Deaths in Mental Health Care

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

It is a pleasure to speak under your chairmanship, Mr Stringer. I pay tribute to all the speakers today; they have spoken very movingly, particularly the hon. Member for Hartlepool (Mike Hill) and even more particularly Ms Leahy, who sounds like an incredible person. All that she is dedicating her life to now is trying to make sure that lessons are learned and changes are made, and that individuals responsible for mismanagement or maladministration are held to account.

The case I allude to is one with which the Minister is familiar. One of my constituents, Andrew Bellerby, was under the care of the Sheffield Health and Social Care NHS Foundation Trust, so these issues do not just pertain to places like the Linden Centre, which sounds horrendous. He presented himself there one evening, having been referred there by his GP. He had a history of suicide attempts. He was seen by untrained nurses who used a triage assessment tool that was designed by the Sheffield trust. These nurses were not trained to use it. Through that tool, they rated him as presenting no risk of suicide. He was then released back into the community, and sadly that evening took his own life.

Mr and Mrs Bellerby, his parents, have championed the cause of trying to find truth and justice, and have been prevented at every turn by Sheffield Health and Social Care NHS Foundation Trust. The communications have been terrible. It has been denial after denial, lie after lie. Eventually, an inquest proved that the Bellerbys were right and that Andrew Bellerby’s suicide was preventable.

All that Mr and Mrs Bellerby wanted was an apology and an admission of the trust’s failure and mismanagement. Instead, there was denial and obfuscation. It cost in the order of £100,000 in legal costs, much of which fell to the taxpayer, although the actual compensation bill at the end was only £9,000. Incredibly, even after all that time and it having been demonstrated that Mr and Mrs Bellerby were right that their son had been poorly treated by the trust, there was no compassion, remorse or proper apology. It is simply unthinkable.

That was back in 2015. The CQC gave the trust a damning rating in 2016, and did another assessment in 2019. The most recent assessment showed that there were 47 breaches of the trust’s legal requirements. It was rated inadequate, and it is now in special measures. One of the things that runs through the report is constant reference to a lack of training. What had been learned in that four year period? Instead of the trust holding up its hands and saying, “Yes, we got this wrong. Yes, we are going to put it right,” which is what the Bellerbys wanted in the first place—I am sure that is what Ms Leahy wants too—the trust was in total denial.

Mr and Mrs Bellerby want to make sure that the assessment tools are prohibited and not used by the health service. They have stopped being used in the Sheffield trust, I am pleased to say, but there are 32 other trusts that may still be using them. The Minister has been great with this family and has met them personally, with me, and he is championing the cause of trying to improve best practice in this area. Questions remain about whether those lessons have been learned in other trusts around the country. Key to the matter, as hon. Members have alluded to in speeches today, is whether the leadership of the trust in question, and other trusts, has been held to account for the maladministration. Kevan Taylor was the CEO at the time, and the accountable officer. He has now left and a new chief executive has taken over. I would really like to know whether he left with a payment, and without any blemish on his track record, or whether he has been held to account or sacked for his underperformance. Demonstrably, for years there has been underperformance by the leadership of the trust. Unless we start to make sure that the individuals who run trusts are held to account if they get things wrong—many do a fine job, of course—such tragic cases will continue to happen.

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[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.

[Kevin Hollinrake]

Assuming that the independent inquiry finds that somebody is culpable within the management, will the Minister set out what sanctions might be available to her or to the inquiry to hold those people to account?

[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.