Investigations surrounding the death of Matthew Leahy while in NHS care have been reopened.
The nursing regulator has reopened fitness to practice cases into three mental health staff who worked at an NHS trust that has been subject to repeated reports and inquiries following the deaths of patients in its care.
The deaths of 25 people at several mental health facilities run by the North Essex Partnership University Trust (NEP) since 2000 have been investigated, yet families of those who died believe they are still being denied the whole truth.
Matthew Leahy was 20 when he was detained in November 2012 under the Mental Health Act and taken to the Linden Centre, a secure mental health unit in Chelmsford, Essex, with a diagnosis of a delusional disorder. Three days after being admitted into what his mother, Melanie, believed was a place of safety, Matthew reported he had been drugged and raped. Four days later he was found hanged in his room.
The post-mortem examination showed traces of the “date rape” drug GBH in Matthew’s blood and four or five needle marks on his groin as well as bruising above and behind both his ankles. He called 999 to report he had been drugged and raped but when police arrived they did not take a statement or examine Matthew as he had been tranquilised by staff and was slurring. The day he died it emerged safety observations on him had not been carried out for hours.
The 2015 inquest into his death heard of serious care failings including the fact Matthew had no care plan, but staff falsified one after his death and back-dated it. Matthew’s paperwork was incomplete or missing and a key worker was not assigned to him. The inquest jury concluded he had suffered “multiple failings and missed opportunities over a long period of time.”
Recording an open verdict, Coroner Caroline Beasley Murray, said the Trust should consider an inquiry. In November 2018, Essex Police dropped a corporate manslaughter investigation into up to 25 deaths at the Trust. Officers said that while it found “basic failings” at the Centre, the legal threshold for corporate manslaughter was not met.
Dissatisfied with the trust’s own inquiry, Mrs Leahy referred it to the Parliamentary and Health Service Ombudsman. Last June, the Ombudsman dismissed NEP’s inquiry as “inadequate”. Its own report into two deaths at the Linden Centre, including Matthew’s, uncovered 19 instances of serious failings regarding his care, including that he did not have a nurse in charge, his physical health was neglected and the failure of observation at a critical time.
The Ombudsman’s report recommends an NHS England-led review into the trust – which is still to occur one year on. Officials say the review will take place after a separate Health and Safety Executive investigation into how the trust managed wards in relation to ligature points between 2004 and 2015, has concluded.
Despite this Mrs Leahy has now succeeded in persuading the Nursing and Midwifery Council (NMC) to reopen three fitness to practice cases against Linden Centre staff closely involved with Matthew’s care. Under investigation are ward manager Naushad Nojeeb, responsible for falsifying Matthew’s care plan and disciplined by the NMC in 2015, Anthony Hunwick, the last person to see Matthew alive, and senior nurse Synthia Sinyoro.
“Given what has happened with Matthew’s case, I think it’s amazing these people are still allowed anywhere near vulnerable patients,” Mrs Leahy, from Maldon, Essex, told i
Concerns not considered
The regulator told her it had decided to reopen the cases because it did not consider all the concerns she had raised over the years had been addressed.
“It is also apparent there is further information we could have gathered to help us look at your concerns. I am very sorry for the flaws in our original decision,” the NMC told her in a letter.Theinvestigations into the three staff members have been put on hold due to the pandemic as the NMC said it wanted the individuals to focus on their work “in the coming weeks”.
Mrs Leahy’s ultimate aim remains a public inquiry into the trust – a call backed by local MP Priti Patel prior to her becoming Home Secretary – to discover whether lives, including Matthew’s, could and should have been saved. Having completed a Government petition securing 105,580 signatories, Mrs Leahy is still very hopeful Parliament will debate the case.
In a letter to Mrs Leahy last year, Mrs Patel said: “I fully sympathise with the hurt, pain and distress the families feel. I commend the steely determination of Melanie Leahy and all the other families who have been campaigning on the issue in tragic circumstances. Questions about the trust’s care of vulnerable patients remain unanswered and I support Mrs Leahy’s call for a public inquiry into this case.”
In for the long haul
Mrs Leahy said: “Getting to the bottom of everything is taking forever, but I’m in it for the long haul. There are so many vulnerable patients needing safe, compassionate care with numbers growing by the day. Whilst I continue to fight for my answers and accountability, I continue to push for change for others.
“I offered Matthew’s death to the Government a number of years ago for them to take it apart bit by bit and learn from it. I still wait for them to take me up on that offer. The ‘lessons learned’ mantra families continue to hear just doesn’t cut it anymore, as clearly lessons are not being learned and real change is needed.”
Clare Strickland, Deputy Director of Professional Regulation for the NMC said: “We recognise that this must be an incredibly difficult time for the family of Matthew Leahy and we want to express our deepest sympathies. We are unable to comment on any potential or actual fitness to practise referrals until they reach a public hearing stage. Where concerns are raised with us or additional information is brought to light on referrals we have already received, we will consider this and take appropriate regulatory action.”