Debate on e-petition 255823, relating to deaths in Mental Health care

Deaths in mental health care

This debate focuses on e-petition 255823, relating to deaths in mental health care. The petition was created by the mother of Matthew Leahy, a young man who died in 2012 whilst receiving care at the Linden Centre, a mental health unit at what was then the North Essex Partnership University NHS Foundation Trust (the Trust).[1]

The petition also raises concerns about a number of similar deaths at multiple sites within the same Trust and calls for a statutory public inquiry into deaths that occurred in the Trust since the year 2000.  

On 16 October 2020, an adjournment debate was held on the subject of Care Quality Commission: Deaths in Mental Health Facilities. The Member in charge, James Cartlidge MP, focused on the case of a constituent, Richard Wade, who took his own life whilst under the care of the Linden Centre in May 2015. During the debate, James Cartlidge raised concerns about the CQC’s handling and investigation of several deaths at the Linden Centre.

In response to the debate, the Government announced an independent review into the serious questions raised by a series of deaths of patients at the Linden Centre between 2008 and 2015. The terms of reference of the review have not yet been agreed – the Government have said they wish to engage with the families affected to agree the scope and terms of reference for the review.[2]  

Reviews and investigations into services at the former North Essex Partnership University NHS Foundation Trust

In June 2019, the Parliamentary and Health Service Ombudsman (PHSO), published its report, Missed opportunities: What lessons can be learned from failings at the North Essex Partnership University NHS Foundation Trust. The report found that there were a series of significant failings in the care and treatment of two vulnerable young men, Mr R and Mr Matthew Leahy, who died shortly after being admitted to the Linden Centre. The PHSO also recommended and agreed with NHS Improvement that it would conduct a review of what happened at the Trust.

In November 2019, the Public Administration and Constitutional Affairs Committee published its scrutiny of the PHSO ‘Missed opportunities’ report. The Committee’s inquiry examined the issues identified in the PHSO report and investigated what actions have since been undertaken in the areas of: safety of acute mental health care provision; leadership; and developing a culture of learning within the NHS. In particular, the Committee noted the significant body of evidence from the Care Quality Commission (CQC), the PHSO report and others that there is a need for significant improvements in the safety and quality of mental health provision throughout the NHS:

• The Committee found that significant improvement in the safety and quality of mental health provision is needed throughout the NHS and it recommends that the Minister and NHS England ensures that this is a top priority. The Committee agrees with the recommendation of the Care Quality Commission that NHS England and NHS Improvement should ensure that patient safety forms part of ongoing mandatory training as part of continuing professional development.
• On the topic of leadership, the Committee concludes that the PHSO report powerfully demonstrates the need for effective leadership within the NHS. We welcome the Government’s proposal to specifically cover plans for leadership in the NHS within the People Plan, to be published later this year. The Government should make clear, however, that ensuring effective leadership within an organisation is not simply a one-off event but rather is an iterative process of continuous improvement.
• On developing a culture of learning in the NHS, the Committee welcomes the Government’s commitment to ensuring the families affected will be involved in the upcoming NHS Improvement and NHS England review. We also welcome the inclusion of Health Service Safety Investigations Bill (HSSIB) in the recent Queen’s Speech, a piece of legislation that the Committee has strongly supported for many years. In particular, we believe that the introduction of the ‘safe space’ principle will facilitate more open investigations and proper learning to reduce repeated incidents and recommend that it be included in the Queen’s Speech after the upcoming General Election.[3]

The Health and Safety Executive (HSE) has also investigated how the Trust managed environmental risks from fixed potential ligature points in its inpatient wards between October 2004 and March 2015.  Following this investigation, an HSE prosecution is now being brought against the Trust under Section 3(1) Health and Safety at Work Act 1974.[4]

As noted above, in response to the adjournment debate on Care Quality Commission: Deaths in Mental Health Facilities (16 October 2020) , the Minister announced that the Government will commission an independent review into the questions raised by a series of deaths of patients at the Linden Centre between 2008 and 2015:

• I am announcing today that she [the Minister] has set out her intention to commission an independent review into the serious questions raised by a series of tragic deaths of patients at the Linden Centre between 2008 and 2015.
• […]
• I hope that this announcement today to commission an independent review into issues at the former North Essex partnership trust shows the strength of our commitment and my hon. Friend’s commitment in addressing the concerns he and his constituents have raised and in listening to and working with the families involved in these tragedies. We are committed to learning lessons at a national level to improve services across the whole mental health system, so that no other family experiences the same devastating loss as Richard’s family and the families of other patients who died at the former North Essex partnership trust.[5]

[1]      North Essex Partnership University NHS Foundation Trust merged with South Essex Partnership University NHS Foundation Trust in April 2017, to form the Essex Partnership University NHS Foundation Trust.

[2]      HC Deb 16 October 2020 c734

[3]      Public Administration and Constitutional Affairs Committee, Follow up on PHSO report: Missed opportunities: What lessons can be learned from failings at the North Essex Partnership University NHS Foundation Trust, 31 October 2019, HC31, page 3

[4]      Health and Safety Executive, HSE to prosecute Essex Partnership University NHS Foundation Trust (EPUFT), 29 September 2020

[5] HC Deb 16 October 2020 c733