Video report by ITV News Anglia's Charlie Frost
Nine deaths between January and March this year are currently being investigated by mental health trust, the Essex Partnership University NHS Foundation Trust (EPUT).
EPUT was formed in 2017 when North Essex and South Essex Partnership Trusts merged.
The Trust says improving patient safety is a 'top priority' and it has spent £2.4 million to date on improvements.
Families of patients who died whilst under the Trusts care over the past two decades are now uniting in calls for a public investigation.
When Richard Wade was going through a bout of heavy depression and psychosis in May 2015 he called police to tell them he was going to hurt himself.
That night he was admitted to the Linden Centre, a mental health unit in Chelmsford. Within 12 hours of being there, he’d taken his own life.
His parents Robert and Linda arrived to visit him, minutes before he was found.
We were taken right down onto the ward so we could see down the corridor to where his room was. We were left there while the care assistant walked around looking for Richard. Then suddenly there was a cry that went up 'He's in the bathroom!' and at that point an alarm went off, the door was opened and on the floor we could partially see Richard.
Robert and Linda have fought ever since for justice for their son.
At the inquest into his death it was found, ‘Adequate and appropriate precautions were not taken to manage Richard’s risk of suicide’ and that the state failed to protect him.
In 2016, Essex Police began an investigation into the deaths of 25 mental health patients from 2000 onwards, including Richard, who had killed themselves whilst under the care of North Essex Partnership Trust, the Trust then responsible for the Linden Centre.
In 2018, detectives told the families there were no corporate manslaughter charges for the Trust to answer.
For Linda and Robert there’s been no accountability for their son's death.
Only through a public inquiry can we get to the truth, only from the truth can we get the justice that is necessary to then move on in peace and then the accountability so that a safe hospital and a safe Trust system can be left in place so that the people of Essex and around East Anglia can have confidence that their vulnerable loved ones will be cared for when they are taken in.
In 2017, the North Essex Trust merged with South Essex Partnership to form the Essex Partnership University NHS Foundation Trust.
Since it has invested £2.4 million in improving safety, saying, “From the first day we established EPUT in April 2017 our top priority has been to continuously improve patient safety. We have an ongoing programme of improvements so that we can provide the best possible care for our patients.”
Melanie Leahy has been actively campaigning for justice for her son Matthew ever since he was found dead at the Linden Centre in 2012.
20 year old Matthew had been there seven days.
Since 2001 seven patients, including Matthew and Richard, have died at the Linden Centre, in similar circumstances.
Earlier this year the Parliamentary and Health Ombudsman released his full report into Matthew's death, finding Matthew suffered multiple failings in his care from North Essex Partnership Trust.
Including having his care plan at the Linden Centre falsified by staff after his death.
After he was admitted he experienced 19 different examples of service failure and maladministration in his care, and that is a shocking history which needs to be addressed to make sure it never happens again.
Responding to the report at the time, EPUT apologised to Matthew’s family and said: “The care provided by the former NEP fell well below acceptable standards..we have carried out its recommendations in full to address the service failings.”
For Melanie it's not enough.
I still don't know what happened to Matthew. All investigations to date have failed to deliver the truth. What needs to happen is a straight down the line statutory public inquiry and bring the staff in and interview them. All these years, eight years and not one member of staff has been interviewed under oath.
In November 2019 Melanie took her fight to Downing Street, petitioning for a public inquiry into Matthew’s death.
Her petition received the 100,000 signatures needed to be considered for a parliamentary debate, but, Health Minister Nadine Dorries MP said a public inquiry into just Matthew’s death would be unlikely: “public inquiries do not happen when it has been individual cases, they tend to be when it’s a systemic problem or multiple numbers, in this case a public inquiry is not an appropriate response.”
Now, Melanie’s pushing for a public inquiry, not just into her son’s death, and not just into the North Essex Trust that failed him, but into deaths of psychiatric patients under the care of all mental health services in Essex; the EPUT as it is now and also the former South Essex Partnership Trust .
Robert and Linda Wade have joined the campaign for this widened and deeper reaching public inquiry, alongside nine other families.
Families who feel their loved ones were taken into places of safety that weren’t safe or who were left in the community unsupported and families who feel lessons haven’t been learned from their losses.
Sofia Dimoglou lost her mum Valerie Dimoglou in 2015:
"A public inquiry would mean that we at least live in a society where someone with authority cares about the lives of those affected by mental health issues - young, old, everyone. Maybe it could really herald a change in Essex and across the country."
Lisa Morris lost her son Ben Morris in 2008:
"A public inquiry is my last hope of ever getting the truth surrounding Ben’s death. How many more have to die? When will it ever end if there is no public inquiry now?"
Amanda Cook lost her brother Glenn Holmes in 2012:
"For me, a public inquiry will help to protect people in the future who suffer with mental health conditions. They deserve the help that my brother did not get but so desperately wanted."
The campaign is also now being backed by a London law firm and Melanie is calling on other families in the county who believe their loved ones were failed to join them.
I didn't want to see myself in this position, I want to be sat here with my boy seeing him grow up, but I'm not alone. I'm urging those families that have lost loved ones, anywhere in Essex, yes get involved, please, we have strength in numbers, don't let their deaths be in vain.
Tomorrow (Saturday 22nd) the families are holding a peaceful, socially distanced demonstration in Chelmsford, in memory of their loved ones.
The Trust says at its board meeting last month it reported it was investigating nine serious incidents relating to the deaths of mental health patients from January to March this year.
In July it also began an internal investigation into the death of Southend teenager Chris Nota.
Meanwhile, the Health and Safety Executive is currently investigating how the former NEP Trust managed mental health environments.
Its investigation covers October 2004 to March 2015, when the Care Quality Commission became the lead regulator.
HSE does not address care issues, only the management of the physical areas of the wards.
It says there are several cases, which are relevant to the investigation in demonstrating risk, including Matthew Leahy’s death.
Response of EPUT and the Department of Health
In a statement EPUT said:
“Essex Partnership University NHS Foundation Trust (EPUT) extends its deepest condolences to those impacted by the death of people in the care of the former North Essex Partnership Trust.
“From the first day we established EPUT in April 2017 our top priority has been to continuously improve patient safety. We have an ongoing programme of improvements so that we can provide the best possible care for our patients.
“We are cooperating fully with ongoing investigations into the care of patients under the former North Essex Partnership Trust.”
“Like all other health trusts, a key part of our patient safety systems is the national learning from deaths mortality review which monitors all deaths of people who were in contact with our services.”
Meanwhile, a Department of Health and Social Care spokesperson said:
“The safety of all patients receiving psychiatric care is paramount and any death is a tragedy.
“Taking account of the Health and Safety Executive’s investigation into the North Essex Partnership Trust (NEP) and any related activity we will set out our plans in due course for a robust and independent process that will scrutinise individual cases as well as gathering together the learning from which all of the NHS can benefit.”
What is a public inquiry?
A public inquiry is a major investigation called by a government Minister. It is run independently by an appointed chairman and often a panel.
A recent well known public inquiry was The Grenfell Tower inquiry following a fatal fire in a London block of flats in 2017.
Under the 2005 Inquiries Act, an inquiry may be held when it appears to a Minister that ‘particular events have caused, or are capable of causing, public concern.’
Inquiries are major investigations that can compel testimony and the release of evidence.
The primary purpose of a public inquiry is considered to be preventing recurrence of anything similar to what it is investigating.
While inquiries may address who is to blame, it has no power to determine any person’s civil or criminal liability.