Regulators tell trusts to ‘learn lessons’ from deaths in 2008 and 2012

In June, the Parliamentary and Health Services Ombudsman published a report into care failings relating to two young men who died at North Essex University Partnership Foundation Trust.

Both cases, which happened in 2008 and 2012, involved patients who had been admitted to the trust’s Linden Centre in Chelmsford, and included serious failures to assess the risk of, and prevent, suicide or self-harm.

In a letter to all mental health trust leaders, NHS England and NHS Improvement have urged them to learn from the PHSO findings. It comes ahead of a “systemic review” into the failings by the national bodies.

However, the mother of one of the boys told HSJ she was “dismayed” by the time it is taking for the NHS to learn from the failings. The ombudsman report for her son’s case took five years to conclude.

The letter, sent on 3 September and obtained by HSJ, urged trusts to “understand the gravity of the lessons being learned”.

It said they should ensure they are meeting national guidance on risk assessments for mental health patients, that risk assessment tools are not being used in isolation, and there is better assessment of ligature points and environmental risks.

The wider review would look at “how the trust leadership and culture contributed to [the] failings in patient safety”, it added.

Matthew Leahy was found hanging in the unit in November 2012. The ombudsman said staff had failed to take adequate action in response to reports he was raped on the ward. Other failures included inadequate planning of Matthew’s care, inadequate observations, and his care plan being falsified.

A prior case, involving a young patient known only as Mr R, happened in 2008. He had been admitted with an early diagnosis of attention deficit hyperactive disorder and considered at risk of taking his own life.

But the investigation found there were missed opportunities to mitigate that risk, and staff did not respond adequately when he threatened to harm himself.

Melanie Leahy, Matthew’s mother, said: “I am extremely dismayed by the obvious delaying and sharing of any of the learning across the NHS… It clearly should not have been up to me to get this learning moving.

“I really have no confidence in the paper shuffle reviews being suggested. The investigations to date have shown that staff must be interviewed under oath for the absolute truth in this case to be uncovered. So, a statutory public inquiry is the only logical option available.”

NHSE/I’s systemic review is due to happen after separate reviews by North East Essex Clinical Commissioning Group and the Health and Safety Executive. The regulators said it would be conducted by the regional directorate and would not duplicate the HSE and CCG work.

Several MPs – including Labour MP Barbara Keeley, Liberal Democrat MP and former health minister Sir Norman Lamb, and home secretary Priti Patel – have backed the call for a public inquiry, and the NHSE/I probe is expected to make recommendations on that to the government.

Last year, Essex Police concluded an investigation into multiple deaths within inpatient units run by the same trust. The investigation could not find grounds to charge the trust with corporate manslaughter but did say it found “clear and basic” failings in care.

North Essex Partnership University Trust merged with South Essex Partnership University FT in 2017 to form Essex Partnership University FT.