Deaths in Mental Health Care

Before we start, I remind hon. Members of the new rules in Westminster Hall. They should be getting used to them now, but some have not been in a Westminster Hall debate. I ask Members to sanitise their microphones using the cleaning materials provided before they use them, and dispose of the materials as they leave the Chamber. Members are also expected to honour the one-way system, which means going round clockwise, coming in by the left entrance and leaving by the other entrance. Members can intervene only if they are on the call list. If you are on the call list, you are expected to be here at the start of debate but, unlike the position prior to covid, it is quite permissible to leave after having spoken.

Before I call the hon. Member for Hartlepool (Mike Hill), I need to advise hon. Members that I have been informed that there are active Health and Safety Executive criminal legal proceedings against Essex Partnership University NHS Foundation Trust relating to deaths in mental health care facilities between October 2004 and April 2015. I have further been informed that the trust has pleaded guilty in those proceedings to failures of care relating to the deaths of 11 patients. Active proceedings are sub judice until sentencing or discontinuance under the House’s resolution. Therefore, Members should be mindful of matters still before the court—in particular, the judgment and sentencing in this case.

I beg to move,

That this House has considered e-petition 255823, relating to deaths in Mental Health care.

It is an honour to serve under your chairmanship, Mr Stringer. I, too, received that advice not long ago, and sought advice on behalf of the petitioner in regard to anything that I have to say. I will navigate through my speech, bearing in mind that legal statement. I apologise in advance if I stray into such territory, simply because to do justice to this petition I have for the most part chosen to reflect the words of the petitioner. That is only right and just. More than 100,000 people have signed the petition. It is a very personal case, and it is personal for other families whose relatives have died in such horrendous circumstances.

The petition attracted 105,580 UK signatories in support, despite the fact that it was curtailed by the Government closure of Westminster Hall last November due to covid. I will read the text of the petition to put it on the record and inform hon. Members fully. I have spoken to the petitioner, Melanie Leahy, on a number of occasions, and I pay tribute to her for starting the petition. She wrote:

“I request a full public inquiry into death of my son, Matthew Leahy. (20 yrs.)

Matthew was taken to ‘a place of safety’, and died 7 days later. 24 others died by the same means, dating back to the year 2000. An indicator that little was done to address the growing problems. Something went terribly wrong with the NHS Mental Health Services provided to my son.

There really is no way that public concern can be allayed, short of an Inquiry. All investigations to date, including police and inquest proceedings, have been based on a Trust Serious Incident Investigation. A four and half year Parliamentary Health Service Ombudsman Report has now concluded that this investigation was not adequate and lacks credibility.

There has been an inadequacy of investigation. A human rights violation. New evidence has been uncovered and I request a statutory inquiry, that compels witnesses to give evidence on oath.

Matthew is not alone. Many others have died”—

in the same institution—

“whilst ‘In The Care Of The State’.”

The petition ends with a link to a press report dated November 2018 detailing how a two-year police investigation sparked by Matthew’s death six years earlier, into the corporate manslaughter of 24 further patients, was dropped, leaving families without “accountability or recourse”, for their loved ones’ deaths.

The statement reads:

“I am mum to Matthew James Leahy, born December 1991. He was a beautiful soul. He understood compassion and he cared for others. He was generous, he was kind, he was smart. He was funny and in his younger years he wanted to be a comedian. He was quite shy in large groups, and was a loyal friend. He was never one to encourage a fight but he would stand up for himself and the ones he loved. And I’m proud to say my son was honest, not a liar, not like some I’ve come across on this journey.

He loved the outdoors, loved anything water sports related and was a fantastic skier. Having left Grammar school, where he excelled in mathematics and computer science, he set up his own computer business, travelling between clients on his motorbike and was doing really well. He had a natural talent for swimming. He actually saved two ladies from drowning and when 18 he became a qualified life guard.

Aged 19 Matthew was having trouble sleeping and complaining of pains in his stomach and having stomach cramps. He was also hallucinating. When Matthew became poorly we turned to so called professionals for help, to help us to understand what was happening with our son. He was sectioned for care and treatment. This sectioning and the failings in care at that time, although noted briefly in the inquest verdicts, have never been investigated.

After Matthew’s death medical records showed that the first psychiatrist involved in his care picked up a B12 and folate deficiency and possible coeliac disease, combined with a thyroid issue. However, these discoveries were never addressed, as a new psychiatrist took over Matthew’s care and put him straight on to anti-psychotic medication. Any further physical checks were minimal.

On 7 November 2012, Matthew was placed under section 3 of the Mental Health Act and admitted to the Linden Centre in Chelmsford, Essex. By 15 November, some seven days in the ‘care of the state’, my son was dead. The last days of his life in a place he called ‘Hell’. And I now believe it truly was a hell on earth.

Alone, malnourished, over-medicated, scared, bleeding, bruised, reportedly raped, injected multiple times, ignored, and frightened. No records of any staff in those last seven days of his life offering him any comfort. I had been advised not to visit and to give him time to settle on the ward. I will live with the guilt for the rest of my life that I listened to so-called professionals and I was not there when my son needed me the most.

An inquest into my son’s death was held in January 2015. An open narrative verdict was reached, which concluded that my son, ‘Matthew James Leahy was subject to a series of multiple failings and missed opportunities over a prolonged period of time by those entrusted with his care. The jury found that relevant policies and procedures were not adhered to, impacting on Matthew’s overall care and wellbeing leading up to his death.’

There are a number of people on the list who wish to speak. I will start with a time limit of four minutes, and call James Cartlidge.

Thank you, Mr Stringer; it is a great pleasure to serve under your chairmanship, and to follow the hon. Member for Hartlepool (Mike Hill), who introduced the debate on behalf of the Petitions Committee. He spoke of the case of Matthew Leahy. It is a terrible tragedy, and I pay a huge tribute to his mother, who has campaigned for years through the pain, which is without limit.

We all sympathise, I am sure, but as the hon. Gentleman said the case of Leahy is not the only one at the Linden Centre, Chelmsford. There have been several others, all tragic, including my constituent Richard Wade. I held an Adjournment debate on the case of Richard Wade in October. At the start of that debate, because the HSE case was live, a much stricter sub judice ruling was given, which meant there were things I could not say in the Adjournment debate that I feel able to say today.

I have a very short period of time and I do not have time to give the full details of Richard Wade’s case. The key point is that, on the day he was found hanging in the Linden Centre in Chelmsford, there is strong evidence that his parents have seen—not just documentary evidence, but other evidence that has come to them, including from people who have worked at the Linden Centre—that when his body was first discovered hanging, still alive, the clinicians who found it either panicked, or for some other inexplicable reason left it hanging, locked the door and allowed some minutes to pass before he was discovered a second time, this time with his parents nearby. At that point he was given resuscitation and urgent medical treatment. We do not know the impact of those crucial minutes on his eventual fate several days later, when he passed away. Essentially, his is a life that I believe could have been saved and a death that could have been avoided.

I will not repeat all the points I made about Richard Wade’s case in my Adjournment debate, other than to say that although he died in May 2015—in fact, I met him going to vote in Great Cornard in May 2015, a few days before I had the great privilege of being elected for the first time, and he was dead several days later—in February 2015 another man, who I believe was called Beecroft, also died by ligature in the Linden Centre in Chelmsford, in the very same bathroom where Richard Wade hanged himself that May. The extraordinary thing is that, when the trust reported on Richard Wade’s death in December that year, it never mentioned that there had been a hanging in the same bathroom three months earlier—as if it were a common occurrence or something. It is quite extraordinary.

These are terribly tragic cases; sometimes they cannot be avoided, of course, but at times they are due to the performance of the trust and perhaps of the management of that trust. Where that is the case, does my hon. Friend agree that the leadership of those organisations must be held to account for their performance?

My hon. Friend makes an excellent point, echoing the concluding remark from the hon. Member for Hartlepool, and he is absolutely right that there must be accountability. However, when we go into an independent inquiry, there is a danger of saying, “Well, it must be a statutory public inquiry,” and getting into the semantics of the mechanism we use.

I think what my constituents the Wades want is the truth. They simply want to know the truth about what happened to their son. We now have a tangible offer from the Department of Health of a mechanism that all the families can use to get involved, to shape the terms of reference and to help us to deliver something in the public interest—as, again, the petitioners seek—to the benefit of the whole country in terms of wider mental health. Above all, that will bring some sense of accountability to all the families who have suffered so tragically at the Linden Centre in Chelmsford, including the Wades and the Leahys. I believe that the Minister will now act and I give her all my support in doing so.

It is a pleasure to speak in this debate with you in the Chair, Mr Stringer. I thank the Petitions Committee for granting this important debate and my hon. Friend the Member for Hartlepool (Mike Hill) for opening it, and I congratulate Melanie Leahy on the strength of her campaigning to get us to this debate.

As we have heard, Matthew’s case is a tragic one, with a catalogue of failures that culminated in his death. I know that nobody here can fail to be moved by what Matthew and his family went through—the hon. Member for South Suffolk (James Cartlidge), who has just spoken, certainly was. Melanie has been fighting for answers and justice for her son for eight years now; I pay tribute to the work she has done, but I also say it should not have been necessary.

Matthew was in the Linden Centre for only a few days. In that time, he reported a sexual assault to the police, but they took no follow-up action on his report. Staff claimed that he lacked mental capacity, despite no assessment being carried out. He was heavily medicated with anti-psychotics and tranquillisers, despite his telling staff that he would attempt to kill himself if he was given injections. As we have heard, only a week after being admitted, he was found hanging in his room and he died.

That catalogue of failures would be shocking in itself, but it ended with a young man dying. In cases such as Matthew’s, we have a duty to learn the lessons and ensure that others in mental health care do not end up dying preventable deaths.

I sympathise greatly with the hon. Lady and the story that she is telling and that other hon. Members have told. Does she agree that when it comes to helping people who have mental and psychiatric issues, who need help more than anyone, it is important that facilities are modern? They need in-patient care and they need the staff to be trained and able to respond. If those things were improved, does she think that would be a step in the right direction to try to help people and prevent such tragedies from happening?

There is much that needs to change, but the hon. Member is right that that is one aspect of it. The mental health estate is known for being run down and out of date.

The learning of lessons has not happened in the Linden Centre or in mental health services in Essex. The charity INQUEST has worked on more than 28 cases involving deaths in mental health settings in Essex since 2013, yet despite the many investigations, reports and inquests that have highlighted failures, preventable deaths have continued. At the Linden Centre, INQUEST is aware of six in-patients found hanging between 2004 and 2019. Despite repeated inspections and visits by the Care Quality Commission, people have continued to die in those services.

The ombudsman’s report found clear signs of a cover-up at the Linden Centre. As Melanie told me:

“Matthew had no key worker. Records of observation levels and when he had been observed were changed. His care plan was falsified after he died. His claims of rape were ignored. Lots of documents were missing and a whole catalogue of policy failings were uncovered.”

That speaks of a culture that is less interested in learning from failings than in avoiding the blame for Matthew’s death.

The only way to restore trust in our mental health services is to publicly demonstrate that all those issues, including the one that the hon. Member for Strangford (Jim Shannon) mentioned, are considered and addressed. Melanie Leahy has suggested that the only way to do that is through a full public inquiry. At the inquest into Matthew’s death, the coroner asked the NHS trust to consider commissioning an independent inquiry.

The ombudsman, in his recommendation, said that the review due to be held by NHS Improvement

“should consider whether the broader evidence it sees suggests that a public inquiry is necessary.”

It is a pleasure to serve under your chairmanship, Mr Stringer. I congratulate the hon. Member for Hartlepool (Mike Hill) on the wonderful way in which he opened the debate and the two preceding speakers on their powerful contributions. I rise to speak on behalf of my constituent, Mrs Marian Coles, who was alerted to the debate and contacted me. I want my speech simply to be what she has written to me, to place her concerns on the record. Mrs Coles said:

“I am writing regarding the Westminster Hall debate concerning deaths in mental health care which calls for independent investigations into deaths in mental health settings. As a family that has been personally affected by this after our son took his own life whilst a mental health inpatient in Kettering in May 2017, we would ask if you would represent us at this debate. This was the second suicide at this facility 7 months apart. Staff failings were admitted at the inquest and 3 nurses were disciplined but they refused to give us the details. It has taken us 3 years for the NHS to settle this case.

We were involved with the serious incident report that took place but strongly support an independent inquiry being held after such deaths as is allowed in other organisations. Why should an organisation investigate itself over a death that may have been caused or contributed to by failures of its own staff or systems? The lack of an independent inquiry hampers the ability to root out issues of system neglect or misconduct and also jeopardises the welfare of future patients by failing to address such concerns. There is overwhelming evidence that the current system for investigating deaths in mental health settings is not fit for purpose.

“We very much hope that you will be able to take part in the debate and offer your support”—

I do—

“for an independent inquiry for families that may be affected by these tragedies. I am deeply traumatised by the death of my son, as is all of my family and we have to live with this every day of our lives”.

It is a pleasure to serve under your chairmanship, Mr Stringer. The circumstances of the debate are truly heartbreaking. I begin by extending my condolences to the family of the late Matthew Leahy and all families who have lost loved ones with mental illness at the hands of those who were supposed to protect them and care for them.

For many decades, mental health has not received enough attention or funding in comparison with physical illness. I draw attention to the mental health unit in Lewisham, which has already been viewed as not being fit for purpose—it was not built for people who have mental health problems—yet funding has never materialised for the changes needed to make it suitable for people with mental health problems. With the pressures of the pandemic, medical professionals are reporting more and more that people are suffering with mental illness due to economic hardship or loneliness, so it is clear there will be greater demand for mental health services over the next few years. It is imperative that we have well-functioning and well-funded mental health services to prevent needless deaths of the most vulnerable who are in need of those services. Medical professionals, the police and everybody around them also need support to be able to care for people with mental health illnesses. They need training, supervision and, most of all, not to be overworked. They also need to be able to debrief when they find things difficult.

I would like to raise the case of the late Kevin Clarke, from my constituency of Lewisham East, who sadly died following a mental health relapse. My condolences go out to his family, who are still bereft from the loss of Kevin, who, despite not posing an immediate threat to anyone, was handcuffed and placed in a leg restraint while telling the police that he could not breathe. In October, an inquest concluded that the officer’s restraint and supervision towards Kevin were excessive and sadly contributed to his death. However, the police were not the only professionals involved in his care. Other professionals were also in contact with him prior to this tragic incident.

Hon. Members have either not turned up or taken less time than expected, so, unusually, I will increase the time limit for the last speakers to five minutes.