Observations and the Use of Technology – Rounding up the Lampard Inquiry’s Interim Recommendations Hearing and Evidence

The Lampard Public Inquiry has now concluded its first set of hearings dedicated to potential interim recommendations. Interim recommendations play a vital role in a public inquiry; they are available for a Chair (or panel) to implement during the lifespan of an inquiry if there is found to be an immediate, ongoing public safety issue within the inquiry’s remit to address. Once identified and provided there is enough evidence to support the making of recommendations, a Chair can recommend immediate action for the Government to take to limit any active risk or correct the urgent issue. This is with a view to the completion of the entire inquiry process where final recommendations will then be made.

In the case of the Lampard Inquiry, Baroness Lampard is considering the need for interim recommendations in relation to two crucial topics:

• Resuscitation; and
• Observations and the Use of Technology.

During her opening remarks at the recent hearings, Baroness Lampard acknowledged the critical importance of these issues not only for Essex, “but for service providers across the entire country” ¹. She explained that since the last hearings in July she had reflected on the urgent concerns raised by core participants, admitting that she too “share[s] some of those concerns” ² and now considers that urgent action may in fact be necessary to address an ongoing safety issue affecting current patients.

These issues, however, are unfortunately not new; observations and the use of technology in particular is one the inquiry has been grappling with since October 2025. Significant efforts were made at an early stage by the campaign group, Stop Oxevision³ who dedicated their efforts to bringing this issue to the Inquiry’s attention. It is predominantly focused on a product called Oxevision, a video-based monitoring system manufactured by ‘LIO’, formerly known as Oxehealth, which EPUT have been using on its wards since early 2020. Oxevision uses an infrared camera to remotely take a patients’ pulse and breathing rate while they are in their bedroom. The pilot began in February 2020 on 4 of its wards; Ardleigh, Chelmer, Peter Bruff and Hadleigh, and within 5 years it had expanded until it covered 30+ wards at EPUT to the tune of more than £4 million⁴.

Over the course of the last year, the inquiry has obtained tens of thousands of records, heard from a vast range of witnesses (including government agencies, EPUT staff members and experts) and has held 3 public evidential hearings investigating EPUT’s use of Oxevision. Hodge, Jones and Allen LLP represent several bereaved core participants whose loved ones’ care involved use of the technology before their deaths, and others with lived experience who recall oxevision first hand as patients. For each of them, this issue is deeply personal. Some have already given evidence, bringing a much needed human perspective to the Inquiry’s work.

One year later and the evidence, in our view, points in one clear direction: that there is no reasonable case for oxevision to be maintained at EPUT. The evidence demonstrates that the technology has fundamental flaws, the financial cost is excessive, the research base is weak and patient safety risks associated with the misuse of the system have caused significant harm.

Some of the key highlights can be broken down as follows:

The premature expansion

EPUT records show that the Trust’s rapid expansion of Oxevision which began in February 2020 was, by all accounts, hurried through without any in-depth audit to substantiate the benefits it was purported to deliver. Zephan Trent, EPUT’s Executive Chief Digital and Information Officer gave a statement to the inquiry where he claimed Oxevision was brought in to tackle risks of ligaturing, self-harm, improve sleep and improve patient safety⁵. Six years later and millions of pounds spent, he now admits that those aims were in large part never realised and that EPUT should and could have done more to fully evaluate the situation sooner:

“No, I’m saying that when we look back, the evaluation clearly could have been better. And that there are tools available which could have been deployed at EPUT⁶ … When we look back, that’s a learning for us. We should have…put clearer outcome measures in place earlier and we should have evaluated those more effectively than we did⁷” – Zephan Trent, 14 October 2026.

The weak evidence base

The inquiry’s instructed expert health statisticians, Professor Christl Donnelly and Dr Maria Christodoulou, gave evidence in July regarding the viability of the research base for oxevision. Their findings were equally stark. They concluded that the current evidence provides only “limited and cautious support for the use of oxevision”. In their view, much more independent research is needed before we can determine with any degree of certainty what the evidential benefits are of the system:

“In summary, Professor Donnelly and Dr Christodoulou concluded that the current evidence provides only limited and cautious support for the use of Oxevision and related VBPMS in mental health inpatient settings. The evidence available suggests that the technology is technically feasible and may have potential operational applications, but it does not provide strong independent support for clinical effectiveness, improved patient safety, acceptability or cost effectiveness in mental health inpatient settings. Professor Donnelly and Dr Christodoulou are of the view that further independent, randomised and adequately controlled research would need to be undertaken before any stronger conclusions could be drawn⁸”– Counsel to the Inquiry, Rebecca Harris KC, 23 July 2026

The lack of clinical effectiveness

In addition to the research base, the inquiry investigated the clinical and therapeutic aspects of oxevision in practice. We heard evidence from instructed experts, Jill Archibald, a Consultant Nurse and Dr Francesca Denman, a Consultant Psychiatrist. Dr Denman’s assessment was clear: in most (if not any) cases, Oxevision is not currently a system that can provide support for clinical decision making, general psychiatric assessments, risk management or to determine a patient’s required observation levels. Jill Archibald emphasised the human connection. She spoke very directly about observations needing to be “human, relational and patient centred⁹”, and that where they are reduced to just a tick box and surveillance exercise, they completely lose their meaning:

“Observations can and do save lives, but it really does boil down to the quality of them and the relationship that you have with the patient. That patient is going to interact with lots of professionals in a day when they’re on enhanced observations and it actually doesn’t matter that there might not be some staff that they don’t like or get on particularly well [with] because you are not going to engage — it’s not normal to have therapy for 18 hours a day. So as long as it is meaningful and there’s certain elements in the day where they get to be with a professional that they do that work with, then it really can change lives…When it’s become procedural or surveillance, that’s when we’ve completely lost the meaning of it.¹⁰” – Jill Archibald, 22 July 2026

The continued misuse and over-reliance

Over the course of several hearings, we also heard evidence from bereaved families directly, including parents of young adolescents who died under EPUT’s care, where the misuse and/or misunderstanding of oxevision featured in the case. Among them, HJA client Victoria Sebastian told the inquiry during her live evidence that her young daughter’s oxevision alarm was muted by staff, leaving her alone and unattended to for an extended period of time following her final suicide attempt. Elise Sebastian was only 16 years old when she died:

“the ability to mute it [the oxevision alarm], or for it not to sound, bearing in mind Elise was there for a good number of minutes, 20 at minimum, without anyone even being alarmed to it…I don’t know how you should be able to do that.¹¹ – Victoria Sebastian, 13 July 2026.

These families now raises serious questions as to whether there is any justification at all for trusts using oxevision when it has proven to be a system that is vulnerable to grave misuse and misunderstanding. We heard claims about staff fatigue because of the frequency of alerts going off, we heard about alarms being turned down, muted and even switched off. Despite it supposedly being an ‘assistive tool’, NHS England reported to the inquiry that they found “57 national incidents”¹² where ward staff used the system’s 15-second video feed function to conduct “all patient checks and planned intermittent frequent checks for patients in their bedrooms”¹³ .

Taken together, this important evidence points to a persistent, fundamental problem with oxevision; its high potential for misuse and/or over-reliance. These concerns have resurfaced in different forms in multiple trusts over several years. It appears to all who advocate for the termination of it, nonsensical, to continue hoping guidance and training will eliminate those risks, instead of Trusts simply treating them as what they are; active and unresolved patient safety issues that may not in fact be fixable. Dr Denman raises similar key questions in her report with reference to the case of Michael Nolan, 63 years old, who died on an EPUT ward on 10 July 2022 after his oxevision alarm was turned off:

“Michael’s distress, before he did a fatal thing, was missed, and second, an alarm expressly designed to signal presence in an at-risk area was turned off. The question is whether systems of this sort as so tempting to pressed staff that the risk can never be mitigated against¹⁴” – Dr Chess Denman, Expert Report

The ongoing national picture

In relation to the national picture, the main cause for concern has been about the issue of consent, specifically ensuring that all trusts with oxevision in place have consent models that respect human dignity and comply with national guidance. The inquiry has learned through EPUT’s own disclosure that it took the Trust 5 years to change its protocol from an implied, opt-out model to an express opt-in one. The change was finally corrected in May 2025 (with version 12 of its Standard Operating Procedure), 3 months after NHSE issued national guidance that made reference to the use of digital technologies needing to be “based on consent¹⁵”. What remains troubling however is the fact that there are 10 trusts across the UK that still operate non-compliant consent models. These trusts have also only been referred to the Care Quality Commission for investigation by NHSE earlier this month. This is despite NHSE’s Digital Principles guidance being issued over a year ago and oxevision being on the market for at least the last 6 years. This devastating and troubling reality raises three stark conclusions: firstly, that government institutions (NHSE, the CQC, the MHRA and even the DHSC) have clearly failed to regulate oxevision effectively, both in terms of monitoring and in taking enforcement action where necessary. Second, it proves that where guidance and advice is issued without the threat of enforcement action, it can render the advice ineffective which is what causes inconsistent approaches being taken by different organisations around the country. Lastly, it proves quite categorically that there are risks to patient safety arising from the infringement of human rights and data protection that remain unresolved. Something which in this late day and age is truly unacceptable.

Concluding thoughts

The Inquiry is expected to turn in the new year to further issues under consideration, including Assessments and Admissions, Safeguarding and Sexual Safety. These topics are incredibly important, but before the inquiry moves on, we strongly believe it can and must now confront the weight of the evidence it has heard regarding oxevision.

In her closing remarks on 15 October 2026, Baroness Lampard reminded the public that all affected families and patients remain at the heart of the inquiry’s work. She has a real opportunity to demonstrate that commitment now by using her powers to deliver much needed change.

We await her decision and stand ready to support and represent the families and individuals that remain steadfast in their campaign for improved treatment and patient safety in mental health care.

Hodge Jones & Allen Medical Negligence solicitors represent a cohort of around 70 Core Participants engaging with the Lampard Inquiry. This includes bereaved families whose loved ones died whilst under the care of Essex Partnership University Trust (EPUT), as well as individuals with lived experience who have suffered significant harm.