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  • Writer's pictureTom Robinson

Essex NHS mental health trust fined £1.5m over deaths of 11 patients

Updated: Jan 26, 2022

There was an article on the BBC News site last week which detailed how a mental health trust has been fined £1.5 million for safety failings over the deaths of 11 patients.

The patients died while they were under the care of the NHS North Essex Partnership Trust (now the Essex Partnership University NHS Foundation Trust) between the years of 2004 and 2015.

Mr Justice John Cavanagh told Chelmsford Crown Court that a ‘litany’ of failings had been identified over a prolonged period, which led to the trust’s failure to prevent suicides. In the report he stated that:

“Time and again opportunities to put measures in place were lost.”

Failings such as these should never be allowed to happen. As patients, we go to our hospitals and doctors to get better, yet in the current mental health system patients are either dying, or having their conditions much worsened by the failed treatments and trauma of the chaotic psychiatric wards.

The situation is totally unacceptable and it’s time that we addressed the problem with careful consideration to prevent further tragedies and spare future families from losing their loved ones to a badly organised and substandard system.

One parent’s campaign for change

This story has been in the headlines for some time and a campaign for a public inquiry has been spearheaded by Melanie Leahy who sadly lost her son Matthew at the Linden Centre in Chelmsford back in 2012.

The prosecution ‘means nothing’ for Melanie who, along with other devastated parents, is continuing in her quest to uncover the truth behind the failures that led to these heartbreaking losses. She says:

"We continue to campaign for a statutory public inquiry. We need to bring people in under oath to be answerable for these repeat failings and to make the changes that are necessary here in Essex and across the nation."

Speaking out in support

Anyone who reads this blog knows that I am not afraid to speak about mental illness as opposed to mental ‘health’, and tackle some of the contentious issues surrounding psychiatric care in this country.

I am determined that my lived experience should be used to help people to gain insight into what it’s like to go through these wards from the patient’s perspective so that we can improve things for others in the future.

I have been following Melanie Leahy’s campaign since she reached out to me a few months ago after a rather brusque post I wrote about the substandard care of NHS psychiatric hospitals for dual diagnoses.

I have been hesitant in the past about speaking up over the reality of the current system because I was fearful of upsetting the staff who work within it, but recently a mental health nurse agreed with me when I spoke out about a ‘chaotic and unsettling environment’, and I realised that even some of those in the profession agree that the current system is failing its patients.

This has given me the confidence to voice my opinions publicly in the hope that I will be able to highlight some of the problems and then work collaboratively to help improve the situation for other people.

Highlighting the problems of the current system

There is absolutely no excuse for patients to die on our psychiatric wards. The only reason that this happens is because of the appalling oversights in care and the failure to implement changes and improvements to make the wards safer.

I know this because I’ve witnessed the chaotic and badly run system as an inpatient myself and I can tell you that not only are these places unsafe, but they don’t currently facilitate a patient’s rehabilitation in any way whatsoever.

There have been numerous failings, miscommunications and blunders in my care over the last twenty years, any of which could have contributed to my death.

As well as the terrible waitlists to see a professional, complete lack of understanding and empathy from staff, and inability to address the seriousness of patient’s conditions, the system is failing its patients for all sorts of other reasons too which I will now discuss in detail.

Unanswered phone calls

The fiasco that very nearly killed me happened almost exactly four years ago when I was given intravenous ketamine for treatment resistant depression.

There was absolutely no follow up or aftercare whatsoever, so when I tried to reach out for help (when I was experiencing horrifying side effects), I was unable to get hold of anyone at all and my condition worsened immeasurably.

The result was that I got to crisis point before anything was done about it and I was then inhumanely bulldozed to the floor, forcibly injected with antipsychotics, and then spent a traumatic three months incarcerated on a chaotic psychiatric ward.

The experience did not help me in any way, in fact, my condition was made so much worse that I spent the next three years fighting to stay alive and spending thousands of pounds with a private doctor to undo the damage done by the failed treatments and psychiatric drugs.

Even more recently when I’ve tried to get help from the NHS (to try to cut the cost of extortionate private medical fees) I’ve come up against the problems of unanswered phone lines and answering machines.

It’s so frustrating that I have now made a formal complaint because I know that this is why we’re losing people – sometimes there’s that one chance to help someone and if no one answers the phone then often that chance is lost.

When I did finally get through to someone from the team I’m assigned to the response was:

‘What do you mean losing people?’

I was so exasperated by this point that I hung up and called the main NHS complaints board instead.

Lack of support or unity

One evening during my last psych ward admission, a young Indian boy came up to me and quietly whispered to me that he wanted to die. I immediately asked him if he had told the staff how he felt and his reply was:

“If I tell them the truth then they won’t let me go home.”

I felt as though I had a responsibility to alert the staff so that his level of care could be adjusted accordingly, but when I did talk to a health care assistant about my concerns, I was rudely and abruptly informed that I should:

‘not get involved in another patient’s care.’

I wouldn’t have minded this at all except for the fact that it appeared to me that there was no care and their reaction to my concern was to lock him out of his room so that he couldn’t sleep all of the time – the only coping strategy this poor young guy had to escape his mental pain and misery.

Messages go uncommunicated

Another massive blunder in my care happened when I was discharged from hospital to an empty house even though my parents had expressly stated that they were out of the country and that if I was to be discharged, could they please be informed so that they could organise alternative arrangements.

This message wasn’t communicated, and the result was another traumatic and horrifying incident when my friends had to rush over and take me back to the hospital.

I was reminded of this recently when I read an article about a mother who had taken her own life whilst under the care of an NHS trust in Birmingham.

Her daughters had alerted staff when she told them that she had suicidal intentions. This message was not communicated, and the result was that the patient’s level of observations and care plan was not revised which resulted in her taking her own life when unsupervised.

These lapses in care and attention result in tragedy time and again. This should never be allowed to happen.

Families need to know that their relations are in safe hands when they go into hospital, not be continuously on a knife-edge worrying whether their needs are being met and if they’re being cared for and looked after appropriately.

The wards are pandemonium

The chaos of a psychiatric ward is impossible to explain in words and you can only appreciate the full extent of the mayhem if you live on one as a patient.

There are alarms blaring out continuously, patients being dragged down corridors screaming, fighting, racism, homophobia and bullying, and the disorganisation at every turn make every day feel like you’re living in some kind of warped and twisted ‘Carry On’ film.

The wards need splitting down urgently – there’s no way that you can have 18 guys locked up together with everything from chronic PTSD to severe psychosis and everything in between – that’s the definition of insanity in itself!

Unfortunately, I know that this is so far from happening because even the ‘136 suite’ (which is where patients in crisis are admitted) was crammed in at the end of my corridor and the bed shortages are so bad that sometimes patients are located hundreds of miles away from where they live.

How is any of that conducive to regaining one’s mental health and well-being?!

Improvements and changes for the future

What people need to understand is that when you are fighting a severe mental illness you don’t have the strength to be fighting a broken system as well. There’s absolutely no point in the government giving out the message of ‘seek help’ when the help is so substandard when you do decide to reach out for it.

Apart from splitting the wards down and making vast improvements in hospital infrastructure and safety, the staff need bucketloads of further education and training as well. These roles involve caring for some of the most vulnerable, frightened, and dangerously ill people and should only be assigned to the most professional, compassionate and caring of individuals.

The psychiatrists need to be making an effort to get to know their patients so that they can understand their individual situations and help them from a more holistic all-round approach rather than relying solely on trial and error with medications and dangerous treatments.

In my last three-month admission not once did someone ask me how I was coping or how I’d ended up being sectioned on a psychiatric ward.

The situation was so laughable that one day myself and a fellow patient stood by the main door on a shift change and asked each member of staff how they were as they came through the door. We were met with grunts and moans and shuffling of feet and NOT ONE MEMBER of staff asked us how WE were!!

There are a small number of excellent staff who work on these wards, and they need encouraging and supporting, but they were so stretched and unsupported by their peers that patients often went unwashed and without a change of clothes for months on end and no one received anywhere near the amount of empathy and understanding that they were capable of providing.

Somehow, (and God alone knows how), I have managed to put the whole ordeal behind me, move past it and fully recover but I would still rather die than ever go through another psychiatric ward again and that’s a very worrying thought that I know I’m not alone in.

I’m lucky though, I have the ability to walk away from this now, to stand up for myself and not revisit the past, but what about people with combined mental illnesses and learning difficulties? Or those that never receive the help they need to recover?

How is this ok for any of them?

Learning from the past

I really hope that this story can help to, not only highlight the problems of psychiatric care in this country, but also be the turning point that instigates a wave of change.

Melanie Leahy and all of the other parents and families deserve to know what happened to their children so that lessons can be learned, and we can do everything in our power to prevent further tragedies in the future.

I hope and pray that one day our psychiatric wards will become safe places where people can rest and recover and where parents can feel confident in the knowledge that their loved ones are being cared for in a safe and healing environment.

If you would like to read the BBC News article detailing Melanie Leahy’s campaign and story, then you can find it here.

Melanie and other bereaved parents will be taking a letter to Minister for Suicide Prevention and Patient Safety, Nadine Dorries and holding a peaceful demonstration at Downing Street from 1 to 3pm on the Wednesday 7th July.

They are encouraging anyone who wants to see change to join them in their call for a statutory public inquiry and I certainly hope to be able to support them there.

Thanks for reading,

Speak to you soon,


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