Deaths in Mental Health Care

James Cartlidge Excerpts

Monday 30th November 2020 Westminster Hall

[James Cartlidge (South Suffolk) (Con)]

Thank you, Mr Stringer; it is a great pleasure to serve under your chairmanship, and to follow the hon. Member for Hartlepool (Mike Hill) who introduced the debate on behalf of the Petitions Committee. He spoke of the case of Matthew Leahy. It is a terrible tragedy, and I pay a huge tribute to his mother, who has campaigned for years through the pain, which is without limit.

We all sympathise, I am sure, but as the hon. Gentleman said the case of Leahy is not the only one at the Linden Centre, Chelmsford. There have been several others, all tragic, including my constituent Richard Wade. I held an Adjournment debate on the case of Richard Wade in October. At the start of that debate, because the HSE case was live, a much stricter sub judice ruling was given, which meant there were things I could not say in the Adjournment debate that I feel able to say today.

I have a very short period of time and I do not have time to give the full details of Richard Wade’s case. The key point is that, on the day he was found hanging in the Linden Centre in Chelmsford, there is strong evidence that his parents have seen—not just documentary evidence, but other evidence that has come to them, including from people who have worked at the Linden Centre—that when his body was first discovered hanging, still alive, the clinicians who found it either panicked, or for some other inexplicable reason left it hanging, locked the door and allowed some minutes to pass before he was discovered a second time, this time with his parents nearby. At that point he was given resuscitation and urgent medical treatment. We do not know the impact of those crucial minutes on his eventual fate several days later, when he passed away. Essentially, his is a life that I believe could have been saved and a death that could have been avoided.

I will not repeat all the points I made about Richard Wade’s case in my Adjournment debate, other than to say that although he died in May 2015—in fact, I met him going to vote in Great Cornard in May 2015, a few days before I had the great privilege of being elected for the first time, and he was dead several days later—in February 2015 another man, who I believe was called Beecroft, also died by ligature in the Linden Centre in Chelmsford, in the very same bathroom where Richard Wade hanged himself that May. The extraordinary thing is that, when the trust reported on Richard Wade’s death in December that year, it never mentioned that there had been a hanging in the same bathroom three months earlier—as if it were a common occurrence or something. It is quite extraordinary.

When the Care Quality Commission came to investigate, because of course, by April 2015, it had taken over from HSE, I am afraid it did not handle the case well. The CQC did not investigate it initially, because, in the words of the report it issued to the Wades in July, the inspectors effectively did not realise that they had taken over statutory responsibility from HSE. It is a catalogue of failures; the Wade case alone would merit an independent inquiry, but there are also Beecroft, Leahy, Morris and potentially other cases.

At the end of my Adjournment debate my hon. Friend the Minister, who was being covered for at the time because she was isolating, announced an independent review into the deaths at the Linden Centre. I was very grateful for that, because I know she has taken huge interest in the matter and very sincerely so. I hope that that can be a full, robust, independent inquiry, like the one we had last week into the Dixon case, which can uncover the truth and can go into places that other mechanisms cannot.

[Kevin Hollinrake (Thirsk and Malton) (Con)]

These are terribly tragic cases; sometimes they cannot be avoided, of course, but at times they are due to the performance of the trust and perhaps of the management of that trust. Where that is the case, does my hon. Friend agree that the leadership of those organisations must be held to account for their performance?

[James Cartlidge]

My hon. Friend makes an excellent point, echoing the concluding remark from the hon. Member for Hartlepool, and he is absolutely right that there must be accountability. However, when we go into an independent inquiry, there is a danger of saying, “Well, it must be a statutory public inquiry,” and getting into the semantics of the mechanism we use.

I think what my constituents the Wades want is the truth. They simply want to know the truth about what happened to their son. We now have a tangible offer from the Department of Health of a mechanism that all the families can use to get involved, to shape the terms of reference and to help us to deliver something in the public interest—as, again, the petitioners seek—to the benefit of the whole country in terms of wider mental health. Above all, that will bring some sense of accountability to all the families who have suffered so tragically at the Linden Centre in Chelmsford, including the Wades and the Leahys. I believe that the Minister will now act and I give her all my support in doing so.

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[Dr Rosena Allin-Khan (Tooting) (Lab)]

It is a real pleasure to serve under your chairmanship, Mr Stringer, and an honour to respond on behalf of the Opposition in this profoundly moving and powerful debate. I thank my hon. Friend the Member for Hartlepool (Mike Hill) for securing the debate, but it goes without saying that every contribution today has been extremely powerful. Everyone who has spoken has stood up for their constituents and represented the issues very well. The points have been made clearly and concisely, and hon. Members have done Melanie Leahy and the other families very proud.

We are here today because of a mother’s love for her son and her desire to receive some answers about his tragic and untimely death. It is fitting, then, that the debate should take place ahead of National Grief Awareness Week. Matthew Leahy was just 20 years old when he was admitted to the Linden Centre in November 2012 after being detained under the Mental Health Act 1983. While in the care of North Essex Partnership University Trust at the Linden Centre, Matthew phoned his parents on numerous occasions to express his unhappiness at being detained there. I know that I am speaking again of things that have already been mentioned, but it is important to give the details as many times as possible, to get what happened across as powerfully as is necessary to see the change we want.

Two days after being admitted, Matthew phoned his father to tell him that he had been drugged and raped on the ward. Following a 999 call made by Matthew, the Linden Centre staff gave assurances to the family that he was indeed safe in their care. Just days later, Matthew was found unresponsive and hanged, in his room. He was transferred to Broomfield Hospital, where he was pronounced dead. Matthew was in the Linden Centre for just seven days.

As a mother myself, I cannot comprehend what Melanie has had to contend with over the last eight years. Sadly for Melanie and the family, the struggle is not over. An inquest concluded with an open narrative verdict that Matthew was subject to multiple failings and missed opportunities over a prolonged period of time, by those entrusted with his care. Multiple investigations and reviews were carried out into the North Essex Partnership University NHS Foundation Trust, and into Matthew’s care, and they raised even more questions about the care that he received and the nature of his death. I want to raise some of the concerns that were found in the various reviews so that everyone here can get further understanding of the scale of the challenge that Melanie and her family have faced for the past eight years.

At post-mortem, traces of the drug GHB were found in Matthew’s system. He had bruises just above both ankles and four to five unexplained needle wounds in his groin. Matthew’s paperwork was incomplete and a key worker was not assigned to him. Staff at the Linden Centre had not issued Matthew with a care plan, but after his death they falsified one and backdated it. A number of ligature points in the Linden Centre previously identified for removal were still there. Essex police dropped a corporate manslaughter investigation into the deaths of 25 patients who were in the care of the North Essex partnership trust at nine separate establishments since 2000. The ombudsman investigated, and agreed that Matthew had not been responded to appropriately after reporting a rape, as well as that the Essex partnership’s investigation of Matthew’s death was inadequate. All this in eight years—the toll it has taken on this family. That is before we consider the prosecution of the Essex Partnership University NHS Foundation Trust by the Health and Safety Executive following the deaths of 11 patients in its care between 2004 and 2015.

The loss of multiple lives and the tearing apart of families were devastating and, most tragically, utterly preventable. We have to learn from those tragic losses so that no other families are affected. I ask the Minister if she will please work with Melanie Leahy on this matter directly, as her predecessor promised to do. I had the honour of speaking to Melanie ahead of the debate. This is her day, Matthew’s day and a day for all who are still seeking answers about their loved ones’ deaths.

The strength it takes to continue this fight after eight long years is commendable. My heart goes out to Melanie’s family and to all who have lost loved ones in similar circumstances, not just at the Linden Centre but in care settings across the country where they were meant to be safe. Many of those people have been mentioned in today’s debate, and I thank Members again for their contributions.

A system is not working properly if it takes so long to investigate such a tragedy, and yet answers are still not forthcoming. A grieving mother should not have to plead with people to sign a petition to get answers surrounding her son’s death. There should be no barriers to the truth. Inquiries and investigations should not be reserved for the most privileged and those who are most familiar with the system.

On the point about time, I highlight that it has taken over a year to have this debate following Melanie’s successful petition. We all understand the mitigating factors that this year has brought, but I would like everyone to consider how every step of the process has been slow. Barriers have been put in place for the family at every single turn.

[James Cartlidge]

Does the hon. Lady agree that, that being so, it would be very much in the interests of all stakeholders if the inquiry took place, ideally, as soon as possible?

[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.

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[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.]

[James Cartlidge]

I am grateful for what the Minister has said. I know that she has battled to get this through because she sincerely believes in the cause and in bringing justice. In my view, it is important that it happens quickly, as I said earlier. My worry is that a statutory inquiry would take months and months to set up. For my constituents the Wades, the key thing is time. The semantics do not matter, as long as what we do finds the truth and probes further. That is exactly what happened with the Dixon inquiry.

[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.