Mother’s hard won parliamentary debate on deaths in mental health care to take place Monday

The mother of Matthew Leahy, who died whilst an inpatient in an Essex mental health ward, secured a parliamentary debate into deaths in mental health care following a successful petition supported by over 105,000 people. The debate will take place in Westminster Hall from 4.30 on Monday 30 November.  

Melanie Leahy called for a debate on the need for a full public inquiry into the failures in the care of her son, and subsequently other families bereaved by preventable deaths in Essex mental health care have joined the call.

Matthew was 20 years old when he died on 15 November 2012, whilst in the care of the North Essex Partnership University NHS Foundation Trust (NEP) run Linden Centre. A critical inquest, police investigation, and damning Parliamentary Health Service Ombudsman investigation followed.

This year the Trust, now the Essex Partnership University Trust, pleaded guilty to failures relating to the deaths of 11 patients, and the Health Minister announced that the government intends to commission an independent review into the Linden Centre.

Since 2013, INQUEST has worked on over 28 cases involving deaths in mental health settings in Essex. These deaths are marred by failures that are repeated time and again and include: poor information sharing and record keeping, inadequate risk assessments, dangerous ligature points. The situation in Essex is a stark example of the systemic failures in the care of people with mental ill health.

There have been countless investigations, inspection reports and inquests highlighting these failures, but despite these, preventable deaths have continued. Concrete action is needed to ensure these families have access to truth, justice and accountability, and to create and sustain change in Essex and more broadly in mental health services across England and Wales.

The Westminster Hall debate is an opportunity to discuss these issues in Parliament. In a briefing for MPs, INQUEST is calling for action on:

  • A statutory public inquiry into Essex mental health services.
  • Independent investigations into deaths in mental health settings.
  • Formation of a National Oversight Mechanism on deaths in detention and mental health settings, which would collate, analyse and monitor learning and implementation of recommendations from state-related deaths, to ensure accountability and prevent future deaths.

Melanie Leahy, mother of Matthew Leahy, said: “I am a mother who is unable to mourn the death of my only child, because I do not have the truth as to how he truly died. There is no giving up on this pathway to truth, justice, accountability and change for others and I see the only way forward is through a Statutory Public Inquiry”. 

Deborah Coles, Director of INQUEST said: “Essex mental health services ignored dangerous practices that led to preventable deaths. If it were not for the dedication and persistence of bereaved families to get to the truth, these failings would never have come to light. It is time that those families are listened to. Only a public inquiry can provide the scrutiny and oversight that is so necessary.” 



For further information please contact Sarah Uncles on 020 7263 1111 or

See the website run by Melanie Leahy, Matthew’s mother, for more information on her campaign. More information on broader issues is available in INQUEST’s briefing for parliamentarians.

The names of people who have died in the care of Essex mental health services, where there has been public reporting, are available here.

Melanie Leahy is represented by Nina Ali and Priya Singh from Hodge Jones & Allen solicitors.

The Essex Partnership University NHS Foundation Trust (EPUT) was established on 1 April 2017, and merged the North Essex Partnership University NHS Foundation Trust (NEP) and South Essex Partnership University NHS Foundation Trust (SEPT).

Earlier this month, the Essex Partnership University Trust (EPUT, the now merged North and South Essex Partnership University NHS Foundation Trust) pleaded guilty to failures relating to the deaths of 11 patients between 25 October 2004 and 31 March 2015. The case brought by the Health and Safety Executive is ongoing.

In October, Health Minister Edward Argar MP told the House of Commons that the government intends to commission an independent review into the Linden Centre, looking at “failures in care” between 2008 and 2015. Following the Ombudsman report, a review by NHS Improvement was also announced which is ongoing.

In May 2017, Essex Police launched a corporate manslaughter investigation into the series of deaths, prompted by Matthew’s family campaign highlighting repeated deaths at the Linden Centre. This investigation was however later dropped due to insufficiency of evidence. The CQC also decided not to bring charges, including following their investigation into the death of Richard Wade.

Parliamentary Health Service Ombudsman investigation in 2019 identified systemic failure of the Trust to tackle repeated and critical failings over an “unacceptable period of time”, and highlighted inadequacies in initial investigations into Matthew and another young man’s death. An inquest into Matthew’s death in 2015 also highlighted multiple failings and missed opportunities in his care.

Journalist should refer to the Samaritans Media Guidelines for reporting suicide and self-harm. 

Credit . Inquest Group

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