Secretary of State, The United Kingdom
United Kingdom

My son shouldn't have died. Please help me get to the truth of what really happened. A public inquiry into his death and the many others before and after his is a must. We demand a public inquiry into the North Essex Partnership Trust.

My 20 yr old son was found hanging behind his room door in the Linden Centre, Chelmsford, Essex, 2012. A psychiatric hospital where he had been taken after suffering a psychotic episode. Day three of admission he had called the police to say he was being drugged and raped on the ward. He had bags packed ready to travel the world. His 21st birthday was only a few weeks away. An inheritance was awaiting him. Four days after this call, he was found dead.

Police failed to secure the scene, interview vital witnesses and even destroyed evidence.

Staff falsified Medical papers after his death.

Four needle wounds were found in his groin at postmortem... to date no explanation as to where they came from.

Suicide could not be confirmed. Lots of questions remain unanswered. The coroner suggested a public inquiry be held but the trust have decided not to hold one.

I need your help to force government to action this inquiry.

Things need changing to stop more people dying under NEPFT care and more families being destroyed like mine has been.

Please sign the petition and share with your friends.
To The Secretary of State

I write to humbly request the assistance of the Secretary of State to help save patient lives by investigating fully why my own son died within seven days of admission to a place he was expected to be kept safe.

I write as the mother of Matthew James Leahy 20 yrs who died 15th December 2012 and had been receipt of mental health services with the North Essex Partnership Trust in the Linden Centre Chelmsford.

At the inquest the coroner requested the trust hold a public enquiry, (See document 1-Regulation 28 report copy enclosed), but on the advice of the Trusts solicitor they refused. I even offered to fund an investigation to the tune of £40,000 myself, but they still refused. (see documents 2 and 3)

Inquest verdict – Open Narrative – stating that,
‘Matthew 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 had not been adhered to, impacting on Matthews’ overall care and wellbeing, leading up to his death.

North Essex Partnership have written to myself, MP Priti Patent l and the CQC January 2015 to confirm all recommendations made after my sons death – (in the serious incident report ) , had been actioned. (See documents 4-5-6-7 enclosed).
It took another patient death in February 2015 for the CQC to actually go in and inspect.

The CQC report published early 2016 has confirmed the fact that anything that the Trust says must be taken with a pinch of salt. The lies have been uncovered! And at the cost of more lives lost.

The recommendations had NOT BEEN actioned!

How are we going to be certain the improvements are fully consolidated into practice and sustained??

Nobody, not one organisation has ever made sure any recommendations made after patient deaths have been actioned and it has only been because of my persistence and more patient deaths that finally something is slowly appearing to be being done to improve services.

Agenices very quickly assumed that referring the issues surrounding the death of my son for a further review would be unlikely to add to the findings of the coroner and North Essex Partnership. They miss the main fact that the investigation the Trust carried out was ambiguous and the coroner was limited to the information provided to help her to discover a cause of death. All agencies involved to date, have only covered the issues surrounding the short stay at the Linden centre.

The community services, the GP involvement, Social workers, EIP Team, the lack of support and police failings, all prior to his death 2011 – 2012 - have never been reviewed. The coroner was clearly of the opinion that things would have been so so different if agencies employed to help my son (a vulnerable person), - had done their job correctly my son would more than probably still be alive. ‘Missed opportunities’.

Eventually after a lot of pressure the cqc went in and inspected the trust in August 2015 to find that none of the recommendations had been actioned.
Since my sons death another five patients have died by the same means.(That I know of…there are probably more..unreported).

I enclose a private investigation that I had commissioned and it proves that the Trust were told to change the doors after another patient death in 2004. (For all areas discussed in this report I have documentary proof):-

Written late 2015.

The NEPFT where two men were found hanged this year had failed to act adequately on recommendations going back a decade on how to minimise suicide risks to patients.

Seven in-patients have now died by hanging at the North Essex Partnership University NHS Foundation Trust since 2004, including the two in the first half of this year.

Internal recommendations made after the first of these deaths were not adopted.
In the years since then, six more people have died and at least three other separate warnings and recommendations were issued, both from the healthcare regulator and internally.

But when the Care Quality Commission regulator, carried out an unannounced inspection following a death in February this year, it found the risks had still not been fully addressed.

The recommendations focused on the issue of ligature points, such as on doors, windows and wardrobes. Most in-patient suicides on psychiatric wards occur as a result of hanging from these points.

Trust bosses were first warned about the doors in 2004 following the death of Denise Gregory, 40. She had hanged herself using a radio lead tied to the hinges of the door of her bedroom in the trust’s Linden Centre in Chelmsford, where there are three wards for adults suffering from acute mental mental ill health.
She was a patient on one of these, the Galleywood ward.

After her death, the trust’s risk management and estates departments issued written advice to bosses on how to reduce the risk of patient hangings. They recommended that wardrobe handles should be flush to the door or integrated, bathroom and bedroom doors should be fitted so that they opened both ways – with safety hinges – and that windows should “offer minimum ligature points”.

Risk assessment
A subsequent risk assessment in 2007 highlighted looped wardrobe door handles used throughout the Galleywood ward as representing a particular risk.
The handles were still in place in December 2008 when Ben Morris, 20, died in his bedroom on the ward. He was found hanging by his belt from wardrobe door handles.

A trust inquiry into the death found multiple failings in Ben’s care. Among other recommendations was a call for a “review of ligature points across the acute wards”.
In 2012, two further in-patients died by hanging at the trust. One, whose name has not been disclosed, was found hanging from the handles of his window in a secure room in a unit close to the Linden Centre.

And Matthew Leahy, 20, was discovered hanging from bedding attached to the hinges of his bedroom door – again on the Galleywood ward.

After Matthew’s death an internal inquiry established that his bedroom door did not open outward or have safety hinges.

The inquiry recommended the type of door hinges used by the trust be reviewed “to reduce the possibility of this method of suicide”.

In June 2013, the Care Quality Commission inspected the Linden Centre. Its report acknowledged that the trust had carried out risk audits but again highlighted ligature points as a concern.

Reassurances given
Trust bosses reassured the inspectors the risk would be addressed. The CQC report said: “This was discussed with the senior management team on the day of our inspection who assured us that this had been noted in the service’s patient safety audit and would be addressed.”

In March 2014, 73-year-old Iris Scott hanged herself from the door of her en-suite bathroom in another of the trust’s units, the Crystal Centre for the elderly.
Eleven months later on February 17, a 57-year-old man died after being found hanged from the door of a shower room in the Linden Centre. The inquest into his death is due to be held next month. The room is understood to have been on one of the acute adult wards – the same wards on which Matthew Leahy and Denise Gregory had died.

Three days later on February 20, the CQC sent in a team to inspect the wards.
When the inspectors’ report was finally published in May, it found “high risk” potential ligature points.

“We noticed a number of potential high risk ligature areas around the ward … the trust’s own patient safety audit did not reflect these findings,” the report said.
“Gaps were seen in the completion of the action plan drawn up in response to the annual ligature risk audit and the patient safety audit. The trust’s programme for managing ligature risks was not available.”

Although five bedrooms on the wards without ligature points had been allocated to patients considered at high risk of hanging themselves, the inspectors found the centre’s risk assessments – which would be used to decide who need to be placed in one of these rooms – were inadequately detailed and had not been not updated to reflect changes in patients’ mental state.

Door hinges not changed
The inspectors also found that no action had yet been taken to replace door hinges on the wards despite the recommendations of the inquiry into Matthew Leahy’s death.

“Following a serious incident in 2012 an action point was to review the door hinges in place throughout this location and this had yet to be fully addressed by the trust,” the CQC report said. While managers had “investigated and trialled options” they had not yet made a final decision on what to do, it added.

On May 21 2015, the day after the CQC inspectors’ report was published, 30 year old Richard Wade died after being found hanged on the Linden Centre’s Finchingfield ward. A date for the full inquest into his death has not yet been set. The Bureau understands that he was found hanging from the door of one of the ward’s bathrooms, although the trust has not confirmed this.

Melanie Leahy, Matthew’s mother, has been campaigning since her son died in 2012 for improvements in the Linden Centre and has set up a Facebook page highlighting the issues there.

She wrote to the CQC this month to complain about the trust’s failure to appropriately change the ward’s doors.

She said that “if this issue had been addressed after my son’s death in 2012” two other men might not have died.

She told the Bureau: “The trust has failed in its duty to others as well as my son. These deaths might have been prevented. I believe my son would still be alive if recommendations made after Ben Morris’s death in 2008 had been followed appropriately.”

The CQC told the Bureau that it had conducted a thorough inspection of all the trust’s inpatient services in August 2015 and that a fresh report was being prepared.
Sadly the cqc have published their report from inspection August 2015 and they rated the trust….’inadequate for safety’. They found that new doors had not even been commissioned and ligature points had not been reduced or addressed and even on the day of inspection a patient tried to hang themselves. They also reported another 25 attempted hangings. My request is a call for urgent action into an independent inquiry.

This clearly is the only option available, as internal investigations completed to date have failed to bring answers. We believe an independent investigation is the only way for truth to prevail. We have been trying to obtain the truth surrounding our only sons’ death for over three years now and continue to hit brick wall after brick wall. He was only a young man, with all his life ahead of him.

Our family has been completely destroyed by his death and we will not give up searching for the answers we so desperately need.

Sadly patients continue die within NEPFT care, with 11 being listed in January 2015 alone.
My intention with fighting for Justice for my son was just that…but now I am in touch with so many patients and families – daily, hearing their problems such as that the crisis line is not answering – that their meds have been changed without consultation – that the community worker keeps changing and they have to re-tell their problems – that they have no care plan – that physical problems do not get dealt with once in the mental health system ( I have experience of this fact. ) -the list goes on – most of these issues I experienced with my son 2011…its still happening now in 2016 …this must change …and the only way to do this – is to review what’s happening and make sure lessons are learned.

Finally the Care Act 2014.

Key elements of the care act came into force on April 1st 2015 which shifts the focus in mental health from a narrow conception of disease management to a broader duty to promote wellbeing and early help and prevention for service users and their carers.

The Clinical Commissioning Group states in their minutes that the North Essex Partnership Foundation Trust is not fully complaint with the Care Act and in fact Essex is facing a severe shortage of qualified Approved Mental Health Professionals.

So where can we proceed from here?

Do you take a review of my sons death and others, so agencies can learn from it and perhaps stop this situation happening again???

I have a petition running, which currently holds 629 signatures and is growing by the day. http://goo.gl/Feo5i4

I have numerous documents to hand regards my sons death and other families loved ones, which the families have entrusted to me in the hope of aiding the progression of this very serious situation.

Please, please help me by commissioning an independent investigation into the deaths of the poor patients already failed, in the hope of stopping more families being destroyed as ours have been.

I eagerly await a promising response,

Yours sincerely,

Mrs Melanie Leahy

Priti Patel MP
Jeremy Hunt MP
Jeremy Wright QC MP Attorney General

Thank you.

We the undersigned back the request into a full public inquiry into all the deaths under the care of North Essex Partnership Trust and the death of Matthew Leahy 20 yrs..who died at the Linden Centre 15th November 2012. The families deserve the truth.

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The My son shouldn't have died. Please help me get to the truth of what really happened. A public inquiry into his death and the many others before and after his petition to Secretary of State, The United Kingdom was written by Melanie Leahy and is in the category Justice at GoPetition.