The Parliamentary and Health Service Ombudsman has asked NHS Improvement to carry out a wider inquiry into North Essex Partnership University NHS Foundation Trust (NEP) after its own probe into the two deaths uncovered “systemic problems”.
”These vulnerable young men and their families were badly let down”
The review will establish whether a public inquiry is needed.
“The lessons learned from this review should be disseminated across the wider NHS,” the ombudsman warned.
The annoucement comes as the ombudsman publishes a report into the care of two vulrenable men who both died shortly after being admitted to the trust’s Linden Centre.
One of the cases investigated was a young man named by the ombudsman as Mr R, who died in 2008.
He was admitted to the Linden Centre with an early diagnosis of ADHD and at risk of taking his own life.
The ombudsman determined that NEP ”missed opportunities to mitigate the risk of him taking his own life” and failed to “adequately manage” his ward leave.
The second case was Matthew Leahy, who died in November 2012, aged 20.
Mr Leahy, who was previously diagnosed as having delusional disorder, was taken to the Linden Centre by police where he was admitted under the Mental Health Act.
While noting that some aspects of Mr Leahy’s care and treatment were in line with relevant guidelines, the ombudsman found he was not adequately observed and did not have a properly allocated keyworker.
The investigation also found that the trust did not respond appropriately when he reported being raped and that record keeping was not robust, meaning some paper work was lost.
Mr Leahy’s care plan was written after his death.
“He was failed in the most appalling way by those entrusted with his care”
Melanie and Michael Leahy
The ombudsman also found that the trust’s own investigation into Mr Leahy’s death was “inadequate” and that NEP was not open and honest with his family.
Following the investigation, NHS Improvement has agreed to establish a review in line with the ombudsman’s recommendations.
In 2017, NEP and the South Essex Partnership University NHS Foundation Trust (SEPT) were dissolved and the Essex Partnership University NHS Foundation Trust (EPUT) was subsequently formed. This is now the organisation responsible for complaints about the former trusts.
In its investigation report, the ombudsman flagged that learning from the deaths had not appeared to prevent mistakes from reoccurring.
The report stated: “The evidence from these cases should have prompted immediate action led from the very top of the trust with senior accountability for delivering and evidencing improvement. Instead, it appears there was a systemic failure to tackle repeated and critical failings over an unacceptable period of time.
“We believe there could be valuable learning taken from a more fundamental review of the approach to leadership, learning and improvement at NEP and why the pace of change only seemed to improve following the merger to create EPUT,” it added.
Rob Behrens, the Parliamentary and Health Service Ombudsman, said he was pleased that NHS Improvement had accepted its recommendation to review what happened at the trust.
“These vulnerable young men and their families were badly let down by NEP,” said Mr Behrens.
“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,” he added.
Melanie and Michael Leahy, parents of Matthew, said they wanted the public to know what happened to their son so it could never occur again.
“The passing of our son Matthew James Leahy has left a void that nothing can fill,” they added in a joint statement.
“The care by the former NEP fell well below acceptable standards”
“Not a day passes when we do not miss him and despair at the thought of how his life was cut short, so needlessly,” they said.
“Sectioned under the Mental Health Act, he was alone, scared and failed in the most appalling way by those entrusted with his care,” they said.
Chief executive of EPUT, Sally Morris, said the trust would implement the ombudsman’s recommendations and would support NHS Improvement’s forthcoming review “in every way possibe”.
“Our deepest sympathies are with these two families whose beloved sons died under the care of the former NEP,” she added.
“The ombudsman reports that, in both these cases, the care by the former NEP fell well below acceptable standards, let alone the high quality of care the NHS strives always to provide, and this has caused deep distress to their bereaved families,” said Ms Morris.
NHS Improvement’s review will only commence once a current Health and Safety Executive (HSE) investigation into NEP has concluded.