This petition was submitted during the 2017–2019 Conservative government
Petition I request a full public inquiry into death of my son, Matthew Leahy. (20 yrs.)
Matthew was taken to, ‘a place of safety’, and died 7 days later.
24 others died by the same means, dating back to the year 2000. An indicator that little was done to address the growing problems.
Something went terribly wrong with the NHS Mental Health Services provided to my son.
There really is no way that public concern can be allayed, short of an Inquiry.
All investigations to date, including police and inquest proceedings, have been based on a Trust Serious Incident Investigation. A four and half year Parliamentary Health Service Ombudsman Report has now concluded that this investigation was not adequate and lacks credibility.
There has been an inadequacy of investigation. A human rights violation. New evidence has been uncovered and I request a statutory inquiry, that compels witnesses to give evidence on oath.
Matthew is not alone. Many others have died, whilst, ‘ In The Care Of The State’.
This petition closed early because of a General Election Find out more on the Petitions Committee website
Parliament debated this topic
This topic was debated on 30 November 2020
This response was given on 2 August 2019
The Government sincerely regrets Matthew’s death. NHS Improvement will review the care that he and others received and will provide advice in due course on whether a public inquiry should be held.
Read the response in full
The Government apologises for the quality of care that Matthew and others have received. We are committed to improving the quality of care in mental health wards for anyone with a mental health issue, learning disability or autism. We know the problems that exist in the system and we are working to address them.
On 12 June 2019, the Parliamentary and Health Service Ombudsman (PHSO), published its report, Missed opportunities: What lessons can be learned from failings at the North Essex Partnership University NHS Foundation Trust, which called for a national review of potential failings to ensure patient safety at the North Essex Partnership University NHS Foundation Trust. This report considered the care provided to Matthew Leahy. The report can be access here: https://www.ombudsman.org.uk/sites/default/files/2019-06/Missed_opportunities_What_lessons_can_be_learned_from_failings_at_the_North_Essex_Partnership_University_NHS_Foundation.pdf
In line with the PHSO’s recommendations, NHS Improvement has agreed to conduct a review of the cases detailed in the report once the Health and Safety Executive’s investigation and any related activity has been completed. NHS Improvement will make recommendations to the Department of Health and Social Care once its review has been completed, including on whether a public inquiry is necessary. The review will also ensure that the learning from these tragic incidents is shared with mental health providers across the country.
The Trust has also recently undergone a Care Quality Commission inspection and NHS Improvement await the feedback from that.
NHS Improvement is leading work to develop a new national patient safety strategy to support the NHS to be the safest healthcare system in the world, this and this includes mental health.
We are introducing a new Mental Health Safety Improvement Programme to address important safety challenges in the mental health sector as well as implementing our ambition for eliminating suicides in mental health inpatient services. Every NHS mental health provider is required to have a zero suicide policy in place. There has been significant progress made by trusts in developing these plans, with regional suicide prevention leads supporting trusts to finalise them.
Cases like Matthew’s have called into question whether these types of institutions and in-patient settings are appropriate places in which to care for vulnerable people for any extended length of time. We are committed to improving the quality of care in mental health wards for anyone with a mental health issue, learning disability or autism. We know the problems that exist in the system and we are working hard to address them.
Department of Health and Social Care.