The Parliamentary Health Service Ombudsman (PHSO) has published a deeply critical report into the deaths of two young men, Matthew Leahy and ‘Mr R’, at the Linden Centre in Essex. The findings of the report, Missed opportunities: What lessons can be learned from failings at the North Essex Partnership University NHS Foundation Trust (NEP), has led PHSO to call for a review into the controversial mental health Trust.
The Ombudsman report summarises their new investigations into the care and treatment of two young men, who both died shortly after being admitted into the care of NEP. It points to a systemic failure of the Trust to tackle repeated and critical failings over an “unacceptable period of time”, and highlights inadequacies in initial investigations into the deaths.
Matthew was 20 years old when he died on 15 November 2012, whilst under the care of NEP-run Linden Centre. The Ombudsman investigation found numerous serious failures in the care provided to Matthew, including there being no care plan in place, he was not adequately observed, he did not have an allocated keyworker, and that there was an inadequate response when he reported being raped. They also found that record keeping was not robust, paperwork was lost, and that Matthew’s care plan was written after his death.
These findings were in stark contrast to the first investigation into Matthew’s death, which concluded that the care and treatment was of a good standard. The initial investigation was carried out internally by the NEP in the form of a Serious Incident Report, and informed other subsequent post-death procedures including the inquest. The Ombudsman has branded that investigation “inadequate” and “not robust enough” on the basis that:
- It contains inaccurate information about how Matthew’s care plan was reviewed.
- It lacks credibility because it was written by a member of staff who was later found to have been involved in the falsification of Matthew’s care plan.
- Matthew’s family were not as involved in the investigation as they should have been.
- The conclusion stated that overall care was of a good standard, but this did not reflect the critical findings in the content of the report.
The Ombudsman now calls for a review to examine the potential failings by former North Essex Partnership NHS Foundation Trust (NEP) to address issues of patient safety, stretching back more than a decade. NHS Improvement will be undertaking the review, which will also consider whether there is sufficient evidence for a public inquiry to be held.
The investigation by the Ombudsman comes after years of campaigning by the families of those who have died. The Leahy family have launched a parliamentary petition calling for a full public inquiry, which now has over 3,500 signatures.
Melanie and Michael Leahy, Matthew’s parents, said: "It’s been a long debilitating seven years to get to this point. The passing of our son Matthew James Leahy has left a void that nothing can fill. Not a day passes when we do not miss him and despair at the thought of how his life was cut short, so needlessly.
"The Ombudsman has shown that the serious incident report authored by the Trust after Matthew's death, is not fit for purpose. A report that has been used as evidence with the police, the coroner and every investigation to date, into our son’s death. Now proving every one of those investigations is flawed and inaccurate.
"The call for another review does not impress. Witnesses must be compelled to give evidence under oath. Time is of the essence. Patients continue to die. More paper shuffling just delays necessary changes to be made sooner. Continued failings have eroded public confidence in services and a public Inquiry is the only way to bring it back.”
Deborah Coles, Director of INQUEST said: “The Ombudsman’s report once again exposes a system of investigation that is fundamentally flawed. This system allowed the North Essex Partnership University NHS Trust to ignore and repeat dangerous practices for over a decade.
"If it were not for the dedication and persistence of bereaved families to get to the truth, these failings would never have come to light. It is time that those families are listened to.
"A national system of independent investigations into deaths in mental health settings is urgently required, to minimise bias like that identified by the Ombudsman, and move closer to a process which can establish truth and accountability.”
* Read the Parliamentary Health Service Ombudsman's report here
* INQUEST https://www.inquest.org.uk/
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