Deaths in Mental Health Care

Debate between Rosena Allin-Khan and James Cartlidge

Monday 30th November 2020 Westminster Hall

[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.