5 News this week revealed that police have begun an investigation into ‘a number of deaths’ at a mental health unit in Essex.
A 5 News investigation revealed on Friday an NHS mental health trust in Essex is being investigated by police over the deaths of a number of inpatients at one of its units. The hospital, called the Linden Centre, was at the time run by the North Essex Partnership Trust. Seven patients have died at the Linden Centre since 2001, all by attaching a ligature to fixtures or furniture on the wards.
On May 19th an inquest into the death of Richard Wade who died there in May 2015 ruled that the state failed to protect Richard Wade’s life. The jury recorded that ‘Richard’s risk of suicide was not properly and adequately assessed and reviewed, also adequate and appropriate precautions were not taken to manage Richard’s risk of suicide: including: ‘a search policy at the time of the incident, the quality of observation and the current policies at the time and previous recommendations on risk and environmental factors were not implemented adequately.’
Essex Police have told 5 News, which is produced by ITN for the network, they are;
“conducting initial enquiries into a number of deaths which have occurred at the Linden Centre since 2000. We are investigating a number of deaths to ascertain whether there were any criminal failings of persons connected to the organisation.”
In 2008, 20-year-old Ben Morris was found hanged in his hospital room after attaching a ligature to a wardrobe. Since his death his mother Lisa Morris has been searching for answers to what happened. 5 News has obtained a copy of the guidelines the trust drew up in 2006 to ensure fixtures and fittings weren’t a risk to suicidal patients on the ward. Those guidelines stated that the wardrobe, especially the handles, were low risk only because it was not fixed to the wall. Ben Morris was admitted two years after those guidelines came into force, and at some point before his admission the wardrobes were fixed to the wall. But the trust failed to reassess the greater ligature risk the wardrobe handles now posed.
“If they had removed them (the door handles) in 2006 or 2007 my 20-year-old son might have all his life left and be with his daughter now. Something so, so simple; not done. How much would it have cost? It wouldn’t have even cost the trust anything to take the handles off. I just think, why? Your whole world stops and it is really, really hard to carry on with life. All the dreams, all the plans you had with your child have gone. It’s nearly nine years later now for me and it is not any easier.” – Ben’s mum Lisa, speaking to Channel 5
Following Ben’s death, the Trust wrote an action plan, promising to focus on “Assessment of Environmental Risk” – like dangerous furniture and fittings. But by 2012, two more patients had died. A man who used a window to attach a ligature, and 20-year-old Matthew Leahy who was found with a ligature attached to a door hinge.
After these deaths in 2012, the Trust wrote two further action plans to again ensure lessons were learnt. In Matthew’s action plan, one of the trust recommendations was to “reduce the possibility of this method of suicide.” 5 News has seen a letter written in February 2015 by the then Chief Executive of the trust to Priti Patel, the local MP. It came after the inquest into Matthew’s death and the Chief Executive assured Ms Patel that “changes have been made to ensure patients are safe and secure and so prevent any similar occurrence in the future”.
Five days after this letter was written another patient – John Beecroft – was found hanged at the Linden Centre. Three months after this death, 30-year-old Richard Wade was also found dead at the hospital. The inquest into Richard’s death has just concluded at Chelmsford Coroner’s Court. The jury have heard how Richard hanged himself using an item the staff had failed to confiscate when he was admitted a few hours before. Richard’s parents had just arrived to visit him when he was found.
“Our son Richard Wade was an intelligent, witty and compassionate man. On the 16th of May 2015, arrangements were made to take Richard to the Linden Centre in Chelmsford. There he was admitted onto the Finching Field ward. Both he and we thought it to be a place of safety. This proved not to be so as barely 12 hours after admission he sustained injuries from which he never recovered. – Richard’s father Robert Wade
Richard’s care on the Finching Field ward was best summed up by quoting an independent consultant psychiatrist’s evidence. His father added;
“I quote, ‘In other words, he might have survived despite, rather than because of measures intended to ensure his safety. My impression is of important systemic flaws in management and procedure and implementation that failed to mitigate Mr. Wade’s risk of suicide.’ My wife and I now wish to go home, be with our family and friends and together with Richard’s brother truly begin the process of recovering from the loss of the son and brother we love and miss so very much.”
Before Richard had died, inspectors from the Care Quality Commission had visited the Linden Centre in response to the death of John Beecroft. The CQC commented that: “the Trust’s programme for managing ligature risks was not available. We noticed a number of potential high risk ligature areas around the ward.” The CQC continued: “following a serious incident in 2012 an action point was to review door hinges to prevent potential use as ligature points. We found that whilst the Trust had investigated and trialled options, a final decision had not been taken. A senior manager told us funding was agreed 2015/16.”
In August 2015, three months after Richard’s death, inspectors from the Care Quality Commission still found “numerous ligature risks” and said (in a report published Jan 2016): “The Trust leadership style did not promote sufficient grip or pace to bring about changes where necessary. Changes took a long time to implement….ligature free doors had not been installed or even commissioned despite these having been agreed some time ago.” The CQC issued a warning for the trust to take action.
5 News has examined the board papers of the Trust and found assurances that changes had been made. In Sept 2015, the chief executive at the time assured one governor “that works to the doors had been completed during July and August 2015; further improvements were planned.”
Despite this, in September last year the Trust was re-inspected and a report published in December. The CQC issued them with a second warning for failing to manage ligature risk on wards. The report said: “Ligature points remained across all wards and included high level door closers, door handles, radiators and window handles. The Trust said they would take actions to make improvements to reduce and manage ligature risk.”
Since Matthew’s death his mum, Melanie Leahy, has been investigating the Linden Centre and campaigning for change. On the police investigation, Melanie told 5 News: “It has been such a hard slog. It’s the length of time these things take but I think it’s a move in the right direction. What a battle it has been to get this far and I don’t think it is going to be over any day soon. When a patient goes in there in a desperate state they need to be safe and it needs to be instant safety.”
“I miss my son, what can I say. I had one baby – that’s my boy. I miss everything about him. Even when he was having bad times I’d have him back tomorrow, today, now having a bad time. But when the good times were there he was just a treasure. Landlords get prosecuted for less. For not having a gas certificate at the right date. If they are not doing their job right then they should be prosecuted. I think it is necessary because people have got away with this for years. Until they realise they cannot continue the way they are – it’s not just happening in the Linden Centre, it’s happening all over the country – and it cannot continue. Someone needs to be accountable and the only way is taking it to the top. I’d like to see them all in court.” – Melanie Leahy, mother of Matthew.
The Trust involved, North Essex Partnership University NHS Foundation Trust, has now merged with another Trust to become Essex Partnership University NHS Foundation Trust.
In response to the 5 News investigation the Trust have said:
“The new Essex Partnership University NHS Foundation Trust extends deepest condolences to the parents, family and friends for the loss of their loved ones. We fully understand that this has been, and remains, an extremely difficult time for them all. The history of serious incidents of self-harm at the Linden Centre is a matter of great concern that the new Trust has already recognised must be addressed. The Trust will fully support any police and HSE investigations.”
The Trust also told 5 News that they are “undertaking a full ligature audit across the entire Trust” and have “set aside significant funding” to act on the results. It is also committed to reviewing training including risk assessments and communications. Lisa and Melanie will continue to fight for the justice they feel their sons deserve. Lisa says: “It is just heart wrenching because when you go through all that inquest you really do believe that the recommendations made are going to put things right and you will hopefully hear good, positive news that other patients are getting the care they need. We can’t give up on this.”
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