12 June 2019

The Parliamentary Health Service Ombudsman (PHSO) has today (12 June) published a deeply critical report into the deaths of two young men, Matthew Leahy and ‘Mr R’, at the Linden Centre in Essex. The findings of the report, Missed opportunities: What lessons can be learned from failings at the North Essex Partnership University NHS Foundation Trust (NEP), has led PHSO to call for a review into the controversial mental health Trust.
The Ombudsman report summarises their new investigations into the care and treatment of two young men, who both died shortly after being admitted into the care of NEP. It points to a systemic failure of the Trust to tackle repeated and critical failings over an “unacceptable period of time”, and highlights inadequacies in initial investigations into the deaths.
Matthew was 20 years old when he died on 15 November 2012, whilst under the care of NEP run Linden Centre. The Ombudsman investigation found numerous serious failures in the care provided to Matthew, including 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.

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.
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.”

Deborah Coles, Director of INQUEST 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.”


For further information, interview requests and photos, please contact Sarah Uncles on 020 7263 1111 or [email protected]

Melanie Leahy, mother of Matthew, has launched a petition calling for a public inquiry into her sons death. Follow the Justice for Matthew Leahy campaign page on Facebook.
The Essex Partnership University NHS Foundation Trust (EPUT) was established on 1 April 2017 following the dissolution of North Essex Partnership University NHS Foundation Trust (NEP) and South Essex Partnership University NHS Foundation Trust (SEPT).
Since 2004, six inpatients have died by hanging at the Linden Centre, run by North Essex Partnership University NHS Foundation Trust (NEP).

  • 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 wardrobe handles should be integrated into the door and doors should be fitted so that they open both ways with safety hinges.
  • BM died aged 20 in December 2008 using the wardrobe handles as a ligature point 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.
INQUEST highlighted concerns about the failing structure for learning and oversight, with reference to a series of deaths at the Lindon centre, in our evidence submitted to the CQC review of investigations into deaths in NHS Trusts in October 2016.
INQUEST is also aware of the following deaths in other mental health units run by NEP:

  • Margaret Richardson died in September 2015. She had suffered at least five falls whilst a patient on a mental health ward run by NEP and the inquest found there were failings in the implementation of NEP’s prevention and management of falls policy on the ward. The coroner issued a report to prevent future deaths.
  • Dorota Kijowska died in March 2015. Her death was self-inflicted The jury found there was a failure to provide a safe environment at the mental health unit run by NEP and the coroner issued a report to prevent future deaths.
  • Iris Scott, 73, died a self-inflicted death in March 2014 whilst on a mental health unit run by NEP.