A review has been ordered into significant failings at an NHS health trust in Essex that contributed to the deaths of two young men.
The Health Service Ombudsman found the former North Essex Partnership NHS Foundation Trust, which ran mental health services, did not do enough to tackle repeated and critical problems.
The mother of one of those who died says her son was let down in the most appalling way.
The Essex Partnership Foundation Trust which now runs the services says it will support the review.
Click below for Serena Sandhu’s report
For nearly seven years Melanie Leahy has fought for justice for her son Matthew. He died in November 2012, aged 20
He was found hanged just eight days after being taken to the Linden Centre
Melanie Leahy, Matthew’s mum, said: "His mood was, ‘Mum I am in hell get me out of here’.
“They said let him settle on the ward. I had texts but the next time I saw him he was dead on the trolley. He was sectioned, he had no choice, he begged me to get him out of there and I didn’t.”
A national review has been called for after the former Essex NHS Trust was found it failed to keep patients safe with years of failings in treatment and care.
The report highlighted systemic failings and said the lack of safety improvements were unacceptable.
Rob Behrens, Parliamentary and Health Service Ombudsman, said: "These vulnerable young men and their families were badly let down by North Essex Partnership Trust.
"The lack of timely safety improvements following their deaths is completely unacceptable and it's important the NHS understands why this happened and what lessons can be learned to prevent the same mistakes happening again.
"I am pleased that NHS Improvement has accepted our recommendation to review what happened at the Trust and to share the findings from this with parliament and the wider health system."
But for Matthew's mum it doesn't go far enough and she's launched a petition calling for a public inquiry.
Melanie Leahy said: "So much documentation has gone missing. The defibrillator has been destroyed, the ligature has been destroyed, the room was cleaned. If that's not a clean up to cover up something then I don't know what is."
Melanie is forever haunted knowing that Matthew was failed in the worst way by those entrusted with his care.
Melanie Leahy added: “It couldn't get any worse could it? My son was left in a room and medicated for a week and I feel terrible that I asked for him to go there and that will live with me forever.
“I sent my son to his death. But I will fight to find out what happened to him and who is responsible.”
Click below for Serena's interview with Sally Morris, Chief Executive of Essex Partnership University NHS Foundation Trust