 individuals attended in person and online, sharing deeply personal experiences and contributing to the discussion around the terms of reference, scope, and leadership of any future inquiry. The meeting formed part of an ongoing consultation process designed to ensure the inquiry reflects the full breadth of concerns raised by those most affected.

Strong representation and collective commitment

Our firm was represented by:

  • Sarah Magson, Partner and Branch Manager
  • Gareth Naylor, Director and Head of Department
  • Alistair Smith, Senior Solicitor
  • Gemma Vine, Partner
  • Dawn Makepeace, Senior Solicitor
  • Sophie Kendall, Maeve Davies and Angela Goodchild (online)

We were also supported by Counsel from Garden Court North Chambers:

  • Anna Morris KC
  • Ciara Bartlam
  • Kate Stone

We currently represent a substantial and growing number of families and individuals seeking answers, accountability and lasting reform.

Key themes emerging from the discussion

Throughout the meeting, families and patients highlighted systemic, long-standing and ongoing concerns that they believe must sit at the heart of the public inquiry.

Establishing the truth and learning lessons

Participants stressed the importance of:

  • Determining how many deaths and serious harms have occurred over the past decade
  • Understanding how care failings contributed to those outcomes
  • Delivering robust recommendations to prevent future tragedies
  • Ensuring a trauma-informed approach that recognises the lived experiences of families and survivors
  • Ensuring change is made now to support current patients and service users
  • Looking deeply at governance and systemic failings

These themes were repeatedly linked to a perceived failure to learn lessons, with families reporting that similar incidents continue to occur despite investigations and action plans.

Many families also expressed that, due to trauma and past experiences, they feel unable to engage with TEWV at present, despite urgently needing support. We have asked the DHSC to address this issue as a matter of urgency.

Scope of the inquiry: system-wide scrutiny

There was strong consensus that any inquiry must examine (amongst other things):

  • Care pathways from community to inpatient settings and back again
  • Crisis response, discharge planning and community support
  • Experiences of children and young people, neurodivergent patients, older adults and rural communities
  • Governance, transparency, whistleblowing and organisational culture from ward to board level
  • Coordination between mental health, physical health, social care and external agencies

Families emphasised that failures are not purely historical, with many describing continuing risks, barriers to care and from today.

Many families were also concerned that the BPD+ Protocol (a protocol for the reduction of harm associated with suicidal behaviour, deliberate self harm and its treatment for people with a diagnosis of borderline personality disorder and related conditions), had become culturally embedded within practice, and that this culture must change as part of any meaningful reform.

Accountability, transparency and meaningful change

Across contributions, several consistent priorities emerged:

  • Full accountability for deaths and serious failings
  • Clear action plans to prevent recurrence
  • Independent scrutiny rather than organisations “marking their own homework”
  • Accurate record-keeping, open disclosure and compassionate engagement with families
  • Assurance that recommendations are implemented and reviewed over time

Families highlighted that TEWV should not be responsible for conducting its own investigations, and that an independent external body is required. This issue will need particular emphasis when the inquiry Chair is appointed.

Many speakers described prolonged struggles to obtain answers through complaints, investigations and inquests, reinforcing the need for a thorough statutory inquiry with real powers, ‘leaving no stone unturned’.

Leadership of the inquiry

A clear majority of attendees supported the appointment of an independent legal chair (ideally a judge with no links to the NHS), supported by specialist expert evidence. This was viewed as essential to:

  • Command confidence from families
  • Exercise statutory powers to obtain documents and evidence
  • Deliver an inquiry that is thorough, transparent and effective
  • Our continuing commitment

This meeting represents another important step in the collective effort to secure:

  • Truth for families
  • Justice and accountability
  • Systemic reform to protect future patients

We remain committed to standing alongside those affected, ensuring their voices are heard at every stage, and working constructively with government and stakeholders to achieve a meaningful, independent public inquiry.

Families have waited far too long for answers. Their experiences must now lead to lasting change.

If you believe you or a loved one has been affected by failings within mental health services under the Tees Esk and Wear Valley NHS Foundation Trust, you can contact our team today for a FREE no-obligation chat. Call us on 01642 070860 or email TEWVInquiry@isonharrison.co.uk.