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Care Quality Commission: Deaths in Mental Health Facilities

Volume 682: debated on Friday 16 October 2020

Motion made, and Question proposed, That this House do now adjourn.—(Rebecca Harris.)

Before I call James Cartlidge, I have a statement to read.

I should inform the House that I have been advised that the Health and Safety Executive has commenced criminal proceedings against Essex Partnership University NHS Foundation Trust relating to deaths in mental health care facilities from October 2004 to April 2015. Therefore, although the case that the hon. Member wishes to speak to is not sub judice, that trust’s management of the physical environment of mental health wards is sub judice and reference should not be made to those proceedings in this debate. I thank the hon. Member for his courtesy in consulting the Table Office in advance of his debate, and I remind any other Member participating in the debate to be equally mindful of the sub judice resolution and matters still before the courts.

I am very grateful to you, Mr Deputy Speaker, for enabling this debate to come forward, and I will entirely abide by your guidance on the case that is ongoing. It highlights, frankly, that this is a very timely debate. Your guidance in relation to the case means that there are important points of substance that I am unable to make today, but the fundamentals are unchanged because, as you say, they relate to a death in May 2015 under the Care Quality Commission rather than the Health and Safety Executive.

The case in question is that of Richard Edward Wade of Great Cornard in South Suffolk and the failure of the Care Quality Commission to investigate his death and provide his family with the justice and accountability that they have sought for so long. On the evening of 16 May 2015, Richard called the police as he was suffering from poor mental health and feared that he would hurt himself. The police assessed him and decided that the best course of action would be to admit him to the Linden Centre in Chelmsford to ensure his safety. I emphasise that Richard voluntarily called for assistance, he was not sectioned, and he was admitted to the Linden Centre on the basis that it would provide a place of care.

Just over 12 hours later, Richard was found to have attempted suicide by use of a ligature. Richard was transferred to the Broomfield Hospital next door, received treatment in the intensive care unit, and passed away on 21 May 2015. Richard, who had a PhD in political science and had published a book two years before, was just 30 years old when he died.

Before I set out my primary arguments about the CQC’s handling of the case, I would like to make three important points. First, I would like to take this opportunity to pay tribute to Richard’s parents, Linda and Robert Wade, who, despite their tragic loss, have shown remarkable resilience in their fight for justice. They have never given up pursuing the truth and I sincerely admire the way they have been able to maintain outer calm whenever describing to me and others, including the Minister, the traumatic details of their son’s last days.

The Minister I refer to is the Minister for Patient Safety, Mental Health and Suicide Prevention, my hon. Friend the Member for Mid Bedfordshire (Ms Dorries). She cannot be here today; the Minister for Health, my hon. Friend the Member for Charnwood (Edward Argar), is covering, but my second point is to pay tribute to my hon. Friend the Mental Health Minister, because she has shown huge personal interest in this case. Back in October, when she met the parents of Richard Wade, she was incredibly moved by what she heard. As the son of a nurse—my mother was a nurse for many decades—I would say that my hon. Friend’s background as a nurse shone through. She showed genuine empathy and sympathy with the Wades, and I know that she has been trying her best in the background to get proactive stuff done on the case.

My third point before I go into my main remarks is that I am very much aware that this is not the only death that has occurred by ligature at the Linden Centre Chelmsford. There are a number of cases with circumstances not dissimilar to those of Richard Wade. For example, Mr Deputy Speaker, you may be aware that the Petitions Committee has received a petition for a public inquiry into one such case that has now received more than 100,000 signatures. I believe that the case for a public inquiry or an independent inquiry is very strong, particularly in the case of Richard Wade, because, in demonstrating how the CQC failed to investigate his death, it prompts the following very simple question. Since that investigation timed out under its statutory time limit, if not an independent inquiry, what else can we offer the Wades in their search for the truth of what happened to their son?

Of course, primary responsibility for the handling of Richard’s clinical case in May 2015 rested with the trust in charge of the Linden Centre, then the North Essex Partnership NHS Foundation Trust and now the Essex Partnership University NHS Foundation Trust, which I will refer to from now on as “the trust”. In January 2016, following an internal investigation into Richard’s death, the Wades received a letter of apology from Andrew Geldard, the chief executive of the trust, stating that Richard’s death in the trust’s care “could have been avoided”. My primary concern today is not the role of the trust but that of the regulator charged by the Department of Health with the legal responsibility for holding the trust to account for its failings, the CQC.

The facts of timing are critical here. In April 2015, following recommendations in the Francis report, which came from the Mid Staffordshire scandal, prosecuting powers in relation to patient care passed from the Health and Safety Executive to the CQC. Richard died a month after the transfer of responsibilities, but, agonisingly for Richard’s parents, through a series of internal failures at the CQC, the regulator failed to prosecute the trust within its three-year statutory limit. The main reason for the failure to prosecute is very hard to take, and is evidenced by the CQC’s own internal report into the handling of Richard’s case, published this July, which is the primary document to which I shall be referring.

The report states that the

“CQC did not undertake its own review or investigation of Richard’s death as staff, who acted as the relationship owner for this location, mistakenly believed that HSE retained primacy of the criminal investigation alongside Essex police”.

In short, the CQC did not investigate because it did not realise it was its responsibility to do so. What reason was given for this shortcoming? The report says that the CQC was “unprepared” for the changes of April 2015, stating:

“The implementation of new powers of criminal enforcement had been given to us at short notice”.

I repeat “short notice”, because that is simply not the case. In fact, these new powers were passed in the Commons in 2014 in the form of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, giving the CQC plenty of time to ensure that its staff were properly informed and trained in these new powers.

In February 2015, the CQC published its “Enforcement policy” document for its staff ahead of gaining the new powers in April 2015. This policy clearly states:

“CQC is the lead inspection and enforcement body for safety and quality of treatment and care matters involving patients and service users in receipt of health or adult social care service from a provider registered with CQC”.

I can also confirm that in the run-up to the CQC taking lead responsibility after April 2015, there was close working between the HSE and the CQC, which included not only a memorandum of understanding to clarify roles and responsibilities, but interim working arrangements and, crucially, training for CQC staff on criminal investigations. It is very hard to believe that CQC inspectors did not know of the new powers at the time of Richard Wade’s death. If it is true that they did not know, it represents gross negligence and a manifest failing on the part of senior CQC management for which nobody has been held to account to date.

The CQC did eventually hold a management review meeting about Richard’s case in May 2017, two years after his death, due to the impending coroner’s inquest, and in July 2017 a lawyer was finally allocated to the case. Over the next six months, because of “staffing continuity issues”, the lawyer changing three times and a lack of response from Essex constabulary, very little progress was made in Richard’s case. According to the report,

“by the time the police provided some evidence on 6 January 2018, the impending limitation date of 17 May 2018 left insufficient time for the case to be considered from a fully informed evidential position, with a view to a potential prosecution.”

Put simply, instead of using those final four months of the three-year time limit to commence the investigation, which, after all, was running late precisely because of mistakes made by the CQC, it would appear that at that stage the CQC simply gave up.

Last week, the CQC announced that it would be prosecuting the East Kent Hospitals University NHS Foundation Trust, following complications that led to the death of a baby in its care in November 2017. This is the first time that the regulator has prosecuted an NHS trust over a safety failure in the clinical care of patients since it gained the powers in 2015. For Mr and Mrs Wade, it has been a painful reminder of what might have been. As I said at the beginning, there have been a number of other cases at the Linden Centre not dissimilar to Richard Wade’s.

In addition to the failure to investigate within the statutory time limit, the other shocking aspect of the CQC’s handling of his death was its failure to see a wider pattern—surely this goes to the very purpose of the regulatory changes that followed the infamous Mid Staffs scandal. In February 2015, just three months before Richard died, another patient died from ligature compression to the neck in the Linden Centre. This occurred in the very same bathroom where Richard attempted to take his life on 17 May 2015. We know that the CQC first became aware of Richard’s case on 18 May 2015. On 20 May 2015, while Richard was in intensive care in Broomfield Hospital, the CQC published its report into the February incident. Richard was pronounced dead the next day. In that context, surely one would have expected alarm bells to be ringing and klaxons to be sounding. The CQC was suddenly aware of two similar deaths by ligature, not only in the same setting but in the same bathroom, but nothing happened—there was no investigation and no emergency investigation. Given the similarity of these cases, I find that extraordinary.

The trust carried out its own serious incident investigation into Richard’s death in December 2015, and the CQC report notes that

“it does not mention that a patient had used a ligature in the same bathroom three months before this accident, and subsequently died”.

Yet there was no challenge to this glaring omission from the CQC and its report states that

“there is no documentary evidence that CQC reviewed evidence and judged if the recommendations from the serious incident were embedded”.

Perhaps most worrying of all, the CQC inspection that occurred into the February 2015 death was a missed opportunity to prevent Richard’s own tragedy. The report on Richard’s death explains that there is no documentary evidence that the February 2015 inspectors gave verbal feedback to the trust about the actions that needed to be taken to prevent another death. Additionally, it states that they

“have no evidence in our records of any action the trust took following feedback from inspectors. After the 2015 inspection, the trust was asked to provide further information regarding environmental risk assessments and care plan reviews. However, there is no documentation of CQC formally reviewing this extra evidence that the trust submitted.”

At every turn, there was inaction by the CQC until it was too late.

That brings me to my final points. In October last year, the Public Administration and Constitutional Affairs Committee held an evidence session on the Parliamentary and Health Service Ombudsman’s report on missed opportunities at the trust. The report focused on the cases of two victims, who did not include Richard Wade, and Mr and Mrs Wade provided written evidence about Richard’s death. During the session, my hon. Friend the Minister for Patient Safety, Mental Health and Suicide Prevention explained that the Department’s position on the calls for a public inquiry was that such inquiries

“do not happen for individual cases; they tend to happen when there is a systemic problem or there are multiple cases. In this case, a public inquiry is not an appropriate response because we are talking about two cases.”

There are multiple cases. I believe there is strong evidence of systemic failure, and on top of that we now have regulatory failure. As such, I believe it is time for the Minister to consider the need for an independent inquiry into all similar deaths at the Linden Centre, including that of Ricard Wade.

A young man lost his life in the place where he had sought safety. Richard identified that he was a risk to himself and asked our mental health service for assistance. Owing to multiple missed opportunities for existing problems to be rectified, he lost his life. Now, his family are being denied the justice that they deserve through patent failures by the CQC within the statutory time limit that has now closed. There is no statutory time limit on the grief of his parents. All they want is to know the truth. If that can come from an independent inquiry, that is the least we can do for them. My hon. Friend the Minister for Patient Safety, Mental Health and Suicide Prevention has been sympathetic and I know she is doing all she can in the background. I hope that today my hon. Friend the Minister for Health can give us some hope for the future.

I congratulate my hon. Friend the Member for South Suffolk (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 (Ms Dorries), 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.

That will be incredibly welcome for all the families connected. Can the Minister confirm that it will include the case of Richard Wade? Does he appreciate that many other Members—particularly those representing Essex constituencies, and many of whom are Ministers and therefore cannot contribute—will be incredibly pleased to hear this announcement? Frankly, none of us expected it, even though we have waited for it for so long.

I am grateful to my hon. Friend. Although the formal terms of reference of the independent review have yet to be fully agreed, the conditions relating to Mr Wade’s death and the date certainly appear pertinent to this review and are likely to be considered as part of it. I will turn to the details in just a second.

This review will build on the recommendations made in the 2019 Parliamentary and Health Service Ombudsman’s “Missed Opportunities” report. I emphasise again, because I know that my hon. Friend has argued for this powerfully, that it will be independent. He rightly alluded to the fact that, although he is raising Mr Wade’s case today, there is a broader context, and there are other right hon. and hon. Members who have constituents who have been in a similar position and families who have approached them about this. I know that they will want to be involved as well.

The Minister will appreciate that this is very significant news for many constituents because of the trauma they have experienced. He is right that the key word he has used is “independent”. Will he confirm that that means, basically, that what those constituents have been asking for will be granted, because it is the best chance they will have to learn the truth of what happened?

I am grateful to my hon. Friend for his intervention. I am just coming on to the process that will be set in train now. I emphasise that although, for the reasons I set out, it is me announcing this to the House, the work has been done by my hon. Friend the Member for Mid Bedfordshire. I want it to be recognised just how much work she has put into this issue.

We have decided to start the process now, so that the lessons learned can benefit care across the wider NHS as quickly as possible. We will work with the HSE to ensure that the review does not in any way prejudice the legal action that is under way.

Turning to the specific issues that my hon. Friend raised, the Minister for Patient Safety, Mental Health and Suicide Prevention will also be seeking as swiftly as possible a meeting with the families affected by these events, as well as with my hon. Friend and other hon. Members who are involved with this issue, to understand what they would wish to see from this process as the terms of reference and scope are agreed. The Minister is very keen to fully involve them in understanding the scope and terms of reference that need to be set and how we can seek through this process to bring them at least some degree of resolution. She will provide further details on that in due course.

The Minister is right to stress the work of our hon. Friend the Minister for Patient Safety, Mental Health and Suicide Prevention, who cares passionately about this. I did say this in my earlier remarks, but I must stress that I know that when she met my constituents—the parents of Richard Wade—it cut to her heart. She has shown huge compassion, which is what has driven this. It is thanks to that that my hon. Friend has announced the news he has today.

My hon. Friend is absolutely right, and I will turn briefly to that in a second. I hope that this announcement today to commission an independent review into issues at the former North Essex partnership trust shows the strength of our commitment and my hon. Friend’s commitment in addressing the concerns he and his constituents have raised and in listening to and working with the families involved in these tragedies. We are committed to learning lessons at a national level to improve services across the whole mental health system, so that no other family experiences the same devastating loss as Richard’s family and the families of other patients who died at the former North Essex partnership trust.

In the few minutes remaining, let me say that my hon. Friend is absolutely right in what he says: my hon. Friend the Member for Mid Bedfordshire brings compassion, decency and determination to her dealings not just on this issue, but across the field of suicide prevention, mental health and patient safety. She is absolutely passionate about it. She has not only a background in medical services, but a genuine passion. It is her energy that is driving this forward and I have to say that it is a privilege to be a colleague of hers and to work alongside her in the role that I hold in the Department.

I conclude by saying once again that, of course, my thoughts and those of colleagues in this House will remain very much with Richard Wade’s family and all the families who have lost loved ones in these circumstances.

Question put and agreed to.

House adjourned.