A mum whose 20-year-old son was among a string of patients who died at an NHS trust has said a £1.5million fine imposed on it this week fails to give her closure or “ease any pain”.
Melanie Leahy, mother of Matthew Leahy who died at the Linden Centre in Chelmsford in 2012, vowed to continue to fight for a statutory public inquiry into a series of deaths across mental health services in Essex.
Her pledge comes after the Essex Partnership University NHS Foundation Trust (EPUT) was fined £1.5million over its “failure to prevent suicide” at Chelmsford Crown Court on Wednesday.
A probe by the Health and Safety Investigation identified deaths of 11 mental health patients where a “point of ligature was used within the ward environment of the trust’s premises”.
EPUT had pleaded guilty in November to an offence under the Health and Safety at Work Act 1974.
Mrs Leahy said after the hearing: “This fine has not given me closure or eased my pain.
"I have to live now without my son, with my anger, denied the release of forgiveness that accompanies justice and some demonstration of remorse.
“What’s kept me going is the need for truth, to find out what happened to my son, and I still do not know that.”
Sentencing EPUT on Wednesday, Judge Cavanagh said a “litany” of “systematic failures” were found to have taken place over a prolonged period, describing the trust’s actions to protect its patients at the time as “woefully inadequate”.
He agreed with the prosecution that there were “repeated” failings to address the risk of ligature points before and after the deaths of patients.
Judge Cavanagh agreed with the prosecution that there were “repeated” failings to address the risk of ligature points before and after the deaths of patients.
He said recommended action was not put into practice in some cases for a number of years afterwards.
“There’s no doubt the failures to remove ligature points were a significant cause in the deaths of 11 people who died during the relevant time period, and of a 12th person who died just after and a number of near misses,” he added.
“Time and time again, opportunities to put measures in place were lost.”
The 11 deaths spanned from October 2004 to the end of March 2015, and occurred by hanging on the wards of the former North Essex Partnership NHS Trust (NEP), which merged with services in southern Essex in 2017 to form EPUT.
They included Ben Morris in 2008, David King in 2009, Iris Scott in 2014 and Matthew Leahy in 2012.
Mr Leahy’s mother is currently fighting alongside 74 affected families for a full public inquiry into her son’s death and several others who died in the care of Essex mental health services.
Health minister Nadine Dorries announced a non-statutory inquiry in March, but it will not compel witnesses to come forward and give evidence under oath.
“Matthew’s death has led to my membership of a club that everyone and anyone would baulk at joining,” she said.
“Seventy-four further parents and families have become part of this club since Matthew’s death in 2012.
"We are not engaging with the independent inquiry announced by the Government and we continue to call for a statutory public inquiry into Essex mental health services.”
Paul Scott, EPUT’s new chief executive, said: “I would like to personally express my deepest sympathies and apologies to the families and friends of those who lost their lives. I am fully committed to ensuring that every lesson is learnt.
“Since joining EPUT as chief executive last October, I have put safety at the forefront of everything we do.
“I am grateful to the families who have shared their experiences in court today, and also with me privately. Their experiences have had a deep impact on our staff and will help the trust to drive continuous improvements to safety on our wards.”
Grief-stricken family members were able to read out victim impact statements in court.
Lisa Anne-Morris, mother of Maldon-based Ben Morris who was 20 years old when he died, described the moment she was told the news, saying “a part of me died with him”.
“Every day is a nightmare I can’t wake up from,” she added, saying her son’s death had also had a profound impact on her own mental health.
In a statement read out by family friend Sally King, the parents of David King began by thanking the court for giving them “a voice”.
Recounting the day they were told their son had died, they wrote: “I invited the policeman and the man from the mental health authority in and he asked us to sit down. I, as David’s mother, instinctively knew something terrible was wrong. That’s when they informed me he was dead.
“I knew I would have to tell his little boy what had happened. George was six years old. It had happened five days before Christmas.
“It was the most difficult thing I have ever done, telling a little boy his daddy was dead. I can’t describe to you the pain that was on his face. This memory never goes away.
“I promised George then that those responsible for his daddy’s death would be brought to court.”
They added: “David tried to ring us on December 20 but it went to answerphone. He had tried to get change for a £10 but staff wouldn’t help him. He said he loved us and would try and call again. But he never did.”
Bernard Thorogood, representing the trust, said: “I would like to make a public expression of apology for these identified series of failures accepted by the trust, and an expression by the trust through me of regret, remorse and sympathy.”
He said Mr Scott had already implemented significant changes, met with families and was committed to continuing to improve the wards.
Mr Scott added that improvements have already been made to services, including an additional £10m spent on ward safety last year.
He said: “We are committed to doing everything we can to ensure EPUT provides the safest possible care so that our patients and our local community have confidence in the services we provide.”
Priya Singh, a solicitor at Hodge Jones & Allen, which represents families of those who died, said in a statement after the hearing: “The fine of £1.5 million handed to EPUT following the HSE investigation simply highlights the failings of mental health care in Essex.
“While the fine is welcome news, the families are still left with many unanswered questions, and this fine does not represent justice.
“It only scratches the surface of what is going so badly wrong in Essex.
She added: “The only way to establish the truth of the gross failings in care across Essex Mental Health Services is through holding a full statutory public inquiry.”
Read more about the Suffolk and north Essex families banding together for a public inquiry here.
If you need help and support, call Norfolk and Suffolk Foundation Trust’s First Response helpline 0808 196 3494 or the Samaritans on 116 123.
Both services are available 24 hours 7 days a week. You can also download the Stay Alive app on Apple and Android.
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