The chairman of an inquiry into the way Southern Health investigates patient deaths and complaints has strongly condemned the intimidation of a witness.
Nigel Pascoe QC was speaking on the last day of a hearing which was prompted by failures in the way the Trust cared for five patients who died between 2011 and 2015.
The Trust provides mental health services across Hampshire and last year it was was rated 'good' by the Care Quality Commission, however it had previously come under fire for a lack of leadership.
Jo Deering, David West, Robert Small, Edward Hartley and Marion Munns were all under the care of Southern Health at the time.
Their families believe that poor care contributed to what they believe were entirely avoidable deaths.
Last year's inquiry was set up to try to learn lessons, but the families withdrew, saying they felt "gaslighted and bullied" by the NHS, still very angry about how complaints are dealt with.
Jo Deering's sister, Maureen Rickman, says: "They need to recognise every death matters, to the health safety and welfare of every carer in the care of the Trust and until that message is recognised, nothing will change."
Nigel Pascoe QC, said at the outset that the anger of bereaved families was 'palpable' and 'had to be addressed'.
His job now will be to filter through the evidence that has been heard over the past three months.
Much of it has been positive from senior staff members who say there has been a 'cultural shift' at the Trust, but some like John Green, a former governor at Southern Health who resigned in frustration say the issues are deep-seated through the whole NHS.
John says: "Whoever comes into the organisation gets subsumed into the culture of the NHS which I've described as both totalitarian and anarchistic.
"The focus should be on the people doing the work and if people are dying, they need to sit down together and improve management and healthcare methodology which prevents those things from happening again."
Closing the hearing on Thursday (29 April), Mr Pascoe said the only serious interruption of proceedings was the 'deliberate and wicked intimidation' of a trust employee which caused considerable distress.
He said: "We have learnt to our utter disgust of further cruel bullying of that witness since she gave evidence..... where that may be appropriate the Law should take its course."
Mr Pascoe said the aim was not to investigate past bad experiences but to report on the present position of the trust and where there is a need to improve to make recommendations.
He is due to report back by the end of June.