Investigation finds ‘numerous serious failures’ in the care of Linden Centre inpatients

‘The passing of our son has left a void that nothing can fill’

Matthew Leahy was found hanging at the Linden Centre in Chelmsford, and his parents are still asking for change nearly seven years later. 

This comes as a report, which highlights systemic failure of a former NHS Trust to tackle repeated failings, has outlined some shocking details about the care of Matthew and one other young man. 

Aged 20, Matthew was admitted to hospital on November 7, 2012, for “his own safety”.

But just a week later he was found hanging at the Linden Centre, located within the grounds of Broomfield Hospital.

Now The Parliamentary Health Service Ombudsman (PHSO) points to a systemic failure of the North Essex Partnership University NHS Foundation Trust (NEP) to tackle repeated and critical failings over an “unacceptable period of time”.

What went wrong? 

Numerous serious failures were found in the care provided to Matthew.

Some of the failures included that there was no care plan in place, he was not adequately observed, he did not have an allocated keyworker, and that there was an inadequate response when he reported being raped.

They also found that record keeping was not robust, paperwork was lost and that Matthew’s care plan was written after his death. 
  
These findings were in stark contrast to the first investigation into Matthew’s death, which concluded that the care and treatment was of a good standard.

The initial investigation was carried out internally by the NEP in the form of a Serious Incident Report, and informed other subsequent post-death procedures including the inquest. The Ombudsman has branded that investigation “inadequate” and “not robust enough” on the basis that:

  • It contains inaccurate information about how Matthew’s care plan was reviewed.
  • It lacks credibility because it was written by a member of staff who was later found to have been involved in the falsification of Matthew’s care plan.
  • Matthew’s family were not as involved in the investigation as they should have been.
  • The conclusion stated that overall care was of a good standard, but this did not reflect the critical findings in the content of the report.


Melanie and Michael Leahy, Matthew’s parents, said:  “It’s been a long debilitating seven years to get to this point. The passing of our son Matthew James Leahy has left a void that nothing can fill. Not a day passes when we do not miss him and despair at the thought of how his life was cut short, so needlessly. 
  
“The Ombudsman has shown that the serious incident report authored by the Trust after Matthews death, is not fit for purpose. A report that has been used as evidence with the police, the coroner and every investigation to date, into our son’s death. Now proving every one of those investigations is flawed and inaccurate.

“The call for another review does not impress. Witnesses must be compelled to give evidence under oath. Time is of the essence. Patients continue to die. More paper shuffling just delays necessary changes to be made sooner. Continued failings have eroded public confidence in services and a public inquiry is the only way to bring it back.” 

The Ombudsman now calls for a review to examine the potential failings by former North Essex Partnership NHS Foundation Trust (NEP) to address issues of patient safety, stretching back more than a decade. 

NHS Improvement will be undertaking the review, which will also consider whether there is sufficient evidence for a public inquiry to be held. 

The investigation by the Ombudsman comes after years of campaigning by the families of those who have died. The Leahy family have launched  a parliamentary petition  calling for a full public inquiry, which now has over 3,500 signatures. 

Deborah Coles, Director of INQUEST, a charity providing expertise on state related deaths and their investigation, said:  “The Ombudsman’s report once again exposes a system of investigation that is fundamentally flawed. This system allowed the North Essex Partnership University NHS Trust to ignore and repeat dangerous practices for over a decade. 

“If it were not for the dedication and persistence of bereaved families to get to the truth, these failings would never have come to light. It is time that those families are listened to.  

“A national system of independent investigations into deaths in mental health settings is urgently required, to minimise bias like that identified by the Ombudsman, and move closer to a process which can establish truth and accountability.”

Six inpatients have died

Since 2004, six inpatients have died by hanging at the Linden Centre.

  • Denise Gregory  died at the Linden Centre run by NEP in 2004. Following her death, written advice was issued by the Trust to the management recommending that certain changes be made to the layout and furniture of inpatients rooms 
  • BM died aged 20 in December 2008, despite the recommendations following Denise’s death
  • Matthew Leahy  died aged 20 in 2012 at the Linden Centre. An inquest into Matthew’s death in 2015 had highlighted multiple failings and missed opportunities in his care and the Coroner had recommended the trust to conduct an independent inquiry into Matthew’s death
  • There was a further self-inflicted death at the Linden Centre in 2012
  • John Martin Beecroft , 57, died in February 2015 whilst under the care of NEP at the Linden Centre
  • Richard Wade , 30, was found hanging in the Linden Centre in May 2015

In May 2017, Essex Police launched a corporate manslaughter investigation into series of deaths prompted by Matthew’s family campaign highlighting repeated deaths at the Linden Centre and lack of learning especially in relation to Care Quality Commission inability to promise but not implement vital changes to save lives.  This investigation was however later dropped due to insufficiency of evidence.

Follow the Justice for Matthew Leahy  campaign page on Facebook.

https://www.essexlive.news/news/essex-news/investigation-finds-numerous-serious-failures-2971646

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