Families of affected patients join together to express importance of a Statutory Public Inquiry into the deaths, abuse, and exploitation of patients under the care of Essex mental health services
Melanie Leahy, who is spearheading a campaign to get a Statutory Public Inquiry into what appear to be calamitous failings within NHS Mental Health Services in Essex spoke to Nadine Dorries, Minister of State for Mental Health, Suicide Prevention and Patient Safety, in advance of the debate. Melanie emphasised the seriousness of the situation to Ms Dorries and made it clear that a full statutory public inquiry is needed – now, and that nothing less will do. Melanie and all the other families have had enough of reviews and investigations that have ultimately boiled down to merely ‘tick box’ exercises and with a report that sits gathering dust on a shelf.
Melanie left the meeting feeling far from reassured. She is upset, angry, and deeply concerned that the Government are going to commission yet another time consuming, and no doubt costly, investigation in an attempt to be seen to be responding, which could be just a paper-pushing exercise.
In a letter to the Minister following the call, Melanie made it clear that a statutory public Inquiry is needed as that is the only way to achieve: “Something real and meaningful, that paves the way for truth, justice, accountability and change, rather than just carry[ing] on the whitewashing tradition of most governments.”
Melanie also stated in the letter that: “I and all the other families that have joined my call want and are now demanding is a full Statutory Public Inquiry. Those responsible for the death of our loved ones, the people responsible for what has been going on under the guise of Essex Mental Health Service must be called to account, and must give evidence on oath.”
The letter sent ahead of the debate is just the latest step in Melanie and the other family’s tireless campaign for the truth that started after Matthew’s death in 2012.
Matthew, who had been experiencing some mental health problems, was admitted to the Linden Centre, Chelmsford on 7 November 2012, for ‘care and treatment’, and to ensure he was safe. During his stay, Matthew contacted Essex Police begging for help. Eight years on, Melanie Leahy has acquired a recording of Matthew’s call to the emergency services: Matthew is heard telling the call operator that he has been raped, that he is bleeding, that he needs medical attention, and that doctors are ignoring him. On 15 November 2012, just 7 days later, Matthew was found hanging in his room. Matthew was taken to Broomfield hospital where he was pronounced dead.
An inquest revealed that there had been multiple failings in the care given to him at the Linden Centre by the North Essex Partnership University Trust (NEP). However, the inquest did not get to the bottom of what had happened and how it was possible for a young man, to have died in this way, while in the care of ‘professionals’ at an institution whose main if not only, remit, is to look after and treat people with mental health problems.
Nina Ali, Partner at Hodge Jones & Allen, emphasized the importance of a Statutory Public Inquiry: “The reason it has to be a statutory public inquiry rather than just a public inquiry or any other type of investigation/review is that only statutory inquires have the power to compel witnesses i.e. the people responsible have to attend and their evidence must be given under oath. It is the only way of really calling people to account and to get to the truth of what is happening in Essex Mental Health care, and finding out what is going so badly wrong there.”
Lisa Morris, lost her son Ben Morris, 20, who died in the Linden Centre in December 2008, expressed her backing of a Statutory Public Inquiry: “A recent Health & Safety Executive investigation has finally proved that the wards of Essex Mental Health Services have never been safe and yet somehow patients and their relatives were never warned of this and hospitals have been allowed to continue as normal. Our government need to stop protecting a system that is not fit for purpose, a system that has allowed vulnerable suicidal patients access to ligature points that should never have been there, a system that allows vulnerable suicidal patients to abscond resulting in death, a system that allows these deaths to continue without any independent investigations as to why they were allowed to happen in the first place and a system that allows these deaths to sail through all authorities including the inquest, remaining unexplained and leaving many facts and vital evidence hidden.
“I urge our government to do the right thing and start protecting our vulnerable mental health patients by commissioning a full Statutory Public Inquiry to get to the core of how and why so many systemic unnecessary deaths have been allowed to happen. How many more will have to die before there is any truth, accountability and change that is so desperately needed?
“There is nothing I can do that will ever bring my Ben back and it is like constant torture having to go over and over my Son’s death in the hope that I can help to prevent this ever happening again. So many families have already been destroyed but my conscience would not allow me to turn a blind to the deaths that continue to happen without trying to make a change.”
Melanie added: “Matthew’s death wasn’t investigated properly – his care plan was falsified after his death, his claim of rape wasn’t taken seriously, he was highly medicated, he was bruised, he had unexplained needle wounds his safety was not taken into consideration. I still don’t have the truth about the circumstances in which he died, which leaves me with a huge sense of pain and injustice.
“I and the other impacted families will be carefully following the debate on Monday in the hope that this will bring much-needed attention to gross failings in Essex Mental Health Services – for Matthew, for all the other families who have lost loved ones and, as importantly, for vulnerable people who are currently in these same institutions and who are being neglected, abused and dying.
“Despite all the investigations to date, nothing has changed. The words ‘Lessons must be learned’ have been endlessly repeated but still, the failings continue, our vulnerable continue to suffer and die, and I and others still do not have the truth. I will not accept any more tick box or lip service investigation. I want a full statutory public inquiry so that the people involved can be called to account and give their evidence on oath!”
Priya Singh, Associate at Hodge Jones & Allen added: “Matthew was owed a duty of care that was lacking and, ultimately, resulted in the premature loss of his life. We want to get to the truth – for his family and all the other families that are owed answers for their loss. A Statutory Public Inquiry will not only bring answers for our bereaved families but also recommendations for change – a change that is urgently needed to help save future lives. While our campaign continues to grow, we would urge anyone else who has concerns about mental health provision concerning this case to get in touch – gathering more stories will help better serve the patients of tomorrow.”
INQUEST, a charity focused on providing expert assistance with investigation into state-related deaths, is also supporting the campaign.
Testimonials from other families fighting for justice with Melanie
Susan Kelly, lost her daughter Sharon Louise Kelly, aged 44, who died whilst under the care of Essex Partnership University trust on June 27th 2019:
“An Article 2 Inquest was held in Chelmsford two weeks ago to investigate Sharon’s death. During the inquest matters were raised giving cause for concern and that in the coroner’s opinion future deaths could occur unless action is taken by the Trust, The Ambulance Service and Essex Police. The investigation concluded that the timing of the mental health act assessment was inadequate.
“We are not willing to accept anything less than a Statutory public inquiry into the historic and. ongoing deaths while under the care of Essex Mental Health Trust community or while in so-called places of safety. An independent inquiry into a few deaths is nowhere near adequate, all our loved one’s lives matter and we need a full Statutory Public Inquiry to get to the bottom of what has and continues to go so very wrong, leading to multiple deaths.”
Holly Storey of Great Dunmow, Essex, lost her husband Kevin Peters, who was under the care of his local GP and was last seen by a team at Harlow A&E, in 2012:
“My Husband Kev worked hard all his life & was never ill, but when he did fall ill with depression he did not receive the care he should of. To know my Husband of 20 years was found dead alone, in woodland is torture, every day.
“An independent investigation into several deaths at the Linden Centre will not give me any answers as to why Kevin was failed. I push with all the other families involved for a full Statutory Public Inquiry into Essex mental health service. We all deserve to know the truth as to why our loved ones died.”
Michelle Booroff, lost her son Jayden Booroff, aged just 23, on the 23rd of October 2020 whilst under the care of Essex Mental Health Services:
“For any of us to get the truth! About how our loved ones were allowed to die under the care of Essex Mental Health Services is to have a Statutory Public Inquiry!
“This will mean that the trust will legally have to provide the correct documents and staff will be called to tell the truth on oath. It will stop members of the trust, yet again covering up their mistakes! This should be a Statutory Public Inquiry because it is a matter of great public concern. History has proven that reviews and investigations into Essex Mental Health Services have not changed anything.
“It is of public concern because mental health difficulties can affect anyone any time and if they live in Essex and suffer from an acute mental health issue, most do not have any other choice than to be placed under the care of Essex Mental Health Services and worse sent to one of their mental health units. Without change and accountability the neglect will continue and more lives will be lost!
“Shifting staff and employing new staff has not changed anything either. My son Jayden was the latest victim to die under their care only five weeks ago! I was hoping he would be the last.”
Julia Hopper lost her son, Chris Nota, 19, on July 7th, 2020, while under the care of Essex Mental Health Services:
“Chris was the love of our lives. There won’t be a day for the rest of my life when I won’t scream at the brutal, cold, evil treatment that he suffered which inevitably resulted in his loss of life at the hands of so-called ‘experts, tasked with healing. We thank Melanie for fighting to prevent my son’s death but she is being ignored. We owe her such a debt for trying.
“Please don’t ever let this happen again. I am begging the government to call a statutory public inquiry into Essex Mental Health Services now. This cull on the most vulnerable in our society must end.”
Amanda Cook, lost her brother Glenn Holmes, aged just 19, while under the care of Essex Mental Health Services. He died in July 2012:
“I am hurt and angered to now find out that the system is once again able to get away with failing my brother, a 19-year-old boy who just wanted some help to live a full and happy life. We need a Statutory Public Inquiry now – we will never give up”
Mr X lost his brother in early 2020 following discharge from an Essex Mental Health Unit:
“We are unwilling to accept anything less than a full Statutory Public inquiry into all of the deaths at the hands of Essex Mental Health Trusts. It is impossible to overstate the further detrimental impact of limiting a review/independent inquiry into several deaths occurring at a single, so-called, ‘place of safety’. My brother’s life was not expendable, no life is.
“This government needs to robustly pursue accountability and justice for all of those lives lost to ensure scrutiny and transparency across the board. We will never stop in our pursuit of this for everyone impacted. Our lives have been totally destroyed.”
Robert Wade, of Sudbury, Suffolk, lost his son Richard Wade, who was placed in the care of NEP in 2015, and died within 12 hours of his admission:
“On 16th May 2015, Richard went to NEPT, Chelmsford, to live; within twelve hours he had sustained the injuries from which he was to die.
“In May 2017, Richard’s Death Certificate stated: ‘Richard’s risk of suicide was not properly and adequately assessed …’ Richard was deemed ‘low risk’ and was under the care of NEPT. In May 2020, Essex Live News stated:’… [a patient] had taken his life hours after being deemed a ‘low suicide risk’ by authorities.’ This patient was under the care of EPUT and EPUT is the successor to NEPT.
“These and other failings are systemic and lessons have not been learnt, there is something profoundly wrong. The deaths can be stopped but it will take a Public Inquiry to do it.”
The debate will take place in Westminster Hall from 4.30 p.m. on Monday 30 November. The debate will be led by Mike Hill MP (Hartlepool) a member of the petitions committee. Anyone wanting to watch the debate can do so by heading to Parliament TV.
Earlier this month, following an investigation the Health and Safety Executive, the Essex Partnership University Trust (EPUT), which merged the North and South Essex Partnership University NHS Foundation Trusts, pleaded guilty to having “failed to meet its duties under Section 3 of the Health & Safety Act 1974, thereby exposing vulnerable patients in its care to the risk of self-harm by ligature”
Those who want to join the call for a Public Inquiry should contact Nina Ali and Priya Singh at HJA Solicitors:
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