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National review into mental health trust failings.

A national review has been ordered into "significant failings" at a former mental health trust dating back more than a decade.

The parliamentary and health service ombudsman found care shortcomings by the former North Essex Partnership University Trust (NEP) in the case of two vulnerable young men who died.

The investigation identified "a systemic failure to tackle repeated and critical failings over an unacceptable period of time."

Parliamentary and health service ombudsman, Rob Behrens, said the men had been "badly let down.”

He added: "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."

The latest review, led by NHS Improvement, will consider whether to recommend a public inquiry.

Chief executive of mental health charity, Sane, Marjorie Wallace, said the trust had shown "an almost cavalier attitude" to patient welfare.

She said: "Little was done despite repeated criticisms and recommendations, some as fundamental as to remove ligature points, let alone take steps to change culture and practice and provide acceptable treatment."

Chief executive of Essex Partnership University NHS Foundation Trust (EPUT), which succeeded NEP in 2017, Sally Morris, said: "We will carry out the ombudsman's recommendations and will support NHS Improvement's forthcoming review into the former NEP in every way possible."

One of the cases reviewed by the ombudsman was that of Matthew Leahy, 20, who died from hanging at the trust's Linden Centre in November 2012.

The review found failures in the trust's response when Mr Leahy reported being raped; said it did not write his care plan until after his death, and was "not open and honest" with his mother about safety improvements.

Mr Leahy's parents, Melanie and Michael, 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."

The ombudsman said the trust should apologise to Mrs Leahy and acknowledge its failings; explain how it would avoid them recurring and pay her £500 for providing "inaccurate information" about safety changes in February 2015.

The other case investigated by the ombudsman involved a man identified only as Mr R, who was admitted to the Linden Centre in 2008 with an early diagnosis of attention deficit hyperactive disorder (ADHD) and considered at risk of taking his own life

The investigation found there were missed opportunities to mitigate the risk of him taking his own life, staff did not respond adequately when Mr R threatened to harm himself and the trust failed to properly assess and manage risk.

Essex Police investigated up to 25 deaths at the trust and, although the force found "basic failings", the case did not meet the corporate manslaughter threshold.

The Health and Safety Executive is still conducting a separate investigation into how the trust managed wards in relation to ligature points between October 2004 and March 2015.

 

 

 

 

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