More than 1,500 patient deaths are to be investigated in the largest-ever independent inquiry into “unacceptable” mental health care.
A probe into the deaths of patients who were cared for by NHS mental health services across Essex has revealed its investigation will cover deaths from 2000 to 2020.
All 1,500 people died while they were a patient on a mental health ward in Essex, or within three months of being discharged from one.
The inquiry is the latest in a line of official investigations exposing “systemic failures” in services now run by Essex Partnership University Foundation Trust.
However, some families of those who have died are calling for the inquiry to be converted into a statutory public inquiry which would be able to compel witnesses and staff who have since left the trust.
In 2018, following an investigation into 25 deaths, police criticised the trust for “clear and basic” failings but did not pursue a corporate manslaughter prosecution.
And in 2021, the Health and Safety Executive fined the trust £1.5m due to failures linked to the deaths of 11 patients. The regulator said the trust did not manage the risks of ligature points for a period of more than 10 years.
Last week The Independent reported on the death of a young woman called Bethany Lilley who an inquest jury ruled died following “neglect” by the trust.
In January 2021, following pressures, former patient safety minister Nadine Dorries commissioned former NHS England mental health director Dr Geraldine Strathdee to chair an independent inquiry.
In an update, Dr Strathdee said that so far the inquiry had information on the cause for only 40 per cent of the 1,500 deaths. The inquiry will cover deaths that occurred under the former North Essex Partnership and South Essex Partnership foundation trusts which merged in 2017.
While it is not known yet how many of the 1,500 deaths were caused by neglect, Dr Strathdee said evidence had so far shown some “unacceptable” and “dispassionate” care.
Only 14 families have come forward to speak to the inquiry team about the deaths of their loved ones so far. Dr Strathdee called for families to come forward and give evidence.
Some of the safety issues raised include problems related to physical healthcare, concerns over assessment of suicide risk, “sexual issues” and the quality of care.
When asked about the need for a public inquiry Dr Strathdee said it is a ministerial decision but that the team were gathering information and would keep ways of doing this under review. Once completed in 2023, the probe will make recommendations for improvements in Essex and at a national level.
Paul Scott, chief executive for Essex Partnership University NHS Foundation Trust, said: “We continue to support the ongoing inquiry and encourage service users, family, carers and staff to share their experiences with the inquiry team so they have a full picture to draw on to make their recommendations.”
‘Systemic failings’
Melanie Leahy, who has campaigned for change within Essex mental health services since her son died in 2012, has been leading the call for it to become a public inquiry on behalf of the families. Her son, Matthew Leahy, died as an inpatient at the Linden Centre, following multiple failings in his care.
A 2018 parliamentary health service ombudsman report on his death, and that of another young man called Richard Wade, identified “systemic” failings on behalf of the trust. These included the failure to manage his risk level, to look after his physical health and to take action when he reported being raped in the unit.
In a statement to The Independent, Ms Leahy said a public inquiry would allow for “an honest and transparent account of what is really happening which can be enough to change the course of history and save the lives of those who are not even being given a sporting chance presently”.
“In areas where there have been far less deaths, we have had inquiries and laws have swiftly changed to save lives. Mental health has been the orphan area of health.,” she added. “While Theresa May attempted to give us parity with other areas of health, nothing changed. Every one of us must feel responsible for the destruction of our most vulnerable and take this weight that we have handed to all mental health trusts and spark the energy required to redesign every aspect.”
Selen Cavcav, senior caseworker at Inquest said only a statutory public inquiry would restore trust and tackle the “unacceptable” death toll of people under the care of Essex mental health services.
She added that previous critical inquests, investigations and inspections have failed to “compel the transformation in culture and leadership that is clearly needed in Essex”.
‘There was no care’
Linda and Robert Wade lost their son Richard in May 2015, when he was an inpatient at the Linden Centre in Chelmsford. They described their son as an “intelligent and fun” young man who finished a PhD at 27 and wrote a book. Within 12 hours of his admission to the Linden Centre, Mr Wade was found ligatured in his room.
His mother Linda told The Independent that on the night he was admitted, “he wanted to feel safe because he was frightened but there was no care there. They didn’t engage with him. He was suffering from psychosis, thought he had motor neurone disease, even so obviously.”
She added: “I cannot understand why they left him with everything, the clinical professionals. Why did they leave him with scissors and razors, knowing he was suicidal? I cannot understand that to this day.”
Richard’s father said there had been “institutional” failings by the trust and that it has “not seemed to be able to confront painful truths” seven years on. “Having not put failures right in the past, it’s extremely difficult to root them out in the present. I don’t believe it’s possible for the current CEO of the trust, who I believe is trying to do the right thing but has an impossible task,” he said.
“This is because the whole of the failure isn’t just the events taking place inside that trust, it is the culture of the trust to be a failing organisation because they have chosen not to deal with the problem, but to leave it ingrained in their structure.”
