Our investigations

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Outlined below are summaries of both of the cases we have investigated and that are referred to in this report. These focus on the key findings that are most likely to be relevant to the Review we have recommended, rather than setting out the full context and detail of the individual cases.

We have shared the full investigation reports with NHS Improvement so that they can be made available to the Review team, as well as CQC and HSE.

Following our investigation into the death of Mr Matthew Leahy, we have recommended that EPUT prepare an action plan to address any outstanding issues. We have said that this should be shared with ourselves, CQC and NHS Improvement so progress can be considered by the Review and as part of future regulatory inspections. We will publish this action plan once we have received it as part of our next relevant quarterly statistics report. 

Mr R’s case

On 8 December 2008 Mr R, aged  20, was admitted to NEP’s Linden Centre as an informal patient. 

Mr R had a history of substance misuse and anger issues, and had been tentatively diagnosed with ADHD and dissocial personality disorder.

On admission atomoxetinewas prescribed to treat ADHD. Lorazepam (a tranquiliser) and zopiclone (a drug to help people sleep) were also prescribed on an ‘as needed’ basis. On 17 December the dose of atomoxetine was increased. The same day Mr R was granted ward leave.  

On 25 December staff physically restrained Mr R. According to the care notes, his behaviour was hostile and aggressive that afternoon. On 26 December Mr R was granted ward leave. 

On the evening of 28 December Mr R asked to be discharged. A short time later, he was found in an unresponsive state in his room. Attempts to resuscitate him were unsuccessful.

After Mr R’s death, the Trust prepared a 7 day report, followed by a Serious Incident Panel Inquiry which was completed in July 2009.  

An inquest into Mr R’s death, in February 2011, recorded a narrative conclusion: ‘[Mr R] …killed himself, while the balance of his mind was disturbed, before his illness was fully diagnosed to ensure a suitable care programme to be implemented to manage his condition. These factors more than minimally contributed to [his] death.’

What we found

We found failings in the care and treatment provided to Mr R, which meant there were missed opportunities to mitigate the risk of him taking his own life. Ms R, his mother, suffers the ongoing injustice of knowing this, and also knowing that he did not receive the standard of care he should have done. 


There was no issue with the dose of medication prescribed but NEP did not take specialist advice or carry out a full risk assessment before prescribing atomoxetine, and failed to properly monitor Mr R for side effects. Staff did not always record the rationale for giving lorazepam and its effect on Mr R. 

Ward leave

NEP failed to manage Mr R’s ward leave in line with its policy. Overnight leave was granted without any documented rationale or an appropriate risk assessment. Mr R was granted leave on the same day as the dose of his medication was increased, and on another occasion, the day after staff found it necessary to physically restrain him.

Physical restraint

Staff did not do enough to de-escalate the situation and behaved unprofessionally during the restraint, shouting at each other and using inappropriate language. 

Care and treatment on 28 December 2008

Mr R’s initial care plan had not been updated, and the assessment and management of risk was not adequate. Mr R had been admitted at risk of suicide but there was no mitigation plan in place other than ‘as needed’ lorazepam. NEP acknowledged through its own investigation that staff had not responded adequately when Mr R threatened to harm himself on 28 December.

Environmental risks were also not properly managed. An assessment in 2007 rated certain ligature points as low-risk. Before Mr R’s death these environmental risks had changed but had not been identified or acted upon.

Matthew’s case

Matthew, aged 20, had been under the care of NEP’s Early Intervention in Psychosis (EIP) team since 2011, and had been diagnosed with a delusional disorder caused by cannabis use.   

On 7 November 2012 the police brought Matthew to NEP’s Linden Centre as a place of safety. He had a formal assessment of his mental health and was detained for treatment under section 3 of the Mental Health Act 1983 as amended in 2007 (the MHA). 

On 8 November Matthew told staff he would hang himself if they gave him injectable medication. 

On 9 November he alleged he had been raped during the night.

On 15 November staff found Matthew hanging in his room. After attempts to resuscitate him, he was taken to A&E at Broomfield Hospital where he died.  

A number of investigations have been carried out into Matthew’s death and the alleged failings in his care and treatment. In January 2013 NEP completed a Serious Incident Panel Investigation that concluded care and treatment was of a good standard. 

In January 2015 an inquest was held that considered a report from an independent psychiatrist which concluded that overall NEP had provided an acceptable level of care. A police report commenting on the independent psychiatrist’s findings said Matthew’s care was appropriate at the time of his death. However, a report by a second independent psychiatrist said the treatment provided to Matthew, ‘fell below the standard of a reasonably competent practitioner.’ 

The inquest recorded a narrative conclusion which said Matthew, ‘was subject to a series of multiple failings and missed opportunities over a prolonged period of time by those entrusted with his care….’

What we found

We found that some aspects of Matthew’s care and treatment were in line with relevant guidelines. But our investigation also identified a number of significant failings in key elements of care. Knowing Matthew did not receive adequate care has caused unimaginable distress to his family.

We also found that NEP’s investigations were not robust enough and that NEP was not open and honest with his family about the steps being taken to improve safety at the Linden Centre. When his family came to us, NEP had not taken sufficient and timely action to put things right. This added to the distress and frustration as there was no reassurance that things had changed for the better.

Care planning

NEP did not ensure Matthew’s care was adequately planned. Matthew had an initial care plan covering the first 72 hours of his admission but it was not updated to reflect all of his needs or address all of the risks present, for example, his reports of rape, substance abuse, aggression and non-compliance with prescribed medication.

The failings were compounded by staff preparing a fuller care plan after Matthew’s death. NEP identified this through its own investigation and took disciplinary action against the staff involved and referred them to the Nursing and Midwifery Council.

Risk assessment and management

The assessment and management of risk during Matthew’s admission was not rigorous enough. While the risk of ‘suicidal ideas’ was recorded, this was not explored with Matthew in any detail, and no plan was put forward to manage this risk.

NEP also failed to adequately manage environmental risks including a ligature point in his room. The failings in respect of the assessment and management of risk are all the more significant since Matthew was at the Linden Centre due to concerns about his welfare and the risks he posed to himself and others. Those risks should have been properly assessed and managed. 

Matthew’s physical health and nutrition 

NEP did not take adequate care of Matthew’s physical health. Matthew should have had a full medical assessment and examination on admission, or as soon as possible following admission.

When Matthew refused a physical examination on admission, staff should have made at least one attempt to undertake a physical health assessment in each 24 hour period. There is no evidence this happened despite suitable opportunities arising.

We saw no evidence that staff acted on Matthew’s reports of cysts or bleeding from the anal area. We also saw no evidence that blood tests or an ECG were carried out, despite a plan for these being documented in Matthew’s records. 

Our investigation saw evidence of concerns about Matthew’s nutrition and weight. Staff failed to act on these in line with NEP policy and did not calculate a nutrition risk score for him. Matthew’s weight should have been checked every week and his food intake monitored and documented.


Doctors prescribed medication which was suitable for Matthew’s needs and at the correct dose. On one occasion, Matthew was given a rapid tranquiliser to calm his agitation.

There was no issue with the drugs prescribed but we saw no evidence that staff considered or used de-escalation techniques before administering rapid tranquilisation, which should have been used only as a last resort.

Observation and engagement 

Matthew’s observations were not properly managed. Staff did not always observe him at the prescribed level, and his observation level was reduced on 13 November without prior discussion with the multidisciplinary team. No rationale for the reduction was recorded.

Although the daily care records provide some evidence that staff engaged positively with Matthew, the observation records often only state his location or observed behaviour. There is little evidence that staff used observation as an opportunity for meaningful engagement with Matthew.

Response to rape allegation

Staff did not take adequate action when Matthew reported being raped on 9 November. Their response indicates they felt his allegation was a symptom of his delusional disorder.

We saw no evidence staff completed actions noted to be ‘essential’ in NEP’s policy on Promoting Sexual Wellbeing with Service Users. They did not complete an incident form or carry out a capacity assessment, and it is questionable whether the police would have been called, had Matthew not phoned them himself.

In the event, the police decided not to take any further action. We saw no evidence that Matthew’s reports of rape went on to be addressed through effective care planning and risk management.

Allocation of key worker

NEP failed to properly allocate a key worker to Matthew. At the inquest, the nurse who had been assigned to Matthew stated that she only discovered this by reading a white board on the evening of 13 November – six days after Matthew had been admitted.

The nurse acknowledged going on annual leave shortly afterwards without taking any action. 

Record keeping

NEP’s record keeping was not always as robust as it should have been. Some paperwork was lost and Matthew’s care plan was falsified. Nursing staff did not record the rationale for administering lorazepam (a tranquiliser which may be a drug of abuse) and its effect, on each occasion Matthew requested it. 

NEP’s Investigations

Overall the investigations into Matthew’s death were not adequate. NEP’s Seven day report 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. 

NEP’s subsequent Serious Incident Panel investigation did not fully meet its terms of reference and the make-up of the panel was not in line with NEP’s policy. Matthew’s family was not as involved in the investigation as they should have been. 

The conclusion of the Serious Incident Panel’s investigation report – which stated that overall care was of a good standard – does not reflect its findings, which identified problems in key areas of nursing practice during Matthew’s final admission, including the management of his observations, care planning and keyworker allocation. The report stated the investigation had been based on the ‘principles of root cause analysis’ yet it did not explicitly refer to any root causes or factors contributing to Matthew’s death.

The recommendations NEP made were not sufficiently robust and comprehensive. NEP failed to assure its commissioners that it had learnt from Matthew’s death and improved patient safety within an appropriate timeframe. 

Lack of timely safety improvements

After Matthew’s death, NEP reviewed some of its policies and practices but did not make substantive physical improvements to the Linden Centre until August 2015. A CQC inspection of NEP’s acute psychiatric wards that month – almost three years after Matthew’s death – indicates that it had not addressed all of the safety problems. 

The CQC found there were still an, ‘unacceptable number of ligature risks’ with self-ligature causing two deaths during the preceding 12 months and similar deaths in previous years.

There had been numerous other incidents involving the use of a ligature on the acute admission wards, with one incident occurring during CQC’s inspection. Risks were not being properly managed even though they had been highlighted during previous inspections. The CQC said NEP had given assurances that changes would be made but it had not fully addressed concerns. 

The CQC also found that there was an over-reliance on bank and agency staff, patient risk assessments on one of NEP’s wards lacked detail, and the majority of care plans were not personalised or holistic.

NEP sent letters to Matthew’s family and MP in February 2015 stating that it had made changes since his death to improve patient safety and prevent similar events in the future.

The fact that the CQC was still finding problems later that year indicates that the changes NEP made had not led to timely, tangible and sustained improvements throughout its wards. This clear failure to learn from mistakes is inexcusable.
 Our recommendations