Timeline of Events

2012

  • November 7th  Matthew has been travelling a long time. He is tired and has not been sleeping. He has not been eating very well. He argues with his dad. The police are called on advice of community psychiatric nurse AH. The police arrive in mass. Matthew panics and climbs up onto a container in the yard. A friend of Matt’s who wants to talk to him, to help him, is stopped by police. Instead nine police officers gather around him. Matt is scared. A three hour stand off, and then police threats to taser him. Matthew gets down and gets into police car and just asks where he is being taken too.

He’s taken to the Linden Centre in Chelmsford. ‘To a place of safety.’ Matthew is seen by the doctor on call, Dr Gopisetty and admitted into the Linden Centre under a Section 3 of MHA.

The doctor tells me he sectioned Matthew as he was extremely agitated and angry. Matthew was paranoid of needles and when faced with the knowledge that he would be injected with medication, I’m told he had said,  ‘he would rather die’.

It is recorded that due to his poor insight and deteriorating mental health he was placed under section.

I am told by Matt’s social worker not to go to see him for the first week and allow him time to settle on the ward.

  • November 8th

Matthew is put on enhanced observation and given medication to sedate him.

  • November 9th
  1. AM. Matthews dad visited the ward in the morning and delivered a computer, charging lead, credit card and cash for Matthew. (Matthew hated hospital food, so with the cash he would be able to order and pay for takeaways.) This money was found two weeks after Matthews death. It had been locked in the safe and never given to him. Despite ward records saying EW- (which means Ate Well) on them, our son had lost an incredible amount of weight in seven days and the post-mortem revealed nothing in his stomach apart from black fluid- which the pathologist confirmed was blood
  2. PM. Matthews Dad had phoned me to say that Matthew had phoned him in an extremely distressed state – crying and screaming down the phone. Saying that he had been raped and that he was bleeding. I immediately phoned the hospital. It was approx 30 – 4.30 pm in the afternoon. – I spoke to a staff nurse on the ward at time. I asked to speak to Matthew. She told me Matthew was ‘ Happy and in Art Class’.

I asked how could he be ?- He has just phoned his Dad in a really distressed state – to which reply came that she could not talk to me on phone as she did not really know who I was. She asked what information I had on Matthews situation and I told her of the conversation that Matt’s dad and I, had had. I gave her my landline and mobile number to which she said she would phone me back. She phoned back approx. 5 mins later to say that she believed I was his mother but still she was only able to tell me that Matthew was happy and in art class.

I immediately got off the phone and called the Early Intervention Team – Tracey Brenhan was not in on that day so another lady at EIT in Chelmsford – phoned the ward to see if she could get anymore information – she was told exactly the same as me.

When I went to the hospital on the day of Matthews death – it came to light that on that Friday afternoon (November 9th) – Police were in fact at the hospital interviewing Matthew with regards to the rape allegation. Not at any time has this event been mentioned in any trust notes – and it is quite clear that the staff nurse that was on the ward that day – was lying, when she said Matthew was happy and in art class!!!

Police took no swabs, no clothing away. They reported Matthew being slurred of speech (through medication) and not having capacity to agree to a rape test. They did not call me or Matt’s Dad, to seek consent.

  •  November 11th

There are No Observation records – AT ALL.

  • November 12th

It is reported that an advocate spoke with Matthew to see if he still wanted to have a physical examination, but Matthew apparently thought that it had been too long and that it would stress him.

There are No Observation records – AT ALL.

  • November 13th

Matthew is still saying he had been raped.

Observations had been reduced by night staff without consultation of multi-disciplinary team, which is against hospital policy.

  • November 14th

Matthew is reported as being unwell and refusing depot injection.

There are No Observation records – AT ALL.

  • November 15th. Matthew Dies

It is reported that Matthew ate well, then attended a ward review in the morning and after it he went into the garden with CPN Tim French to have a cigarette. This supposedly ended at 10.25am and next we know Matthew is found at 12.04.

Another account says how he didn’t go into the garden at all. He left the review meeting and went straight to his room.

By this time Matthew was on hour observations. These hour observations had not been done since the ten am check!!

As for eating well- the pathologist didn’t find trace of one bit of food in Matt’s stomach. Only blood.

Various reports have come in as to the exact way Matthew was supposedly found hanging. What was used. What it was attached to. Who found him.All conflicting.

12.04pm Matthew is found hanging in the room allocated to him.

Staff attempted CPR, ambulance was called, defribulator said don’t shock. Matt was taken to A & E, declared dead 12.52pm

There was no defribulator print out, so we made a request to have the data downloaded. The defribulator was no longer on trust premises and had been destroyed!

1.15pm approx.   I receive a call at from Dr Gopisetty. Who tells me, ‘Matthew had been found hanging.’ ‘It doesn’t look good.’ This was another lie. Matthew had already been declared dead at 12.52pm and records show the doctor knew this when he called me.

3.30pm approx. I’m taken to A & E to see my son. He is in a side room on a trolley. Wearing just a hospital gown and a pair of socks. I’m told I’m not allowed to touch him. ‘He’s a crime scene.’ When I lean in to kiss my son on his forehead. I’m told by police officer, ‘If you touch him again, I will have you removed form this room and arrested.’

  • November 16th   Matthews social worker and a senior trust staff member arrive at my house, with all Matthews’s belongings. Minus his mobile phone, his cigarettes and lighter. There was loose change in the bags so I was happy he had been spending the money his dad took in, to buy food. Matt wouldn’t eat the hospital food. I find out two weeks later that his money had been locked in the ward safe,  along with his credit card, and had never been given to him. (This is against hospital policy).
  • November 17th Matthews tracksuit, that he had been wearing on the 15th was returned. In the pocket was his missing phone.

Essex Police arrive to discuss the post mortem. As Matt had said he had been drugged and raped we discussed him having a full sexual investigation post mortem. The officer left and called me to say that it would cost £3000 and bosses would not authorise this. I and Matt’s Dad said straight away, we would fund it. We wanted it done. A call next day came to say Essex Police had changed their minds and they would fund this full post mortem. I signed a form to say I wanted all Matt’s body parts return for burial or cremation, back to me. (A mistake was made and I was forced to spend the next seven months fighting to get all my son’s body parts returned to me. Eventually they were found in four different police stations across Essex).The post mortem went forward.

Dr Benjamin Swift carries out a post-mortem on our son. He says the cause of death was hanging, but can’t rule out cardiac arrest. Within the post-mortem it is noted that Matthew has enflamed epidermoid cysts. I remember Matthew reporting these a year earlier. The poor boy had not had them dealt with, despite him requesting treatment for them numerous times in his medical records and even on November 8th, 2012 when he saw he doctor.

Matthew also had four possibly five needle wounds in his groin. He had GHB in his system. (Date rape drug). Black liquid (which pathologist said was blood) in his stomach and fresh bruises on both lower legs.

There was no record of any medications being given in the groin at all. DCI Stuart Hooper told me that the needle wounds in my sons groin had been made by the paramedics. This was later found to be incorrect. A paramedic was questioned at the inquest and said they only made one injection site with a canula, in my sons elbow. To this day we do not know where the needle wounds came from, only that according to the pathologist, ‘they were recent.’

The pathologist could not say, either way, if Matt had been raped when he reported it, due to the length of time and the bodies’ ability to heal.

The brain was not examined.

Matthew was cremated.

We find out seven months later that the police DID NOT do a full post mortem. They did the same basic one, as they would for an older person. We had cremated our son. What could we do?

2013.

  • Jan 18th. Matt’s father had been called by Trust into a meeting to discuss the trust Internal SI report. I had not been invited by trust, but Matt’s father informed me it was happening. We both attended. Two staff went through their report and it was full of anomalies which we voiced our opinion on and items we wanted adding and items we wanted changed. Our opinion didn’t matter. It remained the same and was submitted to the commissioners. This report is referred to as the Serious Incident Report. This report has played an important role in every investigation that has followed and has taken me till now to prove that it was not worth the paper it was written on.
  • June Care Quality Commission inspect the trust and acknowledge that risk audits had been carried out, but again highlighted ligature points as a concern.
  • June 11th. Dr Philip Steadman, Consultant Psychiatrist completes a report into the care Matthew receives from North Essex Partnership Trust, Based on the evidence that we have to hand to date. This report is very damming of the failed care Matthew received. It was sent to MP Priti Patel to read. Someone in her office forwarded it to the Trust. Due to this grave error it was not allowed to be used as evidence in the inquest proceedings.

2014

  • March Another patient dies by hanging within the trust.
  • March 14th Family meet with Family Liaison Officer, Lorraine Lumb to discuss report into Matthews’s death authored by DCI Stuart Hooper. Thinking it would address all their concerns. They were left with only more questions having read it. Within the report is reference to Essex Police having reported Matthews’s death to HSE under Riddor. 26/10/2016 HSE confirm that this never happened. There was no file on Matthew Leahy with HSE. (See separate Timeline on Health and Safety Executive correspondence. )
  • September 27th. The coroner, Mrs Caroline Beasley- Murray instructs Dr M. Claire Royston, Consultant in Psychiatry to do an independent report into the care Matthew receives at the Linden Centre. The report highlights multiple failings in care.
  • October 20th Coroners office writes to family to say Coroner is not holding any physical exhibits in relation to Matthews’s death and has requested DCI Stuart Hooper to make contact with family, to make arrangements for a viewing of the ligature.
  • DCI Stuart Hooper contacts me to tell me that the ligature has been destroyed. There’s no photos of it. There’s no written description of it. To this day, despite requests made. PC Trevor Hazell to best of my knowledge has not ever been asked what he can remember about said ligature. Why not?

2015

  • Jan 13th News received from Coroners office that The Trust solicitors have not been able to locate Dr Ankireddypalli or Dr Jayachandram. (These were the two doctors below Dr Gopisetty, involved in Matthews care). The coroner confirmed the inquest would have to proceed without them.

Inquest 26th to 30th January Jan 26th

  • Jan 27th. Article 2 Inquest into the death of Matthew commences.

We hear for first time how three nurses have colluded to falsify a care plan for our son. This is an important document. Two staff were named but a third never named. A whistleblower told us the identity of the third person involved. The Top Operations Manager Naushad Nojeeb was sacked but kept his registration and took a job initially with Bupa. Now with North West London NHS Trust as Matron. The others, Amy Jackman/Constable and Senior nurse Karen Holland given written warnings. All three were referred to the Nursing and Midwifery Council.

  • Jan 28th The inquest hears how C.S is called to assist getting into Matthews room, when a student nurse could not gain access. He describes how he pushes the door open and lowers Matt to floor then calls for scissors to cut ligature off. We have since found out (5.5 yrs later), that another man was first in room. He cut Matthew from door hinge, and then Mattt was lowered to floor. This evidence was never given at the inquest. CS didn’t not mention a second man with him, at all.

DCI Stuart Hooper confirmed to family he had investigated where the needle wounds in Matthews groin had come from. He wrote in his report that the paramedics had made them, when administering adrenaline. When the paramedic was asked to give evidence, she denied this.

Saying that, at no time did they go anywhere near Matthews groin. They administered adrenaline through a cannula they put in his elbow crease.

Family email coroner during inquest to request this matter is investigated fully before inquest concludes. There was no evidence of where they were done. A and E had no record of having done them. We had to leave this issue, (accept maybe done in A and E) and move on with the proceedings.

  • Jan 29th We hear conflicting evidence as to how our son was found hanging. How the ligature was made. How our son was lifted down from door hinge. How the police found ligature in three pieces. One part around the door hinge, one part in a bag, one part on the floor. The evidence offered at this stage did not make sense and still to this day does not. The police had no evidence to offer with regards the ligature itself. It was described during the inquest to be blue, green, and white. To have been made from a bed sheet, a blanket, a pillow case. The ligature had not been photographed or its description written down. The ligature had been destroyed by the police, (in error they say), months before the inquest.
  • Jan 30th. After a draining and extremely emotional 5 day jury inquest the lead juror reads out the findings of the inquest:-

Matthew James Leahy had been subjected 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 been adhered to, impacting on Matthews overall care and wellbeing leading up to his death.

VERDICT: OPEN NARRATIVE.

After the inquest had concluded the coroner called family and the trust into chambers. She suggested that the trust hold a public inquiry into Matthews death, but was mindful she could not force this decision.

The inquest had concluded.

  • without two doctors who were in direct care of our son. Dr Ankireddypalli Dr Jayachandram.
  • Without three nurses who had gone to give CPR to Matthew. C/N Vishali Young C/N Amy Jackman/Constable C/N Doreen Ngwenga.
  • Without three nurses who had falsified Matthews care plan after his death. Naushad Nojeeb Karen Holland Amy Jackman/Constable
  • Without the Health Care Assistant who had failed to carry out his duties of observations of our son. Xris Chigozie Udushirinwa
  • Without confirmation where the needle wounds came from.
  • Without the ligature he was supposed to have hung from. Essex Police have never once asked the officer, Trevor Hazell to provide any detail of the ligature he secured from scene. Why did this officer never photograph it or even describe it in documented form?
  • Without the police officer, who was first on the scene, in attendance.
  • Without a vital witness to an incident reported to have happened over an hour before Matthew was found. S/N Jennifer Miller
  • Without full documentation. Some documents had not been found or did not exist. Some documents had been falsified and some documentation had not even been provided to coroner.
  • Without the Top Operations Manager Naushad Nojeeb in attendance.
  • A second man came to light, who was first into the room to take our son down from supposed hanging point. He did not attend inquest. Police had not taken a statement from him and did not take a statement until mid 2017. His evidence was never submitted to the inquest. The evidence obtained does not concur with the evidence given by C.S. (staff member who described himself finding Matthew). HCA Farayi Admire Muzvuzvu.
  • Trust Internal Serious Incident Report has and was used in every investigation completed by police. It has been deemed totally flawed and basically not fit for purpose, by the Parliamentary Health Service Ombudsman.

Staffing levels reported on the ward, at time Matthew was not seen were extremely poor.

  • HCA who found Matthew initially, had only done three shifts on ward.
  • Student Nurse who couldn’t get into room, had only been three weeks on ward.
  • Student nurse had failed to report an incident only been on ward two days.

Matthew was being cared for by inappropriately inexperienced nursing staff.

  • February 17th Another patient is found hanging in the linden centre and sadly dies.
  • February. 20th .Care Quality Commission carry out an unexpected inspection of Linden centre after another patient death.
  • February 23rd Melanie writes to Mrs Caroline Beasely-Murray. (The Coroner). The coroner said she was going to write a, ‘Prevention of Future Deaths Report’ after the inquest. This has not been received as yet. The coroner is ill. Melanie asks, and requests that when the coroner does write her PFD report she considers reform in the follow areas:-
  • Regular errors keep re-appearing:-
  • No independent pre-inquest investigation to allow a thorough inquiry into contentious death.
  • Lack of support and information to bereaved people following a death
  • Poor systems of information sharing and communication
  • Failures of understanding and compliance with basic policies and procedures, including around risk assessments and observations.
  • Poor record keeping, in that care plans are either not done or incomplete.
  • Inadequate staffing levels and inappropriate skill mixes needed to ensure the safe care of patients (including the use of agency staff unfamiliar with patients and procedures).
  • Inadequate levels of clinical oversight.
  • Inadequate treatment and response to dual diagnosis needs.
  • Inadequate management of ward managers.

Melanie writes…… ’Whilst I appreciate that you, as coroner attempted to investigate the circumstances of my sons death, you had very limited capacity and resources. Without the pre-inquest support of an independent investigatory body it has been very easy for the Trust to hide systemic failings. It has not inspired me or given confidence, that the Trust investigated itself, into the death of my son. A death that may have been caused or contributed to by failures of its own staff or systems. This lack of independence mirrors the discredited practices of the past following previous deaths in other forms of state detention.’

  • April. Family write to Essex Safeguarding Adults Board to request a review into Matthews death. This was refused.
  • April 7th The coroner is still not well and no Prevention of Future Death report is forthcoming to date.
  • April 17th Family understand that a decision not to hold an inquiry into Matthews death, (as suggested by the coroner) has been decided by the Trust Board. Press report due to costing in region of £40 K. Family offer to pay the £40 K and the board still refuse.
  • May 11th Family meet with Trust CEO Andrew Geldard, Chair Chris Paveley and Nathalie Hammond, New Director of Nursing. Lots of items were discussed and promised, but very much an attempt to placate family. The way that Matthew must have been hanging was discussed and family report being horrified when Mr Geldard actually removed his tie and proceeded to place over top of door to demonstrate how he did.!

If Matthew is meant to hung the way Mr Geldard demonstrated, it can’t have been the way its been reported all this time.


April 25th. Essex Police confirm that D/Supt Morris, Deputy Head of Crime & Public Protection Command, assumes responsibility into complaint made by family with regards initial police investigation into Matthews death. This goes on for weeks and Police want to close complaint by way of local resolution. Family do not accept a local resolution is sufficient and request a full investigation into their complaint.

Regards destruction of ligature.

This strand of your complaint was investigated by A/Ch 2928 Murray who reported as follows: ‘Sir, I was asked by you to establish the facts surrounding the disposal of a pillow case ligature seized by Essex Police following the sudden death of Matthew Leahy at the Linden Centre Chelmsford on 15th November 2012. As part of my investigation I have reviewed the original incident (EP-201121115-0476), property entry (CD/053490/12), discussed the matter with you and had contact from PS 1428 Graham Rendell. The facts I have been able to establish are that on 15th November 2012 PS Rendell, whilst performing the role of Response and Patrol Inspector, attended the above location to a report of the sudden death of a patient Matthew Leahy. As part of the investigation an item described as ‘3 parts of a pillowcase used as a ligature’ was seized and booked in to the holding cupboard at Great Dunmow Police Station by PC 640 Hazell later that day. I also note the following entries on the property record

  • 03/12/2012: 1428 Rendell ‘To remain in police possession until completion of coroner’s court’
  • 13/03/2013: 7879 Windibank (Property Officer) ‘Transferred from CU/053490/12’ – this indicates the item was moved to Braintree Police Station.
  • 15/03/2013: 1428 Rendell ‘Will check with Coroner to establish if required’
  • 27/04/2013: 1428 Rendell ‘Believed due to time since event that the Coroner’s inquest has been concluded, therefore can be disposed of, thanks’ Ps Rendell is currently on Annual Leave until he retires on 4th December 2014. He has however replied to your enquiry via email on 28th October with the following response: ‘I recall this unfortunate set of circumstances resulting in the death of this male and the seizure of the pillow case strips. (PC Trevor Hazell would be able to better describe). Having checked the property system and the notes it states ‘believed due to time since event the Coroner’s inquest has been concluded and the property can be disposed’ I deduce from this that I did not contact the coroner’s office for confirmation and presumed incorrectly that it had been concluded. I can only apologise to the family for this presumption and hope this doesn’t cause further grief or halt any closure on their son’s death’ I can therefore only conclude that a genuine mistake has occurred and, presuming it was no longer required, PS Rendell has wrongly authorised the destruction of the ligature’. It is clear that the ligature associated with your son’s death should not have been disposed of and this was the fault of Sgt Rendell who failed to properly confirm that the Inquest had taken place prior to authorising its disposal. This simple administrative error has caused you considerable upset and anger as, understandably, you wished to view it as part of your desire to learn as much as possible about your son’s death. Sgt Rendell retired in 2014 and is therefore no longer subject to Police Conduct Regulations. It is also unlikely that the threshold for misconduct proceedings would have been met had he still been serving but I apologise on behalf of Essex Police for the anger and distress caused to you by the premature disposal of the ligature.
  • May 20th. Care Quality Commission publishes their inspection report. They found risks had still not been fully addressed. High risk potential ligature points still apparent. Poor risk assessments. No action had been taken to replace the hinges or doors, despite recommendations made after Matthews death.
  • May 21st. Another patient is found hanging in the Linden centre and sadly dies.
  • June 1st The coroner is back to work and has finally issued a ‘Prevention of Future Death Report.’

She writes,’ There was evidence of inadequate staffing levels in the linden centre at the time of Matthews admission leading up to his death.

The court instructed an independent expert, Dr Claire Royston, to give her opinion about the care which Matthew received while he was a patient at the Linden Centre. Dr Claire Royston is currently Group medical Director, the Huntercombe Group and Four seasons Healthcare and she has vast experience in carrying out independent investigations on behalf of coroners.

It was her view that it could well be appropriate AND HELPFUL FOR North Essex Partnership to facilitate an independent inquiry into the circumstances surrounding Matthews sad death.

As senior coroner, I am mindful that I have no power whatsoever to order such an inquiry but I ask the trust to give serious consideration to this course of action.

  • June 23rd Family meet with Essex police to have viewing of post mortem photographs of ligature mark on Matthews neck. Family were told they had could not see all of them and only shown two pictures.
  • June 30th Family request permission from coroner to see all photos of their son. Told to go back to Essex Police.
  • July 26th.

MP Priti Patel writes to confirm that, The Secretary of State, Jeremy Hunt, ‘Although he is not supporting a public inquiry at this stage, she is assured that he is now very aware of my son’s death and will welcome an update on the investigation by Essex Police.’

  • July 27th Mr Andrew Geldard, CEO of North Essex Partnership Trust is reported by family to Essex Police for misconduct in public office.
  • Jan/Feb 2015 Mr Andrew Geldard had written to the family, the CQC and MP Priti Patel informing that recommendations made after Matthews death had all been done. He lied. Confirmation was received that new doors and hinges recommended were not even ordered until late 2015 and finished early 2016.
  • August The Care Quality Commission inspects the Linden Centre again. Safety was still a concern and a patient nearly strangled themselves during the inspection.
  • August 5th. Police complaint being looked at in April 2015, continues D/Supt and Peter Hall to carry out.
  • September 12th. Trust board papers say how CQC have reviewed ligature audits at the trust and that the trust were now working with a Professor Bloors, (National lead on suicide), to ensure risk thresholds were inline with best practise. Family contact Professor Bloors. Her response,’ No, I’m not advising NEPFT, or working for or with them on any research project.’
  • October 8th. NMC hearing against Nurse Naushud Nojeeb concludes. He is suspended for three months. Within hearing document he lies yet again and says how he has apologised to the family. He has never apologised.
  • Oct 23rd Chief Executive Officer of North Essex Partnership University Trust tenders his resignation.
  • November 17th Family write to MP Priti Patel. Concerns regards Essex Police policy are raised. It appears there is no policy for investigating deaths of Mental Health inpatients, hence:-
  • Pat tag logs were not seized.
  • Scene was not secured.
  • Officer just visiting hospital attended scene. (No senior officer in attendance ).
  • No photos of scene were taken.
  • Vital witnesses were not interviewed.
  • CCTV was not secured.

There was no policy, so no set procedure to follow. Family expressed great concern that this needs to be addressed and fast.

  • December 11th MP Priti Patel writes to the Coroner to thoroughly consider family requests for the inquest into Matthews death to be re-opened.

2016

  • January 4th Letter received by family from Coroner who says she cannot reopen Matthews inquest without having been ordered to by the court.
  • January 11th. Forms are submitted on advice of MP Priti Patel to the Parliamentary Health Service Ombudsman. The final judicator in the NHS complaints process.
  • January 1st A review into the death and alleged rape of Matthew is completed by David Stevens of Kent and Essex Serious Case Review Team. Family do not get site of this document until September 2017 (20 months after its completed).
  • January 26th CQC publish a damming report on North Essex Partnership Trust.

Press report: Patient strangled themselves during care quality commission inspection of Linden Center.https://www.thebureauinvestigates.com/2016/01/26/patient-strangled-themselves-during-inspection-at-under-fire-nhs-mental-heath-trust-damning-report-reveals/

Referral of Nurse Karen Holland is made to NMC.

  • August 26th

Referral of CPN Anthony Hunwick is made to NMC.

Referral of Nurse Synthia Sinyaro is made to NMC.

Referral of Nurse Caroline Bennett is made to NMC.

  • November 29th Despite numerous email correspondences with Essex Safeguarding Adults Board and requests from family, MP Priti Patel and MP Simon Burns, still a refusal to action a review into Matthews death. Family now take a complaint to The Local Government Ombudsman. An investigation ensues and the complaint is ultimately not upheld months later. Another dead end.
  • November. Kent and Essex Serious Homicide/Crime Squad re-open investigation into Matthews death.

Melanie Leahy has always maintained that evidence recorded just didn’t add up and has been fighting for answers since Matthews death.

  • December. DCI Stephen Jennings, Essex Police is assigned to my sons’ case. And would now make contact with the Health and Safety Executive.

2017

  • March 6th

More evidence – Referral of nurse Amy Jackman/Constable to NMC

More evidence – Referral of nurse Naushad Nojeeb to NMC

Result: No further action

  • March 16th DCI Stephen Jennings, Essex Police, confirms what main lines of enquiry have been set in regards to new investigations into Matthews death.

The main lines of enquiry set by me were to look into the following:-

  • Review the original documentation of the investigation into Matthews Death
  • Obtain copies of all medical records from both the Linden Centre and hospital in relation to his death
  • Identify whether any additional evidence (other than that provided during the inquest) as to the cause of the needle marks in his groin area can be obtained.
  • Re-visit (in person) all key staff witnesses present at the time of Matthews death.

A number of other enquiries noted as ongoing in relation to the potential corporate aspect.

  • June 5th Letters go out from family to various dignitaries and mental health charities, MPs and lords to request they write to Secretary of State to request a public inquiry into Matthews death.
  • June 8th Rethink Mental Illness acknowledged family e-mail of 5th June. Said it had been passed to CEO Mr Winstanley who will respond to you shortly. He never did respond.
  • June 9th. Mind Charity response to families request sent out June 5th:- ‘Thank you for contacting Mind and I am sorry to hear about the tragic circumstances following the death of your son, Matthew – please accept our sincere condolences’. ‘We’re glad to see you have contacted your MP regarding this and hope he will be able to help you in your campaign. At National Mind, we cannot get involved in specific cases such as these’.
  • June 26th . MP Norman Lamb wrote to Secretary of State to request the setting up of a full public inquiry. As did MP Priti Patel.
  • September 27th The review by David Stevens of Kent and Essex Serious Case Review Team into the death and alleged rape of Matthew Leahy is sent to the family.

A thirty two page report makes recommendations and learning opportunities for Essex Police.

Within the report this is noted:- ‘In view of the continued concerns of Melanie Leahy over the circumstances relating to her sons death, and in particular that subsequent reviews of the case have lacked independence, consideration should be given to presenting the facts of this case, before the CPS with a view to a lawyers view being given as to whether any criminal offences have taken place.’ This course of action was suggested as a possibility by Mr Ken Donnolly from NCA. ‘The Reviewing Officer makes this recommendation as a subject for consideration and discussion. The Reviewing Officer does not consider the threshold test for manslaughter has been met and therefore to submit a full file to the CPS for consideration would, in normal circumstances, be inappropriate. Manslaughter is however a controversial and a somewhat subjective offence particularly when it involves medical negligence. Some degree of advisory input from the CPS may be appropriate to comment on the law as it pertains to unlawful killing; the CPS could also be invited to give an opinion on the potential criminal culpability of hospital staff following their improper production of records which led to disciplinary action taken.’ What was the result of this recommendation? Were the CPS consulted? Not as far as family are aware!

  • May 22nd Essex Police announce they are looking into 20 deaths (by ligature) going back to year 2000. A whistleblower comes forward to say he had notified the trust management of safety failings years earlier and nobody took any action.
  • July 17th I receive a letter from Jeremy Hunt at the Department of Health, apologising for what happened to Matthew, on behalf of the government and the NHS offering his profound apologies. He informed me that a lot of work was being done by the Police and the NHS to establish the facts about what happened to Matthew and to make sure they learn from the mistakes.
  • November 2nd. DCI Stephen Jennings of Essex Police refuses to show family full statements taken, in response to new lines of enquiry regards Matthews death- started in March 2017.
  • December. Family meet with DCI Stephen Jennings of Essex Police to discuss on going Corporate manslaughter investigation.

2018

  • February 13th Family meet with CEO Rob Behrens of Parliamentary Health Service Ombudsman to discuss ongoing investigation into poor care which led to Matthews death and also requested a systemic investigation into the trust itself. This request fell on deaf ears.
  • July 26th Dr Edmund Tapp, retired Home Office Pathologist accompanies me to Essex Police Station to give his expert opinion on the photos of Matthew, and post mortem carried out by Dr Benjamin Swift.He was able to question DCI Jennings on hiow Matthew had been found hanging. He said it was difficult to see how Matthew could have hung the way described, but without the ligature even harder. He had experienced many hangings in community, in psychiatric wards and in prison settings, but had not seen a ligature mark like the one Matthews neck. He said he found it difficult to see how Matthew had hung the way described. He also confirmed that the blood in Matthews stomach would not have been caused by hanging. He said by the look of Matthew he had died very quickly so the blood, which would be altered blood, as it was black, could have been perhaps from stress or medication.

2019

  • November 14th. Essex Police drop the bomb shell that they have closed the corporate manslaughter investigation that began over two years ago.

Pushing for a public inquiry

Please spread the word :)

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