Deaths in Mental Health Care

Graham Stringer Excerpts

Monday 30th November 2020 Westminster Hall

[Graham Stringer (in the Chair)]

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.

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[Mike Hill]

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.’

How the inquest concluded I will never know. Staff were not interviewed by police after Matthew’s death. An internal investigation was carried out, which the Parliamentary and Health Service ombudsman has deemed flawed and not fit for purpose. This flawed investigation formed the basis of every investigation actioned after Matthew’s death.

The ligature was destroyed, the defibrillator was destroyed. Door logs were not downloaded. CCTV was hidden for over seven-plus years, and parts of it either not retained or deleted. So, so many more issues exist.

I have not been able to determine or control any of this—investigations, reviews, reports etc—all processes that have happened around me, with me being entitled to some information and some explanation, but little voice, little influence and little power.

I did think that the system would be open and honest, would explain what went wrong, hold to account those responsible for any failings and afford justice for failing my most precious son. However, I have discovered a deeply troubling mismatch between what I expected and what I found. In any other walk of life, if there had been failings, heads would roll. This has never happened, despite criminal offences being proved.

If the tragedy of losing Matthew hasn’t been bad enough, to not know the full circumstance that led to his death ‘whilst in the care of the state’ is unforgiveable. I still do not have full disclosure and have never seen internal statements. ‘Duty of Candour’ went out of the window the moment Matthew died.

It came to light after Matthew died that paperwork had been falsified, backdated and slipped into his files. It took me four-plus years to finally persuade Essex Police to register this falsification of mental health documents as a crime. I thought, ‘At last, they are listening to me.’ Then the bomb dropped. ‘We won’t be prosecuting, as it’s not in the public interest.’

The Trust has failed to take steps to protect patients in their care. The question remains why no individual has been held to account and why some staff involved in failing my son and other patients have actually been promoted to high-ranking positions within the NHS.

The Coroner called for a Public Inquiry after the inquest in 2015. There have also been multiple calls from various MPs in the last five years. The Parliamentary and Health Service Ombudsman went on national television after ‘The Missed Opportunities Report’ was published to say that if he had the power to, he would call a Public Inquiry.

In October last year, the Public Administration and Constitutional Affairs Committee held an evidence session on the Ombudsman’s Report into the failed care of Matthew and of Ben Morris. (Ben died in the Linden Centre in 2008 aged 20 years).

During the session, the Minister for Patient Safety, Mental Health and Suicide Prevention explained, ‘that Public Inquiries do not happen for individual cases. In this case, a Public Inquiry is not an appropriate response because we are talking about two cases’.

I have now been joined in this fight calling for a Statutory Public Inquiry into Essex Mental Health Services by multiple bereaved and failed families. (55 families and growing). How multiple deaths can have gone on unchallenged for so many years and so many people in official positions, not involved with this scandal, have entrapped themselves by collaboration the moment they came across it has baffled me. How the system did not prevent these deaths or at the very least detect the failings/changes needed earlier I’m sure is a question in many failed families’ minds, not just mine.

Where is the Government’s anger? Its thirst for Truth and Justice? Its commitment to getting answers and ensuring it never happens again?

Many families are losing loved ones while under the care of state mental health system. Whether that be due to mental illness, additional vulnerabilities such as autistic and/or learning disabled individuals, those misdiagnosed, or dementia...it does not discriminate.”

The Government are now officially, in Melanie’s words,

“on notice of…Gross and systemic Neglect (resulting in multiple avoidable deaths)…Physical, sexual, and emotional abuse and exploitation of the vulnerable—most of them young, historical and sadly, ongoing.

The right people in Government need to understand the full extent of the Essex Trust’s Failures and I have every faith that once the Government commits to a Full Statutory Public Inquiry into Essex Mental Health, the fundamental truth of what and still is going wrong will be revealed.

Through that knowledge I hope justice and accountability are afforded and that necessary change is made for others who, like I and many others did, look to services when they need safe, compassionate care for their loved ones.”

I have to echo that point in respect of some horrendous cases in the Tees Valley, my own patch.

I will conclude with the following words:

“I offered the Government Matthew’s sad death to be a catalyst of learning and change months ago. Please call a Public Inquiry into Essex Mental Health Services without further delay. Make the changes in Essex and send the learning across the country. I hope then that I can start to grieve the loss of my son and Matthew will be able to then rest in peace.”

I know I have kept my speech narrow, but I felt it appropriate to reflect the true voice of the petitioners. Thank you, Mr Stringer, for allowing me to do that.

[Graham Stringer (in the Chair)]

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.

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[Janet Daby (Lewisham East) (Lab)]

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.

A strategy of care needs to be in place for all mental health patients, one in which patients are listened to and family members are involved, so that loved ones can talk about preventative measures and their concerns, as well as contribute to the care plans that are needed. Mental health doctors, mental health nurses, social workers and care staff all need to work collaboratively with all professionals involved in keeping the most vulnerable people safe and secure, and to prevent these fatal, awful incidents of suicide or types of restraints leading to death. Change needs to happen.

[Graham Stringer (in the Chair)]

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.

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[Dr Allin-Khan]

Yes, of course it would be in everyone’s best interests for the inquiry to take place as soon as possible. After all this time, Melanie deserves some answers. I support her call for a statutory public inquiry into Essex mental health services and for the appointment of an independent chair. It is crucial that lessons are learned from Matthew’s case.

I will take this moment to read a few words from Melanie about why a statutory public inquiry is so important to her:

“To come this far and then get fobbed off with a review or general inquiry…would simply take…us all back to square one.”

She goes on to ask that the Minister do something real and meaningful that paves the way for truth, justice, accountability and change. There is an opportunity here for the Minister to commit to providing a grieving mother with answers about her son’s death, and to learning lessons so that other families do not suffer in this way. We cannot, and must not, delay any further.

[Graham Stringer (in the Chair)]

We have plenty of time, but I ask the Minister to leave enough time for the wind-up at the end.