Deaths in Mental Health Care

Andy Carter Excerpts

Monday 30th November 2020 Westminster Hall

[Andy Carter (Warrington South) (Con)]

It is a pleasure to contribute to this important debate under your chairmanship, Mr Stringer. May I start by paying tribute to the hon. Member for Hartlepool (Mike Hill)? I thought that he opened the debate incredibly well. I also pay tribute to Matthew Leahy’s mother for her campaigning to raise this issue here in Parliament. I am incredibly grateful to the 185 people in Warrington South who signed this petition. Many of them have also been in touch with my office over the last few days to raise their concerns about deaths in mental health care.

There is an unsatisfactory gap in the ability of regulators to enforce sanctions in serious cases and, in particular, those that involve death or serious harm to individuals where catastrophic deficiencies in standards of care were involved. Aware of this debate, I heard over the weekend from Richard Evans, who lives in Appleton in my constituency and whose daughter Hannah tragically took her own life five years ago.

At the time of her death, Hannah was a detained patient on Sheridan ward at Hollins Park Hospital in Warrington. Hannah, a 22-year-old young lady, had spent a short amount of time in a number of different settings as a detained patient and had also been cared for in the community by her family. Despite there being awareness of the fact that Hannah was a complex patient with an extensive history of tying life-threatening ligatures and an intense fear of change, she was given just two and a half hours’ notice of her transfer that day to a different hospital by those who were caring for her. When the decision was discussed with her parents, they did not object. Critically, though, they did not know that Hannah had been involved in nine ligature attempts while in an intensive care unit. They are in no doubt that, had they been aware of the history, they would have attempted to block that movement in order to protect and care for their daughter. A fundamental lack of communication between ward staff, management and the family—the next of kin—led to a decision that ultimately resulted in Hannah’s tragic loss of life.

The inquest on Hannah’s case highlights a series of failings on that ward, but also a national problem regarding the lack of provision in place to properly support vulnerable young adults diagnosed with personality disorders and, more widely, the significant number of people in this country who suffer from mental health conditions.

I welcome plans to establish a new Health Service Safety Investigations Body, a new executive non-departmental public body, but it must have the powers to conduct investigations into incidents that occur during the provision of services and have strong implications for the safety of patients. Critically, that body must also improve the quality and effectiveness of local investigations by developing standards and providing advice, guidance and training to organisations.

I am keen to see stronger steps taken with prosecutions, holding those who lead care settings to account. The Care Quality Commission currently has relatively limited powers to prosecute, in part because of reservations about the value of criminal enforcements in healthcare. Legalities aside, speaking to Richard Evans, Hannah’s father, the key issue with many of these sad cases seems to be a basic lack of communication: firstly between local NHS trusts and services, and then a dialogue with families when deaths sadly occur. That is something that can, and must, be addressed.

It is important that we take a zero-suicide policy to prevent unnecessary harm on individuals and their families in the future, and lessons need to be learned from the past. It is time to review the legislation to improve care, in what should be a place of safety for those who are at their most vulnerable.