Deaths in Mental Health Care

Debate between Mike Hill and Nadine Dorries

Monday 30th November 2020 Westminster Hall

[Mike Hill (Hartlepool) (Lab)]

I beg to move,

That this House has considered e-petition 255823, relating to deaths in Mental Health care.

It is an honour to serve under your chairmanship, Mr Stringer. I, too, received that advice not long ago, and sought advice on behalf of the petitioner in regard to anything that I have to say. I will navigate through my speech, bearing in mind that legal statement. I apologise in advance if I stray into such territory, simply because to do justice to this petition I have for the most part chosen to reflect the words of the petitioner. That is only right and just. More than 100,000 people have signed the petition. It is a very personal case, and it is personal for other families whose relatives have died in such horrendous circumstances.

The petition attracted 105,580 UK signatories in support, despite the fact that it was curtailed by the Government closure of Westminster Hall last November due to covid. I will read the text of the petition to put it on the record and inform hon. Members fully. I have spoken to the petitioner, Melanie Leahy, on a number of occasions, and I pay tribute to her for starting the petition. She wrote:

“I request a full public inquiry into death of my son, Matthew Leahy. (20 yrs.)

Matthew was taken to ‘a place of safety’, and died 7 days later. 24 others died by the same means, dating back to the year 2000. An indicator that little was done to address the growing problems. Something went terribly wrong with the NHS Mental Health Services provided to my son.

There really is no way that public concern can be allayed, short of an Inquiry. All investigations to date, including police and inquest proceedings, have been based on a Trust Serious Incident Investigation. A four and half year Parliamentary Health Service Ombudsman Report has now concluded that this investigation was not adequate and lacks credibility.

There has been an inadequacy of investigation. A human rights violation. New evidence has been uncovered and I request a statutory inquiry, that compels witnesses to give evidence on oath.

Matthew is not alone. Many others have died”—

in the same institution—

“whilst ‘In The Care Of The State’.”

The petition ends with a link to a press report dated November 2018 detailing how a two-year police investigation sparked by Matthew’s death six years earlier, into the corporate manslaughter of 24 further patients, was dropped, leaving families without “accountability or recourse”, for their loved ones’ deaths.

In opening the debate on behalf of the Petitions Committee I want to begin with some background. On 15 November 2012, Melanie, Matthew’s mother, received the call that no parent wants to receive: “Matthew has been found hanging and it’s not looking good,” was the quote. It came to light that Matthew had already been dead for more than an hour when that call was made. Melanie described it to me as the first lie of many more that she would uncover after his death. I will share the background of Matthew’s short life, how he ended up in the care of the Essex mental health system, what went wrong, the journey that his mother has been on since his death to get to any form of truth or accountability, and her continued fight for truth, justice, accountability and change for others. I have received a letter from the right hon. Member for Harlow (Robert Halfon) in support of the case. He has had a case of someone dying in similar circumstances in the same place.

The account is quite long, but that is understandable as Melanie’s fight has taken eight years to date, and has encompassed many trials in getting to this point. I have a statement from Melanie that she would like to have been able to read herself. Obviously that is not allowed in this place, so I will read it for her:

“I write these words not just to represent my son, but to represent the multitude of lives that have been affected by the inadequate care offered by mental health services across our nation.”

Mr Stringer, almost within the last 10 minutes I received a statement from families, who asked for it to be read out. I do not have time to do that, but I ask the Minister to accept it if I forward it to her .

The Minister for Patient Safety, Mental Health and Suicide Prevention (Ms Nadine Dorries) indicated assent.

[The Minister for Patient Safety, Mental Health and Suicide Prevention (Ms Nadine Dorries)]

indicated assent.

[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.