Deaths in Mental Health Care

Catherine West Excerpts

Monday 30th November 2020 Westminster Hall

[Catherine West (Hornsey and Wood Green) (Lab)]

It is a pleasure to serve under your chairmanship, Mr Stringer, and to have the extra few minutes, which allows me to speak about a constituency case. I want to put on record how moving the speech by my hon. Friend the Member for Hartlepool (Mike Hill) was, and how many wonderful speeches there have been today, to give this desperate situation the attention it deserves.

I declare my interest as a patron of Mind in Haringey. I want to put on record my thanks to Deborah Coles, the chief executive of INQUEST, who wrote this important briefing paper and represents, sadly, hundreds of families who face a similar case to Melanie Leahy. They are desperate. They want to know the reasons and what happened prior to losing their child. I hope that at the end we will have a positive statement from the Minister about a proper inquiry and recommendations to be followed as a result of it.

The Minister may well remember Seni’s law, which was introduced by my hon. Friend the Member for Croydon North (Steve Reed), as a result of his campaign with Seni’s family. Seni died as a result of police restraint due to his having a very serious mental health problem but not getting the correct care under the mental health services. This Friday I have a constituency meeting with a constituent who has tragically lost her son in similar circumstances. This is not an isolated incident and it is wonderful to have this debate.

I want to focus on the findings from INQUEST and some of the other experts who have looked carefully at the similarities in these cases. We know that between 2013 and 2016 there were 71 deaths similar to the one that we are talking about today. Despite several recommendations made by the coroner following each one of these to prevent further deaths in similar circumstances, as the hon. Member for South Suffolk (James Cartlidge) said, the lessons simply are not being learned. Are we doing a read across from similar conditions in the prison service, where, I think, the deaths have come down and the lessons have been learned to some degree? I wonder if there can be shared learning across different services.

We know that in November 2020, INQUEST, the voluntary sector organisation that helps families, looked into 20 recent cases of deaths in adult in-patient mental health settings and found the same issues repeated: lack of staff training, poor record keeping, a failure to involve the family in the care of the patient, a lack of local specialist units and staff shortages.

We know that as a result of covid-19, as other hon. Members mentioned, we have an opportunity to do things differently. We know that we can do much better in terms of accessible data on the number of deaths and how people have died. We know that we can do much better in training our mental health professionals. At Care Quality Commission level, we could do much better in terms of inspections, so that this appalling area is cleaned up once and for all.

We also know that there is failure of communication at crucial times, so that for months and months the family are left not knowing what is the next step and what will happen as a result. That is why it is crucial, as we have all said today, that we have the correct oversight at the national level to monitor the learning and implementation, but also that we have a statutory public inquiry. It can be into Essex mental health services, but what matters is that whatever it is, it is generalised across every single mental health setting.

In the context of covid, where we know there will be at least 20% more people suffering from mental health conditions—including more young people, who are disproportionately affected by covid—there is a real urgency to this work. I hope that we as Members can put more pressure on the Department of Health and Social Care to tackle the problem once and for all.

--- Later in debate ---

[Ms Dorries]

My hon. Friend is absolutely right that no stone was left unturned in the Dixon inquiry. It took 20 years to conclude, and the summary was devastating in terms of what happened. A nurse can no longer practise in this country, and it was revealed that the trust, doctors and medical staff had engaged in a cover-up for 20 years. It took 20 years of probing, but the inquiry happened. It might be thought that a public inquiry would find out more, but one of the advantages of an independent inquiry is that it can work much more closely with families and take their considerations into account by talking to them and involving them, whereas that would not happen with a public inquiry. As has been demonstrated by each one that has been conducted, an independent inquiry benefits from the relationship built with families and the information that families have been able to input. It is important that families’ stories are heard, because some of them are complex, painful and detailed.

Extending the inquiry from 2000 to 2020, as I have done this morning, incorporates both the former trust and the existing trust. A situation occurred recently within the new trust, and we are able to incorporate both trusts and even more families.

[Catherine West]

The Minister is being generous in giving way. The people running the inquest certainly say that they think a statutory inquiry would be best. Over a 20-year period, many of us have received emails from constituents whose children are now in social care—for example, a young woman who spent time in 11 different hospitals first went in when she was 14. She is still there at the age of 22, at a cost of £700,000 per annum. What learning is there at an interim level? Will the inquiry allow for learning as we go, rather than our waiting five years for the report? In those five years, we could lose another 10 or 15 patients each year, so what are the interim milestones that could give us support?

[Ms Dorries]

The hon. Lady is absolutely right, and we would hope for an interim report, but it would depend on the chair. Once we have appointed a chair and secretariat and have the ability to appoint a QC, as required for interviewing witnesses, we will have as a Department, as Ministers and as MPs—independent means independent. Nobody can have any influence on the inquiry, but we would ask for an interim report, particularly if there were findings. However, we have to be aware that findings could prejudice something that might come as a result of the inquiry. Learning is absolutely the key, which is why we have established the Healthcare Safety Investigation Branch.

This is an important point at which to mention medical examiners. In April 2019, we introduced medical examiners into hospitals. If there is a death of a patient today, a medical examiner will examine the death certificate—the hon. Member for Tooting (Dr Allin-Khan) will know this, as she is a practising doctor—look into the circumstances of the death and liaise with the bereaved family. We would hope that the circumstances surrounding a death are already improved by the medical examiner system, which incorporates learning too.

It has been some considerable time since there has been any kind of inquiry into a mental health setting, so it is important that we have an inquiry in order to have a 20-year window. We can take those examples, look at the report and take away the learning. If that can be introduced in an interim report that we can take away, that would be excellent. I cannot guarantee that, however, because we do not know what the chair or secretariat will find once the inquiry begins.

I did not finish replying to an earlier intervention. I hope the inquiry will commence in the second week of February, but the chair and secretariat will be appointed before the December recess.