Deaths in Mental Health Care

Jim Shannon 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 The mental health estate is known for being run down and out of date.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 ---

[Jim Shannon (Strangford) (DUP)]

I thank all those who set the scene and the Petitions Committee for what it did.

Our hearts go out to our constituents. Hon. Members have spoken on behalf of them, and I thank them for that. I admire the determination that each and every one of them has shown. A breakdown in care took place, and we must not see another family in that situation.

I want to take a slightly different approach to the issue of mental health and talk about how we can help within the system. Ultimately, that is what the Minister will set out in her response. I have seen too many of my constituents broken, in need of support and let down by the system. I remember one young man, Michael, who came to my office when he was on the edge. He was a young fellow and was homeless and distraught, and the girls in my office were able to reach out and tell him in a helpful, compassionate way, “Your life is important and we will help you.” He broke down in tears.

We were able to help that young fellow get accommodation through the Northern Ireland Housing Executive. We also got him some help from the local food bank, which is always there to help, and were able to sort out his benefits. What happened was that that young fellow had just disappeared off the grid. He clearly had mental health issues and was not able to cope. He got the psychological help that he needed and he got his benefits renewed, so the pressure on him became less of a difficulty because of those who helped—the Northern Ireland Housing Executive, the local benefits office, the food bank, the local churches. All those people came together.

It is my sincere belief—I believe this in my heart—that if Michael had not come to my office, he may not have survived. We all believe that, including the girls in the office and those we spoke to. Every Government body was exceptionally helpful, and we thank them for that.

That is the foundation for mental health. Ours is not to question how or why people have got to the stage that they find themselves it; we must only see how we can help them where they are. The overhaul of the facilities that I spoke about when I intervened on the hon. Member for Worsley and Eccles South (Barbara Keeley) is about updating them, so that the in-patient help gives people hope to reach out. We are desperate to see an upgrade of facilities that are sometimes not fit for purpose.

Sometimes there is no privacy. Sometimes people need a wee bit of privacy where they are, but they also need to be able to reach out and have someone help them at the times when they need that. Some of the wards that I am aware of are mixed-gender wards, where a lack of privacy is obviously even more of a problem. When it comes to people being allowed to visit, they get one hour each, once a week. I do not feel that that is enough; more time should be allocated for visitors.

I am always very aware of the great work that occupational therapists do. They have a brilliant team, with fantastic ideas. They have allocated some rooms for activities. I think that it is important to have some sort of organised activities, so that those who are under pressure psychologically, mentally and socially have somewhere where they can look outwards. The OTs in the area that I represent have come up with a therapy garden. These things can be done in-house and in a way that can really help. There are gardening classes. Again, it is a question of designating an area for people and ensuring that they have it.

To conclude, it is little wonder that patients and those who are in homes remain uninspired and unhopeful if that is how they view a place designed to provide the help and support that they are crying out for. It is clear that we must make massive changes, and if the first step to doing that is an inquiry, that is where we must begin. My heart goes out to all the families who grieve and feel let down. I believe that we can do better, but not only that—we should do better and must do better.