Care Quality Commission: Deaths in Mental Health Facilities

Part of the debate – in the House of Commons at 2:45 pm on 16th October 2020.

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Photo of Edward Argar Edward Argar Minister of State (Department of Health and Social Care) 2:45 pm, 16th October 2020

I congratulate my hon. Friend James Cartlidge on securing this important debate and his dedication in representing his constituents. He is an old friend of mine and I know how committed he is to his constituents’ interests. Having spoken to him about this particular case, I know how much it matters to him. I was very sorry to hear about the tragic circumstances of this case.

I wish to put on record, at her request, the fact that the Minister for Patient Safety, Mental Health and Suicide Prevention would dearly love to have been in the Chamber today, given how closely she has been involved with this case and situation. However, as a contact of a recent positive covid case, she is doing the right thing, as always, and staying away. I know that she is watching this debate as we speak and that she will continue to keep very much in touch with developments. I am sure she will speak to my hon. Friend the Member for South Suffolk very soon.

I thank my hon. Friend for raising the concerns about the tragic circumstances around the care of his constituent, Richard Wade, at the Linden Centre, and the CQC’s role in investigating the events. As my hon. Friend set out, in May 2015, Richard tragically took his own life while under the care of the Linden Centre, a mental health facility in the Essex Partnership University NHS Foundation Trust. I put on record my heartfelt sympathies for and condolences to Richard’s family. I understand the devastating impact this must have had on their lives. The passage of time will do nothing to dim that, so I wanted to put that on the record.

As a Minister in the Department of Health and Social Care, I am fully committed to ensuring that we provide the highest standards of quality and safe services to patients, and that when there are failures in the delivery of those standards, we are transparent about how we are learning lessons. My hon. Friend raised important issues about the failings of the CQC in responding to the concerns of Mr Wade’s family following his death, and I have noted the CQC’s review of its handling of these matters. The CQC states that it decided not to use criminal enforcement powers to prosecute the trust—it states that this decision was taken after liaison with the Health and Safety Executive and Essex police—and instead to use civil enforcement powers against the trust after Mr Wade’s death. The CQC further states that there was, in its view, insufficient evidence to proceed to criminal enforcement as, according to the CQC, the evidence indicated that breaches were committed by a series of individuals whose actions lay outside the CQC’s prosecution powers. However, my hon. Friend has clearly set out his views on that and on the CQC’s actions. The CQC has unreservedly apologised to Mr Wade’s family for its handling of this case.

As my hon. Friend set out, the CQC review findings identified areas for improvement and organisational learning. The CQC has committed to internal learning for staff and to support providers to recognise ligature risks and improve safety for people who use mental health services. The regulator is providing mandatory training across all inspection teams on decision making and has strengthened its enforcement training for new inspectors. Importantly, the CQC works closely with families and ensures that their involvement and feedback is considered as an integral part of what the regulator does.

On the wider health system and learnings, last year the CQC wrote to all NHS providers of mental health services regarding concerns about the quality and safety of care provided on mental health wards. While progress has been made, there is still significant variation across the country, with a lack of improvement in some mental health settings. In July this year, the CQC wrote to all NHS providers of mental health services, highlighting that it will be looking at this in inspections of wards. Where insufficient improvements have been made, the CQC will take enforcement action.

In 2018, we launched a zero-suicide ambition for mental health in-patients, which means that every mental health trust now has a zero-suicide ambition plan in place. Those trusts will be supported by a new mental health safety improvement programme, which we committed to in the NHS long-term plan.

As my hon. Friend will be aware, the Parliamentary and Health Service Ombudsman laid a report before Parliament in June 2019 on a series of significant failings in the care and treatment of another two vulnerable young men who died shortly after being admitted to the Linden Centre: Matthew Leahy and Mr R. My thoughts are with the families of all those patients who died at the former North Essex Partnership University NHS Foundation Trust, and we are committed to learning lessons from those tragic events.

As my hon. Friend said, the Minister for Patient Safety, Mental Health and Suicide Prevention gave evidence to the Public Administration and Constitutional Affairs Committee last year. The Committee looked into missed opportunities and the recommendations made by the PHSO, and my Department is considering its response to the Committee’s report, which it looks forward to publishing in due course.

As you alluded to, Mr Deputy Speaker, the Health and Safety Executive has investigated the trust, and as a result of that investigation, the Health and Safety Executive has brought a prosecution against the Essex Partnership University NHS Foundation Trust. As Members will understand—and in line with your advice, Mr Deputy Speaker, and that of the Clerks—I am unable to go into any further details on the HSE investigation. However, it has advised that the first hearing in that case will take place in Chelmsford in November. I will say no more on the case than that, in line with your guidance, Mr Deputy Speaker. It is never acceptable for patients to be exposed to avoidable risks. When things do go wrong, clinicians need to be open, honest and able to learn from their mistakes.

I turn to one of the key points that my hon. Friend raised. I am very much aware, as is my hon. Friend the Member for Mid Bedfordshire, of the petition from families of patients who have died while under the care of NHS services in the Essex area, calling for a public inquiry into the deaths. I completely understand that they have concerns that they want to have heard in public. They want answers, and they want to know what happened. My hon. Friend the Member for Mid Bedfordshire has given careful consideration to the failures in care at the former North Essex Partnership University NHS Foundation Trust. On her behalf, I am announcing today that she has set out her intention to commission an independent review into the serious questions raised by a series of tragic deaths of patients at the Linden Centre between 2008 and 2015.