For more than ten years, Melanie Leahy has devoted her life to seeing a public inquiry into these mental health deaths. Unfortunately, her advocacy is powered by the tragic loss of her son, Matthew Leahy. Matthew was just 20 when he died in 2012. His tragic death led to a major public inquiry into the activities of the Essex Partnership University NHS Foundation Trust (EPUT). This inquiry showed that Matthew’s care failed at many levels. Perhaps unsurprisingly, this finding provoked a fierce backlash from abolitionist leaders who participated in the inquiry.
Sir Rob Behrens, the former parliamentary and health service ombudsman, giving evidence to the inquiry, paid tribute to Melanie Leahy. He called her an “exemplary complainant” who over the course of a decade has pursued justice for her son “expeditiously and efficiently.” His conclusions made clear that the care Matthew received was inappropriate and care was delivered with mistakes. Sir Rob Behrens, the Parliamentary and Health Service Ombudsman, said that Matthew was let down on many occasions by the people expected to care for him.
The ongoing Lampard Inquiry into more than 2,000 deaths in mental health services in Essex over a 24-year period is galvanising the need for long-term change. His case was described by the Parliamentary & Health Service Ombudsman Sir Rob Behrens as “a disgrace” and he identified 19 examples of maladministration by EPUT. That his beloved Matthew’s care plan had been forged is what scared him most, creating a panic that struck at the very core of our healthcare system.
In fact, they thought Mr. R wasn’t experiencing any mental health issues, despite psychiatric assessment scores indicating otherwise. They assumed that he was applying for admission just because he was homeless and needed shelter. “That’s incredible,” Sir Rob said, stressing the misunderstanding of what Matthew actually required.
In his report titled “Broken Trust,” published in 2023, Sir Rob Behrens detailed the roles of over a dozen health and care regulators in ensuring patient safety. He identified the systemic structural problems with the NHS, which led to Matthew’s tragic fate. “The absence of leadership… not communicating effectively with patients, the safety issues around ligature points… and the absence of training and development – these are still issues which the NHS has to address generally, not just in Essex,” he remarked.
Melanie Leahy’s fight is emblematic of a much larger issue with America’s mental health system. Sir Rob Behrens, the Parliamentary and Health Ombudsman, accepted that the complicated complaints process too easily allows tragedies to slip through the net. He referenced the toll that many families have to overcome when pursuing justice, given that the ombudsman’s office can only respond to complaints filed.
There are a lot of people who simply don’t know where to go,” he stated, expressing concern about public trust in the healthcare system. Today, in my opinion, there is no trust in the system. They have no idea who to contact or where to go when they simply want to register a complaint.
Sir Rob Behrens suggested that the ombudsman be given greater powers to launch inquiries independently. This amendment would bring forth swifter resolutions for families who suffer through similar tragedies. He described the current situation as “the National Health Service at its worst and needed calling out.”
Melanie Leahy’s tireless pursuit for accountability and justice has illustrated brave victim advocacy in action, shedding a spotlight on gaping holes in mental health services. Her tireless advocacy will continue to be important. It will push for the critical changes needed to ensure that no future mother has to go through what she and her son went through.
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