Exclusive
My son died and I said 'you can take him off your books now': Essex's mental health service crisis
ITV News reporter Charlie Frost explores the inquiry into the deaths of hundreds of mental health patients in Essex
Warning: This article contains details that some readers may find distressing
Carole's youngest son Lee took his own life in 2019. Three months after leaving an Essex mental health unit.
"I love you so much and I'm sorry" reads the letter he left for his mother.
"We had to bury him the week after his 21st birthday. The first thought is he should be here. He should be with us, he should be enjoying this with us. He's missed everything and he might not have if he'd got the help that he asked for."
Carole says her son, who was diagnosed with emotionally unstable personality disorder (EUPD), was promised therapy and a support worker in the community after he was discharged. But, despite her calling the service weekly, it never materialised.
"After Lee died, I called them and said to them, 'you can take him off your books now'," she tells me.
"Within half an hour they were on the phone to me apologising and I've got a letter, dated that day I think or the day after, trying to sweep up the problem."
I’ve been reporting on those so-called ‘problems’ - the failings in Essex’s mental health services - since 2019.
But families have been fighting much longer than that for change, and in the five years I’ve been covering their progress it did feel as if there were a few watershed moments.
One was in a courtroom in Chelmsford when a judge handed the provider of mental health services in the county, Essex Partnership University NHS Foundation Trust, a £1.5 million fine for failings that led to 11 people being able to take their own lives on their inpatient wards between 2004 and 2015.
Campaigners outside the crown court, led by Melanie Leahy - whose son Matthew was one of those 11 - were jubilant. A small price, but progress they felt to exposing the truth.
Their big push though has been for a statutory public inquiry into mental health deaths in Essex.
In 2020, then-MP and Minister for Mental Health Nadine Dorries almost granted their wish by ordering a non-statutory inquiry, after Melanie raised the signatures needed for the issue to be debated in parliament.
Almost four years later, the inquiry - now in its statutory form as campaigners wanted - will finally begin on Monday. It will investigate how 2,000 patients died under the care of mental health services in Essex between 2000 and 2023.
Carole is one of those taking part and she will tell the Chair of the inquiry, Baroness Lampard, of her son's story.
Former patients will also give evidence, including one woman who told me that within three weeks of being admitted to the Linden Centre in Chelmsford, she was raped by a fellow patient. As a victim of sexual assault we are protecting her identity.
"You should be saying I'm lucky that I got the mental health support I needed at the right time but no - I'm lucky I survived the Linden Centre," she tells me.
"I can remember at least two other occasions during my time on the ward where other women were raped. We were certainly not kept safe from one another, or from ourselves.
"I think in my case I don't blame the patient who raped me - he was unwell. I blame the staff that weren't able to safeguard me."
Subscribe free to our weekly newsletter for exclusive and original coverage from ITV News. Direct to your inbox every Friday morning.
She says the treatment was cruel, describing how a staff member "smirked" at her when she asked for birth control following the rape.
She also recounts how "dangerous" the ward was, claiming that on occasions members of staff who were being paid to care for her would be distracted or sleep while on shift.
"I managed to abscond from the ward a couple of times. Once I took a very serious overdose. But as I say it was a very chaotic environment.
"It wasn't structured towards people becoming well. It was like you were contained in this pen and people didn't really know what was going on."
The Trust runs 35 adult inpatient wards and three for children and teenagers across the county. The acute wards are now segregated so men and women are separated.
But, in the four years since this inquiry was first ordered, concerns about the Trust have continued to be raised.
In that time coroners have written to the Chief Executive 14 times following 14 separate deaths, demanding "urgent action" is taken to prevent future deaths.
One mother, whose daughter is currently being treated at The Lakes in Colchester, sent me photographs that appear to show staff asleep when they are supposed to be on suicide watch, watching her daughter 24 hours a day.
She says it's led to her daughter being able hurt herself on the ward.
In a statement the Trust's Chief Executive Paul Scott urged anyone with concerns around their care to contact them.
Mr Scott said: “We know how painful this time will be for those who have lost loved ones and our thoughts are with them. We will continue to do all we can to support Baroness Lampard and her team to provide the answers that patients, families and carers are seeking.
"We would urge anyone with concerns around their care, or that of a loved one, to contact us directly so that we can offer direct support.”
Essex Partnership University NHS Foundation Trust has urged anyone affected to contact their Patient Advice and Liaison Service (PALS) on 0800 0857935 or epunft.pals@nhs.net
The Department of Health told me the Secretary of State for Health and Social Care, Wes Streeting, will soon meet the families involved.
Mr Streeting said: “My thoughts are with all those affected, including the families and loved ones of those who tragically died. This is incredibly sad, with loss and suffering on a large scale.
"As part of this, I will be meeting the families shortly to hear directly of their experiences and to reassure them that we take this issue extremely seriously.
"We remain committed to assisting the Inquiry and will work with partners to transform mental health care as we fix our broken NHS.”
Priya Singh, a Partner at law firm Hodge Jones & Allen, is working with 52 families who are taking part in the inquiry.
She told me: "People are continuing to die because of failings at the trust. The failings are continuing to happen. It's happening potentially today, yesterday, tomorrow. This is not something of the past."
For grieving families like Lee's, the damage is already done but the fight continues for justice and reform.
"I don't want any other family to go through what we've been through," Carole says.
"If one of my grandchildren need help when they're older hopefully if they ask for help they'll get it. Things need to change."
And that's what it's hoped this inquiry will bring - truth and change.
If you or someone you know is suffering as a result of mental health, there is help and support available. In an emergency call 999 or go to A&E
Samaritans: Call on 116 123 or visit the website.
NHS 111: Non-emergency advice is available online (Only call 111 if you cannot get help online). People with hearing problems can use the NHS 111 British Sign Language (BSL) service.
MIND: Call 0300 123 3393 or find tips and support on its website. Mind information and support.
Shout: Confidential 24/7 crisis text support. Text "SHOUT" to 85258 or visit Shout Crisis Text Line.
Crisis Support For Young People: Under 35s. Call Papyrus's Hopeline UK from 9am to 10pm weekdays and 2pm to 10pm on weekends. 0800 068 41 41. Text 07786 209697 or visit the Papyrus website.
CALM: The Campaign Against Living Miserably, for people in the UK who are down or have hit a wall for any reason. Call 0800 58 58 58 (daily, 5pm to midnight). Free, anonymous webchat with trained staff or visit the CALM website.
Additionally, if you or someone you know has been a victim of rape or sexual assault, you are encouraged to report it to police by calling 101, or 999 in an emergency. Support can also be found through a number of organisations, including:
Rape Crisis England and Wales: Call 0808 802 9999 or visit its website for help and support.
Rape Crisis Scotland: Residents in Scotland can call for help on 08088 01 03 02. Alternatively, support and advice can also be found here.
Want a quick and expert briefing on the biggest news stories? Listen to our latest podcasts to find out What You Need To Know…