Care Quality Commission: Deaths in Mental Health Facilities
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The Minister for Health (Edward Argar)
I congratulate my hon. Friend the Member for South Suffolk (James Cartlidge) on securing this important debate and his dedication in representing his constituents. He is an old friend of mine and I know how committed he is to his constituents’ interests. Having spoken to him about this particular case, I know how much it matters to him. I was very sorry to hear about the tragic circumstances of this case.
I wish to put on record, at her request, the fact that the Minister for Patient Safety, Mental Health and Suicide Prevention would dearly love to have been in the Chamber today, given how closely she has been involved with this case and situation. However, as a contact of a recent positive covid case, she is doing the right thing, as always, and staying away. I know that she is watching this debate as we speak and that she will continue to keep very much in touch with developments. I am sure she will speak to my hon. Friend the Member for South Suffolk very soon.
I thank my hon. Friend for raising the concerns about the tragic circumstances around the care of his constituent, Richard Wade, at the Linden Centre, and the CQC’s role in investigating the events. As my hon. Friend set out, in May 2015, Richard tragically took his own life while under the care of the Linden Centre, a mental health facility in the Essex Partnership University NHS Foundation Trust. I put on record my heartfelt sympathies for and condolences to Richard’s family. I understand the devastating impact this must have had on their lives. The passage of time will do nothing to dim that, so I wanted to put that on the record.
As a Minister in the Department of Health and Social Care, I am fully committed to ensuring that we provide the highest standards of quality and safe services to patients, and that when there are failures in the delivery of those standards, we are transparent about how we are learning lessons. My hon. Friend raised important issues about the failings of the CQC in responding to the concerns of Mr Wade’s family following his death, and I have noted the CQC’s review of its handling of these matters. The CQC states that it decided not to use criminal enforcement powers to prosecute the trust—it states that this decision was taken after liaison with the Health and Safety Executive and Essex police—and instead to use civil enforcement powers against the trust after Mr Wade’s death. The CQC further states that there was, in its view, insufficient evidence to proceed to criminal enforcement as, according to the CQC, the evidence indicated that breaches were committed by a series of individuals whose actions lay outside the CQC’s prosecution powers. However, my hon. Friend has clearly set out his views on that and on the CQC’s actions. The CQC has unreservedly apologised to Mr Wade’s family for its handling of this case.
As my hon. Friend set out, the CQC review findings identified areas for improvement and organisational learning. The CQC has committed to internal learning for staff and to support providers to recognise ligature risks and improve safety for people who use mental health services. The regulator is providing mandatory training across all inspection teams on decision making and has strengthened its enforcement training for new inspectors. Importantly, the CQC works closely with families and ensures that their involvement and feedback is considered as an integral part of what the regulator does.
On the wider health system and learnings, last year the CQC wrote to all NHS providers of mental health services regarding concerns about the quality and safety of care provided on mental health wards. While progress has been made, there is still significant variation across the country, with a lack of improvement in some mental health settings. In July this year, the CQC wrote to all NHS providers of mental health services, highlighting that it will be looking at this in inspections of wards. Where insufficient improvements have been made, the CQC will take enforcement action.
In 2018, we launched a zero-suicide ambition for mental health in-patients, which means that every mental health trust now has a zero-suicide ambition plan in place. Those trusts will be supported by a new mental health safety improvement programme, which we committed to in the NHS long-term plan.
As my hon. Friend will be aware, the Parliamentary and Health Service Ombudsman laid a report before Parliament in June 2019 on a series of significant failings in the care and treatment of another two vulnerable young men who died shortly after being admitted to the Linden Centre: Matthew Leahy and Mr R. My thoughts are with the families of all those patients who died at the former North Essex Partnership University NHS Foundation Trust, and we are committed to learning lessons from those tragic events.
As my hon. Friend said, the Minister for Patient Safety, Mental Health and Suicide Prevention gave evidence to the Public Administration and Constitutional Affairs Committee last year. The Committee looked into missed opportunities and the recommendations made by the PHSO, and my Department is considering its response to the Committee’s report, which it looks forward to publishing in due course.
As you alluded to, Mr Deputy Speaker, the Health and Safety Executive has investigated the trust, and as a result of that investigation, the Health and Safety Executive has brought a prosecution against the Essex Partnership University NHS Foundation Trust. As Members will understand—and in line with your advice, Mr Deputy Speaker, and that of the Clerks—I am unable to go into any further details on the HSE investigation. However, it has advised that the first hearing in that case will take place in Chelmsford in November. I will say no more on the case than that, in line with your guidance, Mr Deputy Speaker. It is never acceptable for patients to be exposed to avoidable risks. When things do go wrong, clinicians need to be open, honest and able to learn from their mistakes.
I turn to one of the key points that my hon. Friend raised. I am very much aware, as is my hon. Friend the Member for Mid Bedfordshire, of the petition from families of patients who have died while under the care of NHS services in the Essex area, calling for a public inquiry into the deaths. I completely understand that they have concerns that they want to have heard in public. They want answers, and they want to know what happened. My hon. Friend the Member for Mid Bedfordshire has given careful consideration to the failures in care at the former North Essex Partnership University NHS Foundation Trust. On her behalf, I am announcing today that she has set out her intention to commission an independent review into the serious questions raised by a series of tragic deaths of patients at the Linden Centre between 2008 and 2015.
James Cartlidge
That will be incredibly welcome for all the families connected. Can the Minister confirm that it will include the case of Richard Wade? Does he appreciate that many other Members—particularly those representing Essex constituencies, and many of whom are Ministers and therefore cannot contribute—will be incredibly pleased to hear this announcement? Frankly, none of us expected it, even though we have waited for it for so long.
Edward Argar
I am grateful to my hon. Friend. Although the formal terms of reference of the independent review have yet to be fully agreed, the conditions relating to Mr Wade’s death and the date certainly appear pertinent to this review and are likely to be considered as part of it. I will turn to the details in just a second.
This review will build on the recommendations made in the 2019 Parliamentary and Health Service Ombudsman’s “Missed Opportunities” report. I emphasise again, because I know that my hon. Friend has argued for this powerfully, that it will be independent. He rightly alluded to the fact that, although he is raising Mr Wade’s case today, there is a broader context, and there are other hon. and right hon. Members who have constituents who have been in a similar position and families who have approached them about this. I know that they will want to be involved as well.
James Cartlidge
The Minister will appreciate that this is very significant news for many constituents because of the trauma they have experienced. He is right that the key word he has used is “independent”. Will he confirm that that means, basically, that what those constituents have been asking for will be granted, because it is the best chance they will have to learn the truth of what happened?
Edward Argar
I am grateful to my hon. Friend for his intervention. I am just coming on to the process that will be set in train now. I emphasise that although, for the reasons I set out, it is me announcing this to the House, the work has been done by my hon. Friend the Member for Mid Bedfordshire. I want it to be recognised just how much work she has put into this issue.
We have decided to start the process now, so that the lessons learned can benefit care across the wider NHS as quickly as possible. We will work with the HSE to ensure that the review does not in any way prejudice the legal action that is under way.
Turning to the specific issues that my hon. Friend raised, the Minister for Patient Safety, Mental Health and Suicide Prevention will also be seeking as swiftly as possible a meeting with the families affected by these events, as well as with my hon. Friend and other hon. Members who are involved with this issue, to understand what they would wish to see from this process as the terms of reference and scope are agreed. The Minister is very keen to fully involve them in understanding the scope and terms of reference that need to be set and how we can seek through this process to bring them at least some degree of resolution. She will provide further details on that in due course.
James Cartlidge
The Minister is right to stress the work of our hon. Friend the Minister for Patient Safety, Mental Health and Suicide Prevention, who cares passionately about this. I did say this in my earlier remarks, but I must stress that I know that when she met my constituents—the parents of Richard Wade—it cut to her heart. She has shown huge compassion, which is what has driven this. It is thanks to that that my hon. Friend has announced the news he has today.
Edward Argar
My hon. Friend is absolutely right, and I will turn briefly to that in a second. I hope that this announcement today to commission an independent review into issues at the former North Essex partnership trust shows the strength of our commitment and my hon. Friend’s commitment in addressing the concerns he and his constituents have raised and in listening to and working with the families involved in these tragedies. We are committed to learning lessons at a national level to improve services across the whole mental health system, so that no other family experiences the same devastating loss as Richard’s family and the families of other patients who died at the former North Essex partnership trust.
In the few minutes remaining, let me say that my hon. Friend is absolutely right in what he says: my hon. Friend the Member for Mid Bedfordshire brings compassion, decency and determination to her dealings not just on this issue, but across the field of suicide prevention, mental health and patient safety. She is absolutely passionate about it. She has not only a background in medical services, but a genuine passion. It is her energy that is driving this forward and I have to say that it is a privilege to be a colleague of hers and to work alongside her in the role that I hold in the Department.
I conclude by saying once again that, of course, my thoughts and those of colleagues in this House will remain very much with Richard Wade’s family and all the families who have lost loved ones in these circumstances.
Question put and agreed to.