butlincat's blog - a blog...a seeker of the truth

“As long as justice is postponed we always stand on the verge of these darker nights of social disruption...so said Martin Luther King Jr. in a speech on March 14, 1968, just three weeks before he was assassinated.

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......Namaste.....John Graham - butlincat

Jai guru deva om जय गुरुदेव ॐ ... peace!

frank zappa: “The illusion of freedom will continue as long as it’s profitable to continue the illusion. At the point where the illusion becomes too expensive to maintain, they will just take down the scenery, they will pull back the curtains, they will move the tables and chairs out of the way and you will see the brick wall at the back of the theater.”

Tuesday, 26 January 2021

UPDATED: SHOCKING UK AUTHORITIES COVERUPS OVER DEATHS: "Keep fighting even when it's an uphill battle keep going" + "Families United For A Statutory Public Enquiry" VIDEO - PETITION - 26 Jan. 2021

UPDATE 17 Feb. 2021:  #TracyBlackwell #COVERUP 

Keep fighting even when it's an uphill battle keep going.. 

Families United For A Statutory Public Enquiry Live Chat with 3 of the 62 families @ 9pm

  Tracy:- of the family blackwell Streamed live on 24 Jan 2021


PLEASE SIGN THE PETITION - see updateshttps://www.change.org/p/uk-government-please-call-a-statutory-public-inquiry-into-essex-mental-health-services?original_footer_petition_id=&grid_position=&pt=




Instead, Nadine Dorries is organising a very limited and unhelpful non-statutory inquiry which won’t even compel witnesses to testify.

We can’t break the cycle of premature MH death with this.

We need an opportunity to break the back of causation and change direction. This is it...

Lend us your support by signing and sharing the petition below.”

https://www.change.org/p/nadine-dorries-statutory-public-inquiry-into-essex-mental-health-services — with Julia Caro and Melanie Leahy.

Nine deaths between January and March this year are currently being investigated by mental health trust, the Essex Partnership University NHS Foundation Trust (EPUT). 
EPUT was formed in 2017 when North Essex and South Essex Partnership Trusts merged.
The Trust says improving patient safety is a 'top priority' and it has spent £2.4 million to date on improvements.
Families of patients who died whilst under the Trusts care over the past two decades are now uniting in calls for a public investigation.

Melanie Leahy has been actively campaigning for justice for her son Matthew ever since he was found dead at the Linden Centre in 2012. 

20 year old Matthew had been there seven days.

Since 2001 seven patients, including Matthew and Richard, have died at the Linden Centre, in similar circumstances. 

Earlier this year the Parliamentary and Health Ombudsman released his full report into Matthew's death, finding Matthew suffered multiple failings in his care from North Essex Partnership Trust.

Including having his care plan at the Linden Centre falsified by staff after his death.

After he was admitted he experienced 19 different examples of service failure and maladministration in his care, and that is a shocking history which needs to be addressed to make sure it never happens again.

Rob Behrens, Parliamentary and Health Ombudsman, speaking to ITV News in January 2020
Responding to the report at the time, EPUT apologised to Matthew’s family and said: “The care provided by the former NEP fell well below acceptable standards..we have carried out its recommendations in full to address the service failings.”

For Melanie it's not enough.

Melanie Leahy has been campaigning for justice for her son Matthew for eight years. 

I still don't know what happened to Matthew. All investigations to date have failed to deliver the truth. What needs to happen is a straight down the line statutory public inquiry and bring the staff in and interview them. All these years, eight years and not one member of staff has been interviewed under oath.

Melanie Leahy, Matthew's mother
In November 2019 Melanie took her fight to Downing Street, petitioning for a Statutory public inquiry into Matthew’s death.

Her petition received  105,580 signatures needed to be considered for a parliamentary debate, but, Health Minister Nadine Dorries MP said a public inquiry into just Matthew’s death would be unlikely: “public inquiries do not happen when it has been individual cases, they tend to be when it’s a systemic problem or multiple numbers, in this case a public inquiry is not an appropriate response.”

Now, Melanie’s pushing for a Statutory public inquiry, not just into her son’s death, and not just into the North Essex Trust that failed him, but into deaths of psychiatric patients under the care of all mental health services in Essex; the EPUT as it is now and also the former South Essex Partnership Trust . 

Bereaved families are uniting in their call for a Statutory public inquiry into the deaths of mental health patients in Essex. 

Robert and Linda Wade have joined the campaign for this widened and deeper reaching Statutory public inquiry, alongside 61 other families. 

Families who feel their loved ones were taken into places of safety that weren’t safe or who were left in the community unsupported and families who feel lessons haven’t been learned from their losses. 

The families of Valerie Dimoglou, Ben Morris and Glenn Holmes all feel their loved ones were failed by Essex mental health services.

Sofia Dimoglou lost her mum Valerie Dimoglou in 2015:

"A Statutory public inquiry would mean that we at least live in a society where someone with authority cares about the lives of those affected by mental health issues - young, old, everyone. Maybe it could really herald a change in Essex and across the country."

Lisa Morris lost her son Ben Morris in 2008:

"A Statutory public inquiry is my last hope of ever getting the truth surrounding Ben’s death. How many more have to die? When will it ever end if there is no public inquiry now?"

Amanda Cook lost her brother Glenn Holmes in 2012:

"For me, a Statutory public inquiry will help to protect people in the future who suffer with mental health conditions. They deserve the help that my brother did not get but so desperately wanted."

The campaign is also now being backed by a London law firm and  Melanie is calling on other families in the county who believe their loved ones were failed to join them.

I didn't want to see myself in this position, I want to be sat here with my boy seeing him grow up, but I'm not alone. I'm urging those families that have lost loved ones, anywhere in Essex, yes get involved, please, we have strength in numbers, don't let their deaths be in vain.


Ongoing investigations

The Trust says at its board meeting last month it reported it was investigating nine serious incidents relating to the deaths of mental health patients from January to March this year. 

In July it also began an internal investigation into the death of Southend teenager Chris Nota. 

Meanwhile, the Health and Safety Executive is currently investigating how the former NEP Trust managed mental health environments. 

Its investigation covers October 2004 to March 2015, when the Care Quality Commission became the lead regulator. 

HSE does not address care issues, only the management of the physical areas of the wards. 

It says there are several cases, which are relevant to the investigation in demonstrating risk, including Matthew Leahy’s death.

What is a `statutory public inquiry?

A Statutory public inquiry is a major investigation called by a government Minister. It  is run independently.

A recent well known public inquiry was The Grenfell Tower inquiry following a fatal fire in a London block of flats in 2017. 

Under the 2005 Inquiries Act, an inquiry may be held when it appears to a Minister that ‘particular events have caused, or are capable of causing, public concern.’ 

Inquiries are major investigations that can compel testimony and the release of evidence. 

The primary purpose of a statutory public inquiry is considered to be preventing recurrence of anything similar to what it is investigating. 

While inquiries may address who is to blame, it has no power to determine any person’s civil or criminal liability.  


For nigh on 8 years since my son died within the care of Essex Mental Health Services I have uncovered a ring of deceit and death due to the way the Trust has conducted its business.

Multiple unchecked deaths have occurred. Multiple patients and families failed by a system that has killed rather than helped and learnt nothing on the way. 

Essex Police, the Clinical Commissioning Boards, the Care Quality Commission, the Health and Safety Executive, the Trust and now the government all complicit in covering up multiple failings that have happened and continue to happen year in and year out.

we have been campaigning for a Statutory Public Inquiry. The government has today announced a non-statutory inquiry.
this will serve only to coverup and we refute it totally.

Essex families want the Truth. We will fight until we get it.



Statutory Public Inquiry into Essex Mental Health Services.

In Melanie’s own words....

I write these words not just to represent my son, but to represent the multitude of lives that have been affected by the inadequate care offered by mental health services across our nation.

I am mum to Matthew James Leahy, born December 1991.

He was a beautiful soul. He understood compassion and he cared for others. He was generous, he was kind, he was smart. He was funny and in his younger years he wanted to be a comedian. He was quite shy in large groups, and was a loyal friend. He was never one to encourage a fight but he would stand up for himself and the ones he loved. And Iʼm proud to say my son was honest, not a liar, not like some Iʼve come across on this journey.

He loved the outdoors, loved anything water sports related and was a fantastic skier.
Having left Grammar school, where he excelled in mathematics and computer science, he set up his own computer business, travelling between clients on his motorbike and was doing really well.
He had a natural talent for swimming. He actually saved two ladies from drowning and when 18 he became a qualified life guard.
Aged 19 Matthew was having trouble sleeping and complaining of pains in his stomach and having stomach cramps. He was also hallucinating.

When Matthew became poorly we turned to so called professionals for help. To help us understand what was happening with our son. He was sectioned for care and treatment. This sectioning and the failings in care at that time, although noted briefly in the inquest verdict, have never been investigated.

After Matthews death medical records show that the first psychiatrist involved in his care picked up a B12 and folate deficiency and possible celiac disease, combined with a thyroid issue. However, these discoveries were never addressed, as a new psychiatrist took over Matthews care and put him straight on anti-psychotic medication. Any further physical checks were minimal.

7th November 2012, Matthew was placed under section 3 of the mental health Act and admitted to the Linden Centre, in Chelmsford, Essex.
By 15th November, some seven days in the, ʻcare of the state,ʼ my son was dead.

The last days of his life in a place he called, ʻHell.ʼ And I now believe it truly was, ʻhell on earthʼ.

Alone, malnourished, over medicated, scared, bleeding, bruised, reportedly raped, injected multiple times, ignored, and frightened.

No records of any staff in those last seven days of his life, offering him any comfort. I had been advised not to visit and to give him time to settle on the ward. I will live with the guilt, for the rest of my life, that I listened to so called professionals and I was not there when my son needed me the most.

An inquest into my sonsʼ death was held in January 2015.

An Open Narrative verdict was reached which concluded that my son:-

ʻMatthew James Leahy was subject to a series of multiple failings and missed opportunities over a prolonged period of time by those entrusted with his care. The jury found that relevant policies and procedures were not adhered to, impacting on Matthewʼs overall care and wellbeing leading up to his death.ʼ

How the inquest concluded I will never know.
Staff were not interviewed by police after Matthewʼs death.

An internal investigation was carried out, which the Parliamentary and Health Service Ombudsman has deemed flawed and not fit for purpose. This flawed investigation formed the basis of every investigation actioned after Matthews death.

The ligature was destroyed, the defribulator was destroyed. Door logs were not downloaded. CCTV was hidden for over 7 plus years and parts of it either not retained or deleted. So, so many more issues exist.

I have not been able to determine or control any of this. Investigations, reviews, reports, etc. All processes that have happened around me, with me being entitled to some information and some explanation, but little voice, little influence, and little power.

I did think that the system would be open and honest. Would explain what went wrong. Hold to account those responsible for any failings, and afford justice for failing my most precious son. However, I have discovered a deeply troubling mismatch between what I expected and what I found. In any other walk of life if there had been failings, heads would roll. This has never happened, despite criminal offences being proved.

If the tragedy of losing Matthew hasnʼt been bad enough, to not know the full circumstances that led to his death, ʻwhilst in the care of the stateʼ, is unforgivable. I still do not have full disclosure and have never seen internal statements. ʻDuty of Candourʼ went out the window the moment Matthew died.

It came to light after Matthew died, that paperwork had been falsified, backdated, and slipped into his files. It took me four plus years to finally persuade Essex Police to register this falsification of mental health documents as a crime. I thought, ʻat last they are listening to meʼ. Then the
bomb dropped. ʻWe wonʼt be prosecuting as its not in the public interestʼ.

The Trust had failed to take steps to protect patients in their care. The question remains why no individual has been held to account and why some staff involved in failing my son and other patients, have actually been promoted to high ranking positions in the NHS?

The Coroner called for a Public Inquiry after the inquest in 2015. There have also been multiple calls from various MPs in the last five years. The Parliamentary and Health Service Ombudsman went on national television after, ʻThe Missed Opportunities Reportʼ, was published. To say that if he
had had the power to, he would call a Public Inquiry.

In October last year, the Public Administration and Constitutional Affairs Committee held an evidence session on the Ombudsman Report into the failed care of Matthew and Ben Morris. ( Ben died in the Linden Centre in
2008 aged 20 yrs).

During the session, The Minister for Patient Safety, Mental Health and Suicide Prevention (Nadine Dorries) explained, ʻthat Public Inquiries do not happen for individual cases.
In this case, a Public Inquiry is not an appropriate response because we are talking about two casesʼ.

I have now been joined in this fight calling for a Statutory Public Inquiry into Essex Mental Health Services by multiple bereaved and failed families.
(62 families and growing)
How multiple deaths can have gone on, unchallenged for so many years and so many people in official positions, not involved with this scandal, have entrapped themselves by collaboration the moment they came across
it, has baffled me.

How the system did not prevent these deaths or at the very least detect the failings/changes needed, earlier. Iʼm sure is a question in many failed families minds, not just mine.

Where is the Governmentʼs anger?

Its thirst for Truth and Justice?

Its commitment to getting answers and ensuring it never happens again?

Many families are losing loved ones while under the care of state mental health system. Whether that be due to mental illness, additional vulnerabilities such as autistic and/or learning disabled individuals , those misdiagnosed, or dementia…it does not discriminate.

The government is now officially ʻon notice ofʼ-

Gross and systemic Neglect (resulting in multiple avoidable deaths
Physical, sexual, and emotional abuse and exploitation of the
vulnerable ‒ most of them young, historical and sadly, ongoing.
The right people in Government need to understand the full extent of the Essex Trusts Failures and I have every faith that once the Government commits to a Full Statutory Public Inquiry into Essex Mental Health, the fundamental truth of what and still is going wrong, will be revealed.

Through that knowledge I hope justice and accountability are afforded and that necessary change is made for others, who like I and many others did, look to services when they need safe, compassionate care for their loved ones.

I offered the Government Matthews sad death to be catalyst of learning and change months ago. Please call a Statutory Public Inquiry into Essex Mental Health Services….without further delay.
Make the changes in Essex and send the learning across the country.
I hope then that I can start to grieve the loss of my son and Matthew, will be able to then, rest in peace.