Matthew Leahy’s care plan was ‘falsified’ by staff after being found hanged at Chelmsford’s Linden Centre

Melanie Leahy is leading the campaign for a statutory public inquiry into the county’s mental health services

Staff “falsified” Matthew Leahy’s care plan after he was found hanged at an Essex mental health unit.

The 20-year-old was discovered in his room at the Linden Centre in Chelmsford, Essex, in November 2012, before being transferred to Broomfield Hospital where he was pronounced dead shortly after.

A report from the Parliamentary and Health Service Ombudsman in 2019, seven years after Matthew’s death, found there had been “significant failings” in key elements of his care while under the North Essex Partnership Trust (NEP).

His mum, Melanie Leahy, has been campaigning for a statutory public inquiry for eight years in search of truth and justice for her son, and she now has the support of approximately 20 other Essex families who believe their relatives were also failed by the system.

They believe a public inquiry, through which members of staff can be questioned under oath, is the only way to get the answers they claim they so desperately need.

Found hanged a week after admission

Matthew Leahy died a week after being admitted to the Linden Centre in Chelmsford(Image: Ricci Fothergill/RMC)

Matthew had a great childhood.

He excelled throughout his education, went to grammar school and even set up his own IT business.

But his dream of working in accounting was shattered when he didn’t get accepted into college, and that’s when his mental health started on a downward spiral.

Melanie, who lives in Maldon, said: “He got a bit depressed that he couldn’t get into accounting and the first sign of any problem was when he was telling me that he had pains in his stomach.

“He was having trouble sleeping and I wasn’t aware he’d gone to the doctor about it.”

When he was 18, Matthew told his doctor that he could feel things crawling over his skin, and according to Melanie, his condition worsened as the drugs and doses he was being given changed over time.

He was placed under the care of NEP’s Early Intervention in Psychosis team in 2011 and was diagnosed with a delusional disorder, by 2012 doctors say they were looking to see if this was caused by something physical.

In November 2012, Essex Police brought Matthew to the Linden Centre as a place of safety.

But just a week later he was found hanged in his room.

“Multiple failings and missed opportunities”

Melanie has been campaigning for a statutory public inquiry for eight years

A report from the Parliamentary and Health Service Ombudsman (PHSO), released in June last year, investigated reports into the deaths of two men at the Linden Centre between 2008 and 2012.

In Matthew’s case, it found 19 instances of serious failings in his care.

The report found that the conclusion of an internal Serious Incident Panel Investigation compiled by NEP in January 2013 – claiming the 20-year-old’s care and treatment was of a “good standard” – didn’t reflect its findings.

And while the PHSO report confirmed that some aspects of Matthew’s treatment were in line with the relevant guidelines, it also identified a number of “significant failings” in key elements of his care.

According to the PHSO report, Matthew had a care plan in place for the first 72 hours of his admission, but it wasn’t updated to reflect his needs and the risks that presented themselves in the following days.

It also found that members of staff had gone back and “falsified” the care plan after his death, which resulted in disciplinary action against the staff members involved. They were subsequently referred to the Nursing and Midwifery Council which EssexLive understands is still investigating.

The PHSO also made reference to NEP’s ‘Seven day report’ which contains “inaccurate information” about how Matthew’s care plan was reviewed.

The report found 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”.

In response to the 2019 report, Melanie and Michael Leahy, Matthew’s dad, said: “Our son was ready to go travelling and celebrate his 21st birthday.

“He should never have died. Sectioned under the Mental Health Act, he was alone, scared and failed in the most appalling way by those entrusted with his care.

“We want the public to know what happened to our son so this never happens again.”

Emma Broadbent, director of Professional Regulation for the Nursing and Midwifery Council, said: “We know Ms Leahy was disappointed by our previous decision not to open a full investigation into this matter.

“After careful review and new information we’ve received, we’re now looking further into the concerns raised. We remain in touch with Ms Leahy to ensure she’s kept informed about any further action we take.

“Unfortunately we are unable to comment further at this stage.”

Despite being admitted to the Linden Centre due to concerns for his welfare and the risk he posed to himself, the PHSO report found that NEP failed to “adequately manage” the environmental risks at the unit including a ligature point in Matthew’s room.

Matthew’s observation level was also reduced just two days before his death without prior discussion with the multidisciplinary team.

According to the PHSO report, no rationale for the reduction was recorded.

Matthew was subject to “a series of multiple failings” at the Linden Centre in November 2012

A spokesperson for the Essex Partnership University NHS Foundation Trust (EPUT) said: “We know the circumstances surrounding Matthew’s death have caused enormous pain and distress to his family and we offer our sincere condolences.

“Since EPUT was established in 2017 our top priority has been to continuously improve patient safety.

“The trust has fully accepted all the recommendations in the Ombudsman’s Missed Opportunities report relating to the former North Essex Partnership University NHS Foundation Trust – including making sure we work with every patient to create a personalised care plan when they are admitted.

“As part of our ongoing programme of improvements we have also introduced a number of new safety measures at the Linden Centre, like increasing CCTV, introducing anti-barricade doors, and improving the safety of our bathrooms and bedrooms.”

The allegation of rape

Matthew was declared at Broomfield Hospital following attempts to resuscitate him

On November 9, 2012 – six days before he died – Matthew called the police alleging to have been raped during the night.

During the call, part of which has now been released by Essex Police, the 20-year-old claimed that the doctors “refuse to acknowledge it”.

No further action was taken by Essex Police, but the PHSO report confirmed that staff at the Linden Centre failed to take “adequate action” in response to Matthew’s claims.

The report found that staff didn’t complete an incident form or carry out a capacity assessment, and said it’s “questionable” as to whether the police would have been called had Matthew not phoned them himself.

As a result, the PHSO saw no evidence that Matthew’s reports of rape went on to be addressed through effective care planning and risk management.

The fight for a public inquiry

In November 2012, Melanie Leahy’s son Matthew was found hanged at the Linden Centre in Chelmsford just a week after being admitted under the Mental Health Act.

She has been pushing for a statutory public inquiry, through which witnesses can be made to give evidence under oath, into the county’s mental health services ever since.

According to Melanie, it’s the only way the affected families will achieve justice for their loved ones.

There are now around 20 Essex families supporting the fight for an inquiry, all of whom have lost a relative during or after being under the care of a mental health service, but the number is growing.

The group has now secured the support of Hodge, Jones & Allen Solicitors who have agreed to work on a pro bono basis to try to secure a public inquiry.

Nina Ali, Partner at HJA, said: “HJA is intent on helping these families secure the justice that they deserve.

“It is essential to get to the truth of what happened – all those families whose loved ones died whilst they were under the care of Essex mental health services are owed answers for their loss.

“A public inquiry is needed to ensure that a comprehensive and in-depth investigation is carried out and those responsible are held to account. It is only then, that things can and will begin to change for the better.

“We urge all affected families and individuals to get in touch with HJA. The call for a public inquiry is to include everyone affected by the failings of Essex mental health services: families of children, adolescents, adults, and the elderly who have died and individuals who have been through ‘the system’ and suffered but survived.”

Priya Singh, Associate at HJA, claims: “It is not only families of the bereaved who are coming forward but also ex-patients from whom we’ve heard shocking reports of abuse suffered by the victims whilst in care. These stories are harrowing.

“Vulnerable people have entered what are meant to be centres of trust and safety – a number voluntarily submitted themselves for help – only to be abused and exploited by some professionals who should protect them.

“They come in with mental health issues and leave – if they leave – in a much worse off state than before.

“No family, no individual should ever have to go through that. These families have been failed by the organisations that are set up to treat and care for patients.”

Rob Behrens, the Parliamentary and Health Service Ombudsman, said: These vulnerable young men and their families were badly let down by North Essex Partnership Trust.

“The lack of timely safety improvements following their deaths is completely unacceptable and it’s important the NHS understands why this happened and what lessons can be learned to prevent the same mistakes happening again.

“I am pleased that NHS Improvement (NHSI) has accepted our recommendation to review what happened at the Trust and to share the findings from this with parliament and the wider health system.”

Petition gains 100,000 signatures

The families want justice for their loved ones (Image: Ricci Fothergill/RMC)

Last year, Melanie set up a petition in a bid to secure a statutory public inquiry into Matthew’s death.

The petition was forced to close early due to the General Election, and when Melanie was informed she’d only managed to gather 47,000 signatures.

But after a last-minute campaign in the centre of London with posters, radio interviews and viral videos, Melanie secured a further 58,580 signatures in just two days.

It meant that she now had more than 100,000 names before the deadline passed – the number of signatures required for Parliament to consider a debate in the House of Commons.

Melanie is still hopeful that a debate will happen as she believes a statutory public inquiry is the only way her and other families will secure the truth and justice for their loved ones.

“There’s a lot more to come out,” she said.

“I know other things happened to my son, and in the last eight years not one member of staff has been interviewed under oath.

That’s the only way I can get the truth, through a statutory public inquiry. That’s the major factor.

“I’m going to fight this. This is a national crisis, if what I’m doing can create change here it’s going to happen elsewhere, it has to.”

“Truth, justice, accountability and change, what we all want.”

Credit: Elliot Hawkins

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