Episode 1: Failing Matthew

Warning. This is a true crime podcast and is not suitable for all audiences. Please use discretion. This series details descriptions of suicide and sexual assault. Please take extra care while listening. An investigation into the deaths of over 2,000 people is now a public inquiry. They died whilst under the care of Essex Mental Health Services. Many in unexplained circumstances. Their loved ones died in a setting that was supposed to keep them safe. The same ligature point paid a role in multiple deaths. The HIV in his blood and urine. He had bruises above both ankles. On the 27th of October 2023, the UK government confirmed that a public inquiry would investigate the deaths of over 2,000 people with mental health issues. Those people were in the care of NHS trusts in Essex England. This inquiry is called the Lampard inquiry. It's being conducted by Baroness Lampard, who was previously appointed to investigate the abuse conducted by Jimmy Savile in NHS hospitals. This inquiry will investigate why over 2,000 lives were lost within Essex Mental Health Services or within three months of them being discharged from the hospitals. This podcast is an important but extremely harrowing listen. So, I want to place an extra warning here. There will be descriptions of alleged abuse, sexual assault, suicide and medical trauma. Over 10 episodes, you will hear from family members of those who have lost their lives. Whistleblowers, professionals involved in the case and those fighting for justice. We'll lay out the facts and this series will also give a voice to the thousands of family members. Desperately trying to understand why their loved one is no longer with them. Because many of these family members feel their loved ones died because of someone else's actions. I'm Naomi Channel and this is Investigating Essex, dying to be saved. [Music] I've written my introduction to this podcast over and over again. I know what I'm about to tell you and what you're about to hear and it's so incredibly tough. Before I start, I just want to tell you why I'm the one producing this podcast. Firstly, I was the first one to ask those involved to do one. If you haven't listened to any of my previous podcasts, I've been a TV producer for almost 20 years and I started podcasting in 2022. I have a weekly true crime podcast and I've produced five other true crime long-form series. Those were all about missing and murdered people and more investigative in nature. But the common thread through all the podcasts that I've produced is justice. This one is no different. I'm lucky to have a fairly large audience and when I discovered that this inquiry was investigating potential crimes that are practically on my doorstep. Once within services that I've personally had to use myself, I couldn't believe I didn't know more about it. In fact, I knew nothing. I also teach broadcast journalism and ethics at the oldest journalism school in the country. So I'm usually up to date with the news, especially local news. So why is this inquiry not getting significant coverage? Why has nobody outside of the families involved that I've spoken to heard that this was going on? Through the series, I'll try to find out why. This series is not an investigation. That investigation is in the hands of those working on the public inquiry. This is a series to give a voice to some of those who have been affected that are fighting day after day and desperately need to be heard. This is to give them more than a two-line quote that they would usually get within a newspaper or a local news broadcast. There's been a woman at the centre of this inquiry, a woman who lost her son whilst he was an inpatient at an Essex Mental Health facility. Her name is Melanie Leahy and her son's name was Matthew. Melanie does not believe that her son took his own life. Matthew died by hanging at the Linden Centre, which is a mental health facility in Essex. It's in the town of Cheltsford. And there are several very troubling and suspicious circumstances surrounding his death. Matthew died in November 2012 and for the last 12 years, Melanie has fought to be heard every single day. Melanie has been pivotal in getting this inquiry into fruition. I've spoken to many families whose loved ones' deaths are currently being investigated and every single one of them that I've spoken to have had the utmost respect for Melanie. Melanie is humble. I'm not quite sure she understands just how crucial she is, not just to the inquiry but to so many people. In this series, I'm going to go through all the facts. But first, I want you to hear Matthew's story because it was when I heard Matthew's story that I became utterly compelled by this investigation. You're going to hear Matthew's story from his mother because Matthew is not here to tell it himself. Here's Melanie. Melanie, when people ask you who you are or what you're doing, what do you tell them? I'd say just a mum and a story. The ones who know the truth are why and how her son died while he was in safe hands, supposedly. The journey to do that has become much, much more now. It's really to save lives of others and to stop it happening. Melanie kindly invited me into her home in Essex. It's beautiful. She's got a gorgeous dog who you might hear in the background from time to time. Around her home are photos of the sweetest looking little boy. As I scan around the room, that sweet boy morphs into a handsome, smiling young man. What struck me is how healthy and wide I'd he looked in all of the photos. He looked content. Melanie, did you know you were having a boy when you fell pregnant? Well, no, I went for a scan and it was a girl. Yeah. I ended up having a cesarean and I know when dad was presented with a baby boy, he'd go back and said, "No, why's a girl?" Two scans and both times, yeah, it was a girl. I wanted a boy so I was really, really happy. Going back to the beginning, as Matthew starts to develop from a baby into a toddler and then a preschool child, what was he like? Yeah. Rascal at times like most kids had an amazing upbringing, loved to swim, anything outdoors, academic. He just seemed to excel at maths, computer games, you name it. You know, just got any normal kid. You know, he had a lot of friends around. In fact, we had a big family living next door. I think there was seven kids. They always end up in my house. You know, so we always had a lot of kids around. the usual bits of hard-easter eggs and just go to carnivals and have fun. He was such a caring individual, highly sensitive, very caring about others. I've even since he's died, I've found little notes that he wrote. Somebody was poorly and he wanted him to get better. He was very kind in that respect. Matthew did well at school. He loved maths and he wanted to be an accountant. After he took his GCSEs, he applied to study at Southend Technical College, but he didn't get a place. And this is when Melanie said that she saw a change in his behaviour. She felt like he was starting to get down and possibly depressed. So Melanie suggested that he start his own business fixing computers. We set up his own computer repair business, so I don't know how he did it, but he used to strap people's towels to the back of his motorbike, bring them home repair, I'm afraid the memories, but he'd do it. I would go around the houses and help them out. One of Matthew's good friends also moved away around this time. And he was also having stomach pains. It was then that he turned to cannabis to help him cope. It starts to isolate. You could just tell he was smoking cannabis and I didn't understand when he's asking me for money and I'm getting upset because you're smoking this smoking cannabis. It said mum, it takes away the pain. He used to tell me a pain in his stomach and it took away the pain, but all I see is the red flag cannabis. He did go to the doctor and he was telling the doctor we bought him some kits from America, which you do a body cleanse, you know, not remove all the toxins and stuff like that, but he knew something was wrong. So he went to the doctor and he's asked him for help. And I see, you know, he's sectioned. That was in 2011 and you're probably wondering how a visit to the GP ended up with Matthew being sectioned. The GP sent out a community psychiatric nurse to visit Matthew. They're also known as CPNs and it was that nurse that felt like Matthew needed to be sectioned. I remember the situation exactly. There was a CPN in the house and Matthew was trying to explain that he had a problem in his stomach and he was saying so angry that he nobody would listen to him and he wanted to have scans down. He wanted checks to be done and nobody would do anything. And he said, "Well, if I've got to do it, if I've got to cut myself open so you can see there's something wrong without a recession." He was sent to the Peter Braff Unit in Clapton, which I'm living in Maldon at that time. It's a good hour and a half drive to get out there. So I'd go up there and I would spend the day there. I wouldn't just sit there for the hour. I'd spend the day until they keep me out. It was during one of these visits that Matthew told his mum that he knew there were rapes and sexual assaults happening on the ward. He used to tell me that there was rapes going on in the hospital when he would stay and make sure that they were right, stay awake and then sleep during the day and they could keep an arm him, you know. I can't even imagine what that was like having to hear that. We'll come back to that but what were your impressions of the hospital and the ward when you were there? I know you said you sat with him for days, for days. What did you take from it? What did you see or hear? He was horrendous. There'd be people screaming, being pinned down. Most were totally dragged out of their heads. Staff would sit watching TV. I remember saying, you know, if you've got any board games and they said, yeah, they're locked in the cupboard and I said, can you open the cupboard up there? No, I ain't got key. So there's nothing for anyone to do, sit for sit and talk and change smoke and I do remember walking in and this one girl says to me, she looked up, looked to Matthew as I walked in and said, oh my god, you've got a mum. I just thought, oh, probably because she didn't. He grew very close to this girl in the short time he was there. He said, it went really quiet. He said, what happened? He said, there was this member of staff, this young bloat that keeps boasting about he goes on holidays and he smokes dope all the rest of it. The member of staff. He really gave her a load of brief and he told her that she was this sat on the other. I won't repeat what he said to her but he said, she's gone in her room, she was really quiet. He said, I went round to look and she was hanging. She was hanging with her, she always carried her stuff in her rucksack. She got the string and she'd hung it around her light and Matthew got it down. He said, I've never seen anyone with black eyes mum and he said, I've really owed the abuse that the staff member closed to her. He said, I've handed my phone in to the office. He said, I've deleted it. He said, have I seen him kill him? I said, where is he? He said, he's given him leave. I said that he's stressed. He said, he's not stressed. He didn't even help. Melanie raised to the hospital. She wanted to see for herself what was going on. The girl who had tried to hang herself had been discharged. Matthew was transferred to the Linden Centre in Chelmsford just five days later. So now he ends off at the Linden Centre. Then the medicate in begins and he's given, I think, a whisperer down at that time. We were arguing that we wanted health checks done and some checks were done. You'd do a lot of push on, point of come back. Couldn't do it because the label wasn't put on the jar properly. Then another test to be done. Yeah, it's all come back okay. In retrospect, since he's there, I've looked at the files and it come back that he had a partial blockage in the right ventricle of his heart. So he shouldn't have been on any of those medications. It came back at the impossible celiac disease. He's bitten B12 with dangerously low. They had started giving him some B12, whatever that was. Vitamins, liquid drink and I remember that, that's liquid drink he was being given. And he said, "Mum, I've not bought my drink." He said, "I've not ordered any him." But documents say Matthew refused to drink it. No. Three weeks into his stay at the Linden Centre. The girl that he had helped save from the other hospital when she was found hanging came in as an inpatient and joined him at the Linden Centre. Because she's poorly still. So she ends up on the ward and he protects her and they become momentary close. And I think that's how it enabled him. He was in there for five months. And that's how he was able to get through that period of time. But in that period of time, I think we were about two weeks before discharge. He reports to me that he's been moved. And he was having leave at that time. So he asked me to take him to the police station, which I did. So we go to the front desk and they said, "What's your name?" And he said, "I'll only give my name." And the officer's not happy to deal with him about telling his name. So I'll take him after�, you've got to give your name. He said, "If I give my name, they're just going to say that I'm a mental health patient and I'm going to listen to me." So we go back to the desk and say, "Look, can you just examine him for any signs of rape? If there are signs, then we'll give her name and the situation can escalate from there." And they refused. So at that time, in Springfield, there was a walk in A&E. So I drove to the walk in A&E at Springfield and we waited and a doctor examined Matthew. And he had anutez and bruising. But I can't say it's rape, I can't say it's whatever, but it's documented. Anyway, he has to go back. He's got two weeks to be discharged. And I'll forever live with a girl. I said to him, "Matt, the way you've been treated just now." I said, "Just keep your head down, keep your mouth shut. They're not going to listen to you. Get discharged." I said, "Then he was frightened that if he did say anything, he'd be made to stay." And a section would be reinstated. So he comes out. And at that time, he was he was doing all right. He was on something like a regular depot injection of 25 milligrams whisperer down. He didn't like injections. I want it to come off them. He in a shared house knows and other lads and I'd go down and see him regular and he's doing good. I don't know, something's really, yeah. Well, you were doing good, what's happened? And he's tripling and he said, "No, I'm having terrible nightmares. I've got terrible pains in my back." And he was shuffling and he said, "You know, they've got my medication by 25 percent, aren't we?" So I've taken to the doctor, the GP. She has nothing to, nothing that tells her that Matthew's been section for the last five months. There's no paperwork from the hospital. She has no idea what he's been through. Nothing. But she can see that he's busy, he's got blood vision, he's shuffling, he's dribbling and he's overdosed, I'm respirating or whatever. Yeah, the drug is. So she advises that he come off it. Because what else can she do? You can't stay like that. So the next time the community nurse comes around with the social worker, we refuse. Respiradone is a medicine that helps with symptoms of some mental health conditions, such as schizophrenia and bipolar disorder. It's an anti-psychotic medicine. It doesn't cure the conditions, but it can help with some of the symptoms. If the dose is too much, it can cause serious side effects, such as feeling sleepy or tired, unusual body movements, problems standing and walking. They can feel dizzy, a heart will be fast, and they can even result in acesia. I think between that sort of April, May to the November, five times we see crisis, and he needed help. And at different times it was, oh, can you have him, can you call him for crisis before five o'clock? Because we can't access his files. Can you call him? We've got no beds available. We can't do this because we, you know, and then it gets to November and crisis again. This time, so brutal, the police came. They took him, they pushed him against the wall, and then they offered so I wanted to search him, and my fuse started refusing to be searched. He's now wrestled to the ground. He's fighting to get up. I watched the officer pin put his thumb into a pressure point in the back of his ear. He was screaming in agony, and I couldn't do anything as his mother rums stood there, just having to watch, because there was just so many police arriving. So now we've got leg restraints being put on him. He was tiny, couldn't breathe. They were pinning him down. He was just finding to the back of the police fan. And my fuse diaries said they drove me home, a silly speed frighten the life out of him. He was educated how to hang himself in a police cell, and he was sent back half past one in the morning, covered in bruises. He had no help whatsoever. No assessment was done on his mental health. There is something called the EO506 procedure. They're guidelines for custody mental health assessments. At the detainee reception, the custody sergeant has a responsibility to ensure that any detainee is fit to be detained in custody. This will commence from when the detainee is first brought in before they authorise their detention. It is then a continuing duty throughout the detainee's detention in custody, and prior to their release, that the custody sergeant must complete a risk assessment. He'd gone to his dad's, they just said it wasn't up in the morning. He was standing in the caravan out the back, he hadn't done the washing up. And there was some talk about a £5 that he owed his dad, and I think the pressure and think how much he was feeling. He just exploded. The police came and thing my fuse to do as a child is, if he got upset, he'd run away. I've had him sat on the top of the garage before when he was about eight. Just giving time and he'd come down, sorry mum, he'd get loosely overwhelmed. We did the same at the marina, and he got overwhelmed. He went to sat up in a container and it ends up with, I think it was nine police officers. Threats to taser him. Finally, he came down three hours later, absolutely petrified, and I said, yeah, we got in a crisis where you're taking me, and I said, "Lindon's in, only just a police don't take me there, it's not me anywhere but there, but they took him back to the Lyndon Centre." And, well, in seven days he was dead. In November 2012, Matthew Lee, he was sectioned and placed back into the care of the Lyndon Centre in Chelmsford. Melanie is now going to tell you what she believes happened to her only child. Another warning, this will be incredibly hard to listen to. He was in a very sad place at that time, and he needed help. And I was told, don't leave it a week, let him settle down, there'd be a review coming, we'll invite you to the review. So I never look to see him alive again. The medication was horrendous because he was given drugs that he's never been given before. He was taking the medication they've given him, and he was being compliant on every tablet they gave him because there was no way he was going to have an injection. And yet, the consideration of giving him injections was not considered. He was so fearful of that, and though that he died, they were planning, that was it, they were going to give him the depot injection. He was given lorazepam on the first night. A drug he's never had before. The medical records are incorrect in the amount he was given. One say, he's given this match, and other one say, he's given this match. And then he was put on to haloparadol. From what I've seen in the records, there was, I think it was day four, he called home to say he'd been drugged and raped. Now, at that time, the police were called, by the time the police got there, they said that they had no capacity, although no meant to pass the assessment from being numb. And he was slurred at speech. Well, I've got the police call seven years after, seven and a half years after the event, and he's totally going here. But by the time the police arrived, apparently he's slurred at speech, he's got no capacity. And the records show the amount of haloparadol that he was given just one after another. Haloparadol is a medicine that helps with mental conditions, such as confusion and aggression at the end of life, or anxiety and schizophrenia. Laraza Pam is also used to treat anxiety and sleeping conditions. If both of these drugs are used together, then the side effects can include dizziness, drowsiness, confusion, and difficulty concentrating. And it seems as though Matthew had several of those side effects. With Melanie's permission, I'm now going to play you the 999 call that Matthew made that afternoon in the Linden Centre. Hello, I'm here. This is our section of mental hospital. Right. And since being here, I've been right and the doctors refuse to acknowledge it, I've been right over the last two days, and I'm bleeding heavily, and the doctors refuse to believe me. The staff have been right to me. It's okay now. I can tell me where you are. Charles is in the Linden Centre. I'm in the centre. And what are you lying? Matthew meeting. Matthew? I'm in the centre. I'm in the centre. I'm in the centre. The centre? Yes. The centre? Yes. When is this happened? When is this right? Yes. And last night, before the opening of the hospital three days, it happened two and a three. Okay. Are they giving you a medical attention? I don't know. I just told the doctor that she says, she sees his surgery, she says, "I can't believe I made this use of this, I'm actually being called 247 observation, but this is when I woke up, right through the 247 observation. I'll just go take enough observation today, and I'll try to meet that con, because I'll tell them what happened. They're not there here, they're here. Hello? Right, who did it? I don't know, I think it was looking awesome. I think it must be the better. Hello? Hello, you need medical attention. Yes, yes. Right, so then I will talk a lot about medical attention. No, it's either she's in here in the same number. Melanie, what did Matthew tell you about the rapes? Obviously he was on so many different medications. And I know looking at the reports. They gave him some and then counteracted those with other drugs to stop things like muscles basamins. So he had a lot of drugs in his system. Did he have any more information? Or was his brain just so clouded from all the drugs that he'd been given? In the last two days, because he's been so medicated, he's just coming around. But it's the last two nights. Somebody's raped him. Melanie and Matthew's father had separated. And Matthew had called his father and told him that he'd been raped. It was then Matthew's father that called Melanie. On the day itself, so his dad calls me and said, "Matthew's just found me is in absolute total distress." The saying has been raped. So instantly, I get on the phone to the ward. I don't know what you're on about. He's in art class. What can you take the phone to? No. And we've got his phone in the office who can't call you at the moment. Come see him Friday. So then I called the early intervention psychosis team that had also been working with him. And I spoke to a lady there. She found the ward. She was told exactly the same thing. But Matthew was not enjoying an art class. Something much worse was happening. I got a call from the doctor at 115, I think it was around then. To say, Matthew's been found hanging. It doesn't look good. Oh, that's it. He'd been declared dead at 12.52. That's what it was. So the doctor already knew Matthew was dead. So instantly, I'm in the car. So when I had a drive in my dad drove me to Bumfield Hospital. And I think I was at the early stoves, old tin. And he passed me over at Mumpass. No, Mum was here. My partner passed me over at Travel Suite. And one of them, Tim ones, and he had an angel on the top. And I remember saying, "Don't worry, don't rush. It's okay. No fuse of the angels." And he had already died. And I knew. I knew. And then I arrived at the Lyndon Centre. And normally you go in and you run a downstairs. I was taken up to set a stairs. As I got to the top, I heard a female voice say, "Oh, she's here." And I was shunted into a room with some doctors. One on our note, to be mushroom no Jeep. He was the operations manager. And just some top bots. And they were questioning me about what I knew, what had happened. And all I'm saying is, "Where's my son? Where's my son?" And they kept me in that room for about 20 minutes before they would let me leave. And then I had to walk down to A&A. He was in A&A on a trolley. In a hospital down this east. So I went in to see him and instantly he just wanted to grab him and hold him. And I wasn't allowed to. No touching. He's a crime scene. He had bruises on his ankles. I never saw them because socks had been pulled up on his ankles. I could see a slight mark on his neck. But not conducive to hanging the way that was. It wasn't under his chin. He had no swelling of his face. No ponchoos, no pitchonilla, no bulbous eyes, no bulbous tongue. He was perfect laying there. And I ignored what the police officer said at one stage. And I leaned down and I kissed my son's forehead. And that stayed you fretting to arrest me. Melanie is asked what funeral director she's planning to use. She tells them that she's planning his 21st birthday. She thought her son was safe. Now so far you may be thinking that something awful has happened. One of the worst things a human can endure. Melanie's only child, her beautiful kind son, has taken his own life. But then the coroner's report comes back. There was some very concerning physical marks on Matthew's body. The post mortem observed four to five needle marks in his groin. And to this day there's been no explanation as to where they came from. The police said paramedics made them. That they used it for adrenaline and cooling fluid, which is often used during resuscitation. Atat Matthew's inquest, the paramedics said that they administered those via the elbow. Melanie tried to contact the ICU doctors to see if they were responsible for them. But they never replied. The post mortem also found minimal doses of GHB in Matthew's blood and his urine. Now you may recognise GHB as the date rate drug. It's a central nervous system to present. It can cause drowsiness and reduce heart rate. It was originally used as a type of anesthetic, but it made its way onto the party scene because it's harder to detect and can be slipped into someone's drink easily. A prescription form of it can be used to treat conditions such as narcolepsy. But Matthew had not been prescribed GHB by anyone. So why was it in his system? There is one important thing to note. The body can naturally produce GHB. But it would usually only be present for a few days after death. Matthew's post mortem was done five days after he died, though it's not impossible for traces to still be picked up after five days. Also, remember Matthew's 999 call? He said he'd been drugged and raped. When the police arrived to take his statement, Matthew was slaring an ingaherent, so they weren't able to take a statement from him. Was this down to the GHB or was this down to his medication? Of course, the lack of a care plan meant that this was such a great area. I think it was documented properly. He died shortly afterwards, so the police never returned to go and get his statement regarding his alleged rape. Essex police were involved in the investigation into Matthew's death. Melanie, can you tell us? Do you remember the first time you had any contact with Essex police after Matthew had died? I remember Essex police wanting to come and search where he'd been living. Looking for drugs, I found nothing. I bought the sniffer dog in. I found nothing there. He hadn't been doing any drugs whatsoever, and that's the first thing they wanted to put on him that he'd been doing drugs. No, he hadn't been doing any. And then there are discussions with me about the sexual assault, and I requested that they did a full sexual post-mortem. I was told that it wouldn't be done because it's expensive, it costs £3,000. So then I said I would pay for it myself. Then I was called back to say yes, they would do it. So I trusted that that would happen. Anyway, Matthew's belongings were delivered back in a complete mess, in the case that he'd taken to the hospital. And there was some money in there. So I was quite, you know, I just saw a list of you, because he didn't like the hospital food. And I remember he said it's all yellow. And I'd go in there and I'd say well look what's it in there. Oh yeah, and there'd be yellow potatoes, yellow cauliflower, yellow chips, yellow ice cream. You know, I asked Matthew, you're not wrong. It was just, you know, so he used to get takeaways all in, or crap food, I'd take him bags of crisps and drinks and pop, and you know, all sorts of stuff. He started taking it £100. And so I thought oh, this is the change from it. Anyway, I think it was day two, I can't remember. I went into the ward again, to see the staff again. Again, that was interviewed in question. But prior to the meeting, I sat and spoke to two patients. One in particular said, "Are you Matt's mum?" It was a nice lad. He said, "I've got a son. He's aged." He said, "He was like my son." He said, "We had nice chats." He says, "But he didn't eat very well." So I shared my trinos within the other night. And I said, "He didn't eat. I said he had money." Anyway, his £100 was found in the safe two weeks after he died. He hadn't given it to him. He hadn't eaten. given his card. So he had no means of buying any food. And although they said on the documents, he'd eaten well, eaten well, eaten well at Postmortem, there was nothing in his stomach but blood. He had no food in his stomach and yet he's meant to have it well. And especially that morning that he died. Something alerted me to the police and the sexual postmortem. I actually found the police and said to them, "Did you carry out that?" And they said, "No." All that time I thought they had and they didn't. They didn't do the full postmortem that they promised they were going to do. The inquest happened. A Matthew's death was not ruled a suicide. I'll let Melanie explain. Open narrative, which means that if more evidence comes forward, then the case can be re-opened because there was no proof that Matthew killed himself. There was no suicide. There was no talking about it. There was no proof whatsoever. Something untoward happened to Matthew and that's what I intend to find out. Whilst the inquest did not provide answers, it did provide more questions. At the inquest, Melanie learned that when her son was admitted to the Lyndon Centre, he had several lumps that were causing him pain in his genitals. When he died, he'd still not been seen by a doctor, despite telling staff that they were causing him a lot of pain. These turned out to be epidermalid cysts, and they caused so much pain if they go untreated. She also learnt that the full postmortem had not been done. They'd not examined his brain. Since Matthew's death was sudden and unexplained, this could have provided them with some answers. But there was further heartache to come for Melanie. She'd had a private funeral for Matthew, with just her and Matthew's father present. Samples of Matthew had been gathered during his postmortem, and the year after he died, something made Melanie ask the police if they still had those samples. She said the police told her that they had been destroyed. After she complained about this to the independent office of police conduct, they were suddenly rediscovered. She told me that parts of his heart, liver, eye, hair and nails were still with the police, and they were found in storage across four different locations, along with his boxer shorts and his socks. Melanie then had to arrange for them to be dropped off at the funeral home. She was offered the cremated remains from the rest of her son, but she felt she'd already said her "buys". This was just more pain that she had to deal with. And now, Melanie didn't feel she could trust Essex police. So she decided to take things into her own hands, and she started investigating her son's death. She asked the police if she could have the ligature that Matthew had used in his death. She told me she wanted it, so she could possibly get an independent advisor to look at it. The way it was tied, how it was used. These questions could help them get answers surrounding Matthew's death. She also wanted to see it, because it had been described differently in different reports. In one report, they said it was a green ligature. In one, they said it was blue. In another, they said it was a blanket. In another, they said it was a pillowcase. It was never photographed, so it could never be determined. The police told Melanie that the coroner had it. The coroner told her the police had it. The police finally admitted that they discovered that it had been accidentally destroyed. Whilst this was another blow for Melanie, she wasn't deterred, and she started to think about how else she could get answers. She wanted to speak to other families in her position. Other ones, whose loved ones, had died whilst they'd been in Essex mental health services. I was meeting with other patients, I'd become a detective, really. I thought the inquest slide, everyone does. The inquest will serve you the review of the answers you need. I had found a legal team, but they weren't really specialised in inpatient psychiatric deaths. I'm just saying I should have picked a different team. However, they did the best they could do, and they got the result we did. It wasn't enough. There was more questions. Then the work began. I ended up, I think, in the end with seven families, and all their documents and information, and we cross-reference staff that ran duty. I started attending inquest, going through old press reports, who died, who hadn't died. Then I found, oh, health and safety executive, let's try him, because if he's meant to have died on this particular thing, we had, if he's meant to have died hanging off the door, we've got records which show that they were meant to have been removed. Melanie spoke to the health and safety executive. He then agreed to take a look at the case. His name was Richard Judge, and he delegated it to Norman MacRitchie. But when Norman went to look in Matthew's patient file, it was empty. This was a huge red flag for Melanie and for the health and safety executive team. Melanie was now finally being taken seriously. Why was his file empty? When she goes to see Norman, she has crates full of documents relating to Matthew's death, and the health and safety executive team need to individually take each piece of paper and copy it for their own internal investigation. It takes them 15 hours. They bring her sandwiches whilst they copy every single sheet, and when they're done, Norman tells her not to expect anything for around 10 years. But shortly afterwards, Norman was replaced in his post. He went onto a different job, and the new health and safety executive said that they thought there'd been enough failings in Matthew's care to meet the criteria for corporate manslaughter, and the investigation was then transferred back to Essex Police. It was there that more deaths were added to their investigation. Other families came forward, and they thought their loved ones may have been the victim of corporate manslaughter as well. Essex Police were now facing an investigation with 125 deaths in Essex mental health services. But as the investigation went on, that number was whittled down. And after four and a half years, the police decided that there was not enough evidence to say that it was corporate manslaughter on any of those deaths. In a statement, Essex Police said the case for corporate manslaughter had not been met, and that it would not take any further action. This blow seriously impacted Melanie and the rest of the families who were waiting for answers. But whilst they were devastated, again, they were not deterred. Melanie continued to meet with officials, including people who ran the trust. She recalls an incident that really ignited the fire in her belly for this long and drawn out fight. I think what done me was I had a meeting with the CEO, Andrew Goldard, and his sidekeep, Chris Pavley, who was the chairman of the trust, and Natalie Hammond, who was Director of Nursing, I believe. Myself, Matthew's father and a friend. I was a bit harder at that time. I was able to hide my emotions so much, but he was suffering. And during that meeting, Andrew Goldard got up with the CEO, removed his tie, and walked over to the door and went on to demonstrate how Matthew must have had. But I think it was like so horrible that I did say to him, "I will take you down." Andrew, "I will take you down. I'm not having this." He turned around and he looked at me and he just said, "You do what you have to do, Mrs. Lee." I will never forget those words. At that stage, I was up for anything. Corporate manslaughter, any slaughter, someone just think, "No, this has to stop and someone has to be accountable." So, when someone says, "Don't upset my mother," I think it's a true saying, because he ignited a fire in my belly that is still burning. And I want to see that man it's going to be in the public inquiry now. I want to see him be answerable for why so many people were allowed to die under his watch. And so many we don't even know how they died." In 2020 a health ombudsman looked into Matthew Lee his death as well as another patient and they did come up with a report and it made national news. A damning report by the Health Ombudsman details a series of significant failings in the care and treatment of Matthew and Mr R, another young man who died at the unit. Matthew didn't have an allocated key worker or an up-to-date care plan. In fact, staff falsified it after his death. Matthew reported being raped while in the unit, but staff dismissed the allegation as delusional and didn't complete an incident form. He told nurses he was suicidal but they made no plan to manage the risk and left him in a room with a ligature point. The report also found he wasn't properly observed by staff, or given a full physical assessment and paperwork was lost. The trust which ran this unit where Matthew and Mr R died has now been taken over and today pledged to support the review. "Any death is a tragedy and the impact it has on the family we fully understand. As a new organisation we've brought in and made a number of changes to improve patient safety and to raise the quality of care." In June 2021, the trust was fined £1.5 million per serious failings after 11 patients died from the same ligature point, including Matthew Leahy. E putt had pled guilty to an offence under the Health and Safety at Work Act in a prosecution that was brought in by the Health and Safety Executive. Paul Scott, the Trust's CEO, said, "I'm fully committed to ensuring that every lesson is learned." Just over a year later, 27-year-old Sophie Alderman died by ligature, under E putt's Willow Ward at Rockford Hospital on the 19th of August 2022. The £1.5 million is not compensation for the victim's families. That money is then put back into the system and reinvested to the providers to help them address the underlying causes of the breaches that have taken place. Whilst this was a small positive step, there was still so much more that Melanie needed to know. After countless reports, internal investigations, and now this report, she still didn't know how or why her son died. So she kept on protesting. She wanted a public inquiry. Look at you guys. What an amazing tribute to everyone that's passed at the care of the state, under the care of the state. Look at how many of you are and fill this road with the spirit of all those that have passed because we're not alone today. The sun's been shining and the heavens have been singing for us. I felt the emotion listening to all the families talk before me and I felt their passion and we are fighting to keep loved ones. The next generation alive and safe when they are asking for care. Now I stand here today calling for a statutory public inquiry into Essex Mental Health Services. We are now 93 families and growing sadly because the children, elderly, middle-aged, are all being fouled and are continuing to die needlessly. Black wire, it doesn't matter. Young old, it doesn't matter. It's all of us now, it is touching all of us. It's like a cancer that is growing. We know that this is happening across our nation and people say why just Essex? It needs to be national. The thought for us is that it's too thin to go national. We are calling for Essex. We've been through Parliament. We've been to the Parliamentary Health Fund. There's an independent inquiry ongoing. That's what they gave us in Parliament. It has no statutory powers. We cannot bring in staff under oath. We need them in. We need, that's the only way we're going to see them in public. The answer is all for why this has been allowed to continue. Melanie never gave up and kept fighting and in June 2023 she got the news that she wanted. An inquiry looking into mental health death in Essex from 2000 to 2020 say 1500 people could be affected but they've only heard from a handful of former patients and their families. The chair is calling for more people to come forward so they get a full picture of what's going on. More and more families started to come forward and at the time of the publication of this podcast there were around 2000 people and their families that could have been affected. I want to tell you a bit more about being inquiry now. I'm going to quote straight from them so you can grasp the magnitude of it. The duration of time now being investigated has been amended. To the 1st of January 2000 to the 31st of December 2023. Regarding the locations the investigations will focus on the trusts which provide mental health in patient care in Essex. These include the Essex Partnership University Foundation known as EPIT and the North East London Foundation, the NELFT and their predecessor organizations were relevant which provided care in Essex during this time period. The inquiry's definition of inpatient death is interpreted as those who died on an NHS mental health in patient units in receipt of NHS funded inpatient care within the independent sector, whether detained under section or informally. The inquiry will also include people who died whilst on leave from any of those units including supervised leave. Those who died whilst absent without leave or having absconded from any of the above units including transfer to a physical health setting or to an out of area mental health service. And those who died during a transfer from any of those units within three months. And also those who died whilst waiting for a bed within three months of assessment at an inpatient facility where a decision was made not to admit someone as an inpatient and then they died within three months. And those who also died within three months of being discharged from one of these units. This is going to be a huge undertaking but it needs to happen during this inquiry the chair will hear from families including Melanie and Crucially from former inpatient and their families and so will we. Next time we'll hear from another mother who lost her son whilst he was in the care of Essex Mental Health Services. He ended up going to the Lindon Centre voluntary and our God just that's where it all went so wrong so so wrong. I believe there's all beings who shouldn't have seen and then members of staff didn't want him leaving that hospital. Episode two is out now and available to listen to. I'm Naomi Channel and this is Investigating Essex dying to be saved. [Music]