PARLIAMENT DEBATE 30/11/2020

In Melanie’s Words:-

I write these words not just to represent my son, but to represent the multitude of lives that have been affected by the inadequate care offered by mental health services across our nation.


I am mum to Matthew James Leahy, born December 1991.

He was a beautiful soul. He understood compassion and he cared for others. He was generous, he was kind, he was smart. He was funny and in his younger years he wanted to be a comedian. He was quite shy in large groups, and was a loyal friend. He was never one to encourage a fight but he would stand up for himself and the ones he loved. And Iʼm proud to say my son was honest, not a liar, not like some Iʼve come across on this journey.


He loved the outdoors, loved anything water sports related and was a fantastic skier.
Having left Grammar school, where he excelled in mathematics and computer science, he set up his own computer business, travelling between clients on his motorbike and was doing really well.
He had a natural talent for swimming. He actually saved two ladies from drowning and when 18 he became a qualified life guard.
Aged 19 Matthew was having trouble sleeping and complaining of pains in his stomach and having stomach cramps. He was also hallucinating.


When Matthew became poorly we turned to so called professionals for help. To help us understand what was happening with our son. He was sectioned for care and treatment. This sectioning and the failings in care at that time, although noted briefly in the inquest verdict, have never been investigated.


After Matthews death medical records show that the first psychiatrist involved in his care picked up a B12 and folate deficiency and possible celiac disease, combined with a thyroid issue. However, these discoveries were never addressed, as a new psychiatrist took over Matthews care and put him straight on anti-psychotic medication. Any further physical checks were minimal.

7th November 2012, Matthew was placed under section 3 of the mental health Act and admitted to the Linden Centre, in Chelmsford, Essex.
By 15th November, some seven days in the, ʻcare of the state,ʼ my son was dead.

The last days of his life in a place he called, ʻHell.ʼ And I now believe it truly was, ʻhell on earthʼ.


Alone, malnourished, over medicated, scared, bleeding, bruised, reportedly raped, injected multiple times, ignored, and frightened.

No records of any staff in those last seven days of his life, offering him any comfort. I had been advised not to visit and to give him time to settle on the ward. I will live with the guilt, for the rest of my life, that I listened to so called professionals and I was not there when my son needed me the most.

An inquest into my sonsʼ death was held in January 2015.


An Open Narrative verdict was reached which concluded that my son:-

ʻMatthew James Leahy was subject to a series of multiple failings and missed opportunities over a prolonged period of time by those entrusted with his care. The jury found that relevant policies and procedures were not adhered to, impacting on Matthewʼs overall care and wellbeing leading up to his death.ʼ


How the inquest concluded I will never know.
Staff were not interviewed by police after Matthewʼs death.

An internal investigation was carried out, which the Parliamentary and Health Service Ombudsman has deemed flawed and not fit for purpose. This flawed investigation formed the basis of every investigation actioned after Matthews death.


The ligature was destroyed, the defribulator was destroyed. Door logs were not downloaded. CCTV was hidden for over 7 plus years and parts of it either not retained or deleted. So, so many more issues exist.


I have not been able to determine or control any of this. Investigations, reviews, reports, etc. All processes that have happened around me, with me being entitled to some information and some explanation, but little voice, little influence, and little power.

I did think that the system would be open and honest. Would explain what went wrong. Hold to account those responsible for any failings, and afford justice for failing my most precious son. However, I have discovered a deeply troubling mismatch between what I expected and what I found. In any other walk of life if there had been failings, heads would roll. This has never happened, despite criminal offences being proved.


If the tragedy of losing Matthew hasnʼt been bad enough, to not know the full circumstances that led to his death, ʻwhilst in the care of the stateʼ, is unforgivable. I still do not have full disclosure and have never seen internal statements. ʻDuty of Candourʼ went out the window the moment Matthew died.


It came to light after Matthew died, that paperwork had been falsified, backdated, and slipped into his files. It took me four plus years to finally persuade Essex Police to register this falsification of mental health documents as a crime. I thought, ʻat last they are listening to meʼ. Then the
bomb dropped. ʻWe wonʼt be prosecuting as its not in the public interestʼ.


The Trust had failed to take steps to protect patients in their care. The question remains why no individual has been held to account and why some staff involved in failing my son and other patients, have actually been promoted to high ranking positions in the NHS?


The Coroner called for a Public Inquiry after the inquest in 2015. There have also been multiple calls from various MPs in the last five years. The Parliamentary and Health Service Ombudsman went on national television after, ʻThe Missed Opportunities Reportʼ, was published. To say that if he
had had the power to, he would call a Public Inquiry.

In October last year, the Public Administration and Constitutional Affairs Committee held an evidence session on the Ombudsman Report into the failed care of Matthew and Ben Morris. ( Ben died in the Linden Centre in
2008 aged 20 yrs).


During the session, The Minister for Patient Safety, Mental Health and Suicide Prevention explained, ʻthat Public Inquiries do not happen for individual cases.
In this case, a Public Inquiry is not an appropriate response because we are talking about two casesʼ.

I have now been joined in this fight calling for a Statutory Public Inquiry into Essex Mental Health Services by multiple bereaved and failed families.
(55 families and growing)
How multiple deaths can have gone on, unchallenged for so many years and so many people in official positions, not involved with this scandal, have entrapped themselves by collaboration the moment they came across
it, has baffled me.


How the system did not prevent these deaths or at the very least detect the failings/changes needed, earlier. Iʼm sure is a question in many failed families minds, not just mine.

Where is the Governmentʼs anger?

Its thirst for Truth and Justice?

Its commitment to getting answers and ensuring it never happens again?

Many families are losing loved ones while under the care of state mental health system. Whether that be due to mental illness, additional vulnerabilities such as autistic and/or learning disabled individuals , those misdiagnosed, or dementia…it does not discriminate.


The government is now officially ʻon notice ofʼ-

  • Gross and systemic Neglect (resulting in multiple avoidable deaths
  • Physical, sexual, and emotional abuse and exploitation of the
    vulnerable ‒ most of them young, historical and sadly, ongoing.

The right people in Government need to understand the full extent of the Essex Trusts Failures and I have every faith that once the Government commits to a Full Statutory Public Inquiry into Essex Mental Health, the fundamental truth of what and still is going wrong, will be revealed.


Through that knowledge I hope justice and accountability are afforded and that necessary change is made for others, who like I and many others did, look to services when they need safe, compassionate care for their loved ones.

I offered the Government Matthews sad death to be catalyst of learning and change months ago. Please call a Statutory Public Inquiry into Essex Mental Health Services….without further delay.
Make the changes in Essex and send the learning across the country.
I hope then that I can start to grieve the loss of my son and Matthew, will be able to then, rest in peace.


THANKYOU.