Deaths in Mental Health Care

Baroness Keeley Excerpts

Monday 30th November 2020 Westminster Hall

[Barbara Keeley (Worsley and Eccles South) (Lab)]

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 him 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.

[Jim Shannon (Strangford) (DUP)]

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?

[Barbara Keeley]

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 The mental health estate is known for being run down and out of date.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.”

In an interview on ITV, the ombudsman went further on the failings, including about Matthew’s care plan being altered after he died and his claim of rape not being investigated. He described them as

“a catalogue of failings which are entirely unacceptable.”

He also said that he would fully support a public inquiry if one was recommended, and that he would like to have investigated further if he had had the powers.

Both public officials who have investigated Matthew’s death, the coroner and the ombudsman, have said that they would support a public inquiry. I ask the Minister, on behalf of Melanie Leahy, to set up a public inquiry. Only a public inquiry will have the transparency and broad participation needed to rebuild trust in the services. The Minister will know that that is the only way that witnesses can be compelled to give evidence without seeking to apportion blame, and evidence must be given on oath.

As Melanie has said,

“Since Matthew’s death I have been on a mission to get to the truth of what happened to Matthew and to get justice for him. On my journey I have not only found that many other families are in the same position as me, but also individuals who have the survived the quotes ‘care’ that they received.”

In this most tragic case, inadequate and neglectful care led to the death of a young man like Matthew. His mother has had to take on a fight over many years to get to the truth. I thank all the families and parents such as Melanie Leahy who have put so much of themselves into their campaign. I return to what she said to me:

“To say the current situation is not good enough is a massive understatement. We know what has to change and we have known for decades. What will make the Government take real action? How many times do we need to hear the same information and recommendations? How many more Matthews have to die?”

--- Later in debate ---

[The Minister for Patient Safety, Mental Health and Suicide Prevention (Ms Nadine Dorries)]

It is a pleasure to serve under your chairmanship once again, Mr Stringer. I congratulate the hon. Member for Hartlepool (Mike Hill) on securing such an important debate on the e-petition calling for a full public inquiry into the tragic circumstances surrounding the death of Matthew Leahy, and the wider issue of deaths in mental health in-patient settings.

I thank all hon. Members present for making such valuable and powerful speeches on such an important issue. I am going to make quite an important announcement. Therefore, if anybody feels the need to intervene, could they wait until I have finished so that there is no ambiguity on the part of the relatives who may be listening, and so that they fully understand what I am saying and the reasons why I am saying it? In this case, that is quite important, particularly for Mrs Leahy and the relatives.

Matthew Leahy took his own life while he was in the care of the NHS.[Official Report, 3 December 2020, Vol. 685, c. 3MC.] His death was avoidable, as were the deaths of a number of other people in the same facility. While nothing that I or any of us can say today can ease the pain of their families and friends, I am determined that we learn the lessons of these tragic events.

[Barbara Keeley]

I should like to raise a question with the Minister. She said that Matthew took his own life. Melanie Leahy does not accept that, and I think it would be easier if we used the words “he was found hanging”. The inquest recorded an open verdict, so I do not think it is appropriate in this debate to say that he took his own life.

[Ms Dorries]

Until we have proceeded a bit further, there is a form of words that I have to use at the moment, and that is the form of words. There is absolutely no contention about how Matthew died or the appalling circumstances in which he was found, but I have to use a particular form of words at this point.

As I said, nothing can ease Melanie’s pain, or that of the relatives of others who were found in similar circumstances in the Linden Centre. Matthew died in November 2012 while he was in the Linden Centre, a mental health facility in the former North Essex Partnership University NHS Foundation Trust. I understand the devastating impact that that has had on Matthew’s family, especially Melanie, whom I have spoken to twice. My heartfelt condolences go out to them now, as was the case when I spoke to them and will continue to be so.

The petition we are debating today calls for a public inquiry into the death of Matthew Leahy on the grounds that past investigations have been inadequate. I first met Melanie last year and I was deeply moved by her story. I took that story away and have continued to work since I first spoke to her. I have since met her again and I have met some of the other families whose loved ones have died at the Linden Centre, and my thoughts are equally with them.

As a result of what I have heard from both Melanie and other relatives, I can confirm today that there will be an independent inquiry into the events at the Linden Centre, covering the period from 2000 to the present day, as requested in Mrs Leahy’s petition. This will mean that all the tragic events are given the attention they deserve to ensure that lessons are learned. The scope will not go earlier than 2000 or later than 2020, in order to keep the inquiry focused and to have it report in a timely manner. I consider that 20 years is a more than adequate timeframe to enable us to understand what happened at the Linden Centre and to learn from it.

I am in the process of appointing an independent chair, and I am considering half a dozen leading candidates at present. They will need to be robustly independent and command the confidence of the families. I have chosen to go down the route of an independent inquiry rather than a public statutory inquiry so that we can move quickly. To inform its findings, the inquiry will be able to call witnesses and undertake a close examination of what actually happened to patients who died at the trust. I will also appoint a barrister—a QC—to assist the chair in their investigations, along with a full secretariat. The inquiry will be independent and will consult families on the specific terms of reference. As an independent inquiry, it can determine how it wishes to work with the families so that they are able to give their accounts.

I will not pull any punches. Hon. Members will be aware of the report of the inquiry into the life and death of baby Elizabeth Dixon, published last week, which set out the details behind what it described as a “20-year cover-up”. I can cite two more inquiries: the Morecambe Bay investigation and the Paterson inquiry, both of which were independent inquiries commissioned by my Department. They left no stone unturned and were frank in their criticisms.

I expect witnesses to come forward irrespective of the type of inquiry. While public inquiries can compel witnesses to appear and give evidence under oath, importantly, they do not have to give evidence that would incriminate them. However, it is incumbent on all holders of public office, and on health professionals, to demonstrate their fitness by voluntarily co-operating with independent inquiries that seek to protect future patients and offer closure to families.

[Barbara Keeley]

Will the Minister give way?

[Ms Dorries]

I will when I have finished this point.

The independent Paterson inquiry—this is an important point—referred to the General Medical Council two doctors who had refused to give evidence to the inquiry, and they are being investigated. It is not the case that if someone in a professional capacity refuses to give evidence to an independent inquiry, they are not held accountable. That is patently demonstrated by the case of the doctors who are being investigated by the GMC.

With the timeframes that we originally set, I had hoped that the inquiry might report within 18 months. As I have today extended its scope to cover a 20-year span from 2000 to 2020, it will take longer, but I hope that it will report its findings within two years. I hope to announce the chair and outline the terms of reference in a written ministerial statement—

[Barbara Keeley]

Will the Minister give way?

[Ms Dorries]

I will.

[Barbara Keeley]

I think it would be easier if the Minister just let me ask the question. It was clear from what my hon. Friend the Member for Hartlepool (Mike Hill) said that Melanie Leahy is not necessarily happy with an independent inquiry. We should be clear about that. There is the question of compelling witnesses to attend.

The Minister is talking about appointing the chair. It is important that, for complete independence, any inquiry has the support of families such as Matthew’s. Can she tell us whether she will consider having the position of chair approved by an independent body or, for instance, the Health and Social Care Committee? I do not think people will be comfortable with her appointing the chair. As other hon. Members have said, there has been too much of people appointing other people, and saying, “You review me and I review you.” That is an important point.

[Ms Dorries]

I would like to get the inquiry going. As in all other inquiries, I believe it is the case—I will come back to the hon. Lady with the reasons why—that ministerial responsibility has to be taken.

As I was about to say, I want to get the inquiry under way before Christmas. I would like to make a written ministerial statement to the House before the Christmas recess to set out the terms of reference of the inquiry and to name the chair, with the provision that the inquiry will commence in the second week of February.

[Barbara Keeley]

The point has been made that Melanie Leahy has campaigned on this for eight years and has done a wonderful job. I understand the reasons for trying to do this quickly, but it is too hasty for the Minister to move ahead and appoint a chair unless she is clear that the families, and particularly Melanie Leahy, are happy with that. The chair has to be seen to be independent. I am not sure that I am particularly happy with what the Minister is outlining.

[Ms Dorries]

We will go through the processes that we have been through within the Department of Health and Social Care. They are set in law and abided by during every inquiry; that has included all the past inquiries such as the Dixon inquiry, the Paterson inquiry and the Morecambe Bay inquiry. The same protocols and the same process will be adhered to.[Official Report, 3 December 2020, Vol. 685, c. 4MC.]

--- Later in debate ---

[Ms Dorries]

As a Minister, it is not my role to issue sanctions, but if the chair discovered anything even remotely untoward during the inquiry, it would be referred to the police. The inquiry does not cover up criminal activity—that is the case for any inquiry, not just this one. There would be accountability.

[Barbara Keeley]

I want to touch on inquests. Given the new evidence in Matthew’s case and many others, does the Minister think it would be appropriate to revisit inquests that returned open or narrative verdicts? That can be important to the families.

[Ms Dorries]

I cannot comment because, as the hon. Member knows, inquests and coroners are under the jurisdiction of the Ministry of Justice. Coroners are almost in the vein of judges, so that is a legal question for the MOJ to answer; it is not within the jurisdiction of the Department of Health and Social Care. Our job is to launch an inquiry, ensure that it has a robust, independent chair, that it is fully funded and staffed, that it establishes terms of reference in consultation with as many families as possible as soon as possible, and that it commences as soon as possible.

As hon. Members will be aware, the Health and Safety Executive has investigated how the trust managed environmental risks from fixed potential ligature points in in-patient wards between 25 October 2004 and 31 March 2015. As a result of the investigation, the Health and Safety Executive has brought a prosecution against the Essex Partnership University NHS Foundation Trust, which was formed following the merger of the North Essex Partnership University NHS Foundation Trust with the South Essex Partnership University NHS Foundation Trust. I am sure hon. Members will understand that I cannot go into the details of those proceedings as they are before the courts.

I could say quite a bit about the petition and the cases, but I will conclude to let the hon. Member for Hartlepool have the final say. I thank Melanie Leahy for her years of campaigning. I hope she will understand that a robustly independent inquiry that is unafraid to turn over stones and work with the families, calling those it sees fit to give evidence, is a way to discover what has happened at the Linden Centre over the past 20 years, including what culture developed, what practices were in place and what happened to those young boys who died there. As my hon. Friend the Member for South Suffolk (James Cartlidge) said, what is important is that we get to the truth. It does not matter what the framework or structure is; what matters is the truth, knowing how those young boys died, what happened and what we can learn from those dreadful mistakes.