Deaths in Mental Health Care

Nadine Dorries Excerpts

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.

--- Later in debate ---

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

It is a pleasure to serve under your chairmanship once again, Mr Stringer. I congratulate the hon. Member for Hartlepool (Mike Hill) on securing such an important debate on the e-petition calling for a full public inquiry into the tragic circumstances surrounding the death of Matthew Leahy, and the wider issue of deaths in mental health in-patient settings.

I thank all hon. Members present for making such valuable and powerful speeches on such an important issue. I am going to make quite an important announcement. Therefore, if anybody feels the need to intervene, could they wait until I have finished so that there is no ambiguity on the part of the relatives who may be listening, and so that they fully understand what I am saying and the reasons why I am saying it? In this case, that is quite important, particularly for Mrs Leahy and the relatives.

Matthew Leahy took his own life while he was in the care of the NHS.[Official Report, 3 December 2020, Vol. 685, c. 3MC.] His death was avoidable, as were the deaths of a number of other people in the same facility. While nothing that I or any of us can say today can ease the pain of their families and friends, I am determined that we learn the lessons of these tragic events.

[Barbara Keeley]

I should like to raise a question with the Minister. She said that Matthew took his own life. Melanie Leahy does not accept that, and I think it would be easier if we used the words “he was found hanging”. The inquest recorded an open verdict, so I do not think it is appropriate in this debate to say that he took his own life.

[Ms Dorries]

Until we have proceeded a bit further, there is a form of words that I have to use at the moment, and that is the form of words. There is absolutely no contention about how Matthew died or the appalling circumstances in which he was found, but I have to use a particular form of words at this point.

As I said, nothing can ease Melanie’s pain, or that of the relatives of others who were found in similar circumstances in the Linden Centre. Matthew died in November 2012 while he was in the Linden Centre, a mental health facility in the former North Essex Partnership University NHS Foundation Trust. I understand the devastating impact that that has had on Matthew’s family, especially Melanie, whom I have spoken to twice. My heartfelt condolences go out to them now, as was the case when I spoke to them and will continue to be so.

The petition we are debating today calls for a public inquiry into the death of Matthew Leahy on the grounds that past investigations have been inadequate. I first met Melanie last year and I was deeply moved by her story. I took that story away and have continued to work since I first spoke to her. I have since met her again and I have met some of the other families whose loved ones have died at the Linden Centre, and my thoughts are equally with them.

As a result of what I have heard from both Melanie and other relatives, I can confirm today that there will be an independent inquiry into the events at the Linden Centre, covering the period from 2000 to the present day, as requested in Mrs Leahy’s petition. This will mean that all the tragic events are given the attention they deserve to ensure that lessons are learned. The scope will not go earlier than 2000 or later than 2020, in order to keep the inquiry focused and to have it report in a timely manner. I consider that 20 years is a more than adequate timeframe to enable us to understand what happened at the Linden Centre and to learn from it.

I am in the process of appointing an independent chair, and I am considering half a dozen leading candidates at present. They will need to be robustly independent and command the confidence of the families. I have chosen to go down the route of an independent inquiry rather than a public statutory inquiry so that we can move quickly. To inform its findings, the inquiry will be able to call witnesses and undertake a close examination of what actually happened to patients who died at the trust. I will also appoint a barrister—a QC—to assist the chair in their investigations, along with a full secretariat. The inquiry will be independent and will consult families on the specific terms of reference. As an independent inquiry, it can determine how it wishes to work with the families so that they are able to give their accounts.

I will not pull any punches. Hon. Members will be aware of the report of the inquiry into the life and death of baby Elizabeth Dixon, published last week, which set out the details behind what it described as a “20-year cover-up”. I can cite two more inquiries: the Morecambe Bay investigation and the Paterson inquiry, both of which were independent inquiries commissioned by my Department. They left no stone unturned and were frank in their criticisms.

I expect witnesses to come forward irrespective of the type of inquiry. While public inquiries can compel witnesses to appear and give evidence under oath, importantly, they do not have to give evidence that would incriminate them. However, it is incumbent on all holders of public office, and on health professionals, to demonstrate their fitness by voluntarily co-operating with independent inquiries that seek to protect future patients and offer closure to families.

[Barbara Keeley]

Will the Minister give way?

[Ms Dorries]

I will when I have finished this point.

The independent Paterson inquiry—this is an important point—referred to the General Medical Council two doctors who had refused to give evidence to the inquiry, and they are being investigated. It is not the case that if someone in a professional capacity refuses to give evidence to an independent inquiry, they are not held accountable. That is patently demonstrated by the case of the doctors who are being investigated by the GMC.

With the timeframes that we originally set, I had hoped that the inquiry might report within 18 months. As I have today extended its scope to cover a 20-year span from 2000 to 2020, it will take longer, but I hope that it will report its findings within two years. I hope to announce the chair and outline the terms of reference in a written ministerial statement—

[Barbara Keeley]

Will the Minister give way?

[Ms Dorries]

I will.

[Barbara Keeley]

I think it would be easier if the Minister just let me ask the question. It was clear from what my hon. Friend the Member for Hartlepool (Mike Hill) said that Melanie Leahy is not necessarily happy with an independent inquiry. We should be clear about that. There is the question of compelling witnesses to attend.

The Minister is talking about appointing the chair. It is important that, for complete independence, any inquiry has the support of families such as Matthew’s. Can she tell us whether she will consider having the position of chair approved by an independent body or, for instance, the Health and Social Care Committee? I do not think people will be comfortable with her appointing the chair. As other hon. Members have said, there has been too much of people appointing other people, and saying, “You review me and I review you.” That is an important point.

[Ms Dorries]

I would like to get the inquiry going. As in all other inquiries, I believe it is the case—I will come back to the hon. Lady with the reasons why—that ministerial responsibility has to be taken.

As I was about to say, I want to get the inquiry under way before Christmas. I would like to make a written ministerial statement to the House before the Christmas recess to set out the terms of reference of the inquiry and to name the chair, with the provision that the inquiry will commence in the second week of February.

[Barbara Keeley]

The point has been made that Melanie Leahy has campaigned on this for eight years and has done a wonderful job. I understand the reasons for trying to do this quickly, but it is too hasty for the Minister to move ahead and appoint a chair unless she is clear that the families, and particularly Melanie Leahy, are happy with that. The chair has to be seen to be independent. I am not sure that I am particularly happy with what the Minister is outlining.

[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.

[Catherine West]

The Minister is being generous in giving way. The people running the inquest certainly say that they think a statutory inquiry would be best. Over a 20-year period, many of us have received emails from constituents whose children are now in social care—for example, a young woman who spent time in 11 different hospitals first went in when she was 14. She is still there at the age of 22, at a cost of £700,000 per annum. What learning is there at an interim level? Will the inquiry allow for learning as we go, rather than our waiting five years for the report? In those five years, we could lose another 10 or 15 patients each year, so what are the interim milestones that could give us support?

[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.

[Barbara Keeley]

I want to touch on inquests. Given the new evidence in Matthew’s case and many others, does the Minister think it would be appropriate to revisit inquests that returned open or narrative verdicts? That can be important to the families.

[Ms Dorries]

I cannot comment because, as the hon. Member knows, inquests and coroners are under the jurisdiction of the Ministry of Justice. Coroners are almost in the vein of judges, so that is a legal question for the MOJ to answer; it is not within the jurisdiction of the Department of Health and Social Care. Our job is to launch an inquiry, ensure that it has a robust, independent chair, that it is fully funded and staffed, that it establishes terms of reference in consultation with as many families as possible as soon as possible, and that it commences as soon as possible.

As hon. Members will be aware, the Health and Safety Executive has investigated how the trust managed environmental risks from fixed potential ligature points in in-patient wards between 25 October 2004 and 31 March 2015. As a result of the investigation, the Health and Safety Executive has brought a prosecution against the Essex Partnership University NHS Foundation Trust, which was formed following the merger of the North Essex Partnership University NHS Foundation Trust with the South Essex Partnership University NHS Foundation Trust. I am sure hon. Members will understand that I cannot go into the details of those proceedings as they are before the courts.

I could say quite a bit about the petition and the cases, but I will conclude to let the hon. Member for Hartlepool have the final say. I thank Melanie Leahy for her years of campaigning. I hope she will understand that a robustly independent inquiry that is unafraid to turn over stones and work with the families, calling those it sees fit to give evidence, is a way to discover what has happened at the Linden Centre over the past 20 years, including what culture developed, what practices were in place and what happened to those young boys who died there. As my hon. Friend the Member for South Suffolk (James Cartlidge) said, what is important is that we get to the truth. It does not matter what the framework or structure is; what matters is the truth, knowing how those young boys died, what happened and what we can learn from those dreadful mistakes.