The investigation of deaths of mental health inpatients in Essex between 2000 and 2023 this week heard evidence from Sir Rob Behrens, who was parliamentary and health service ombudsman from 2017 to 2024.

An ombudsman report found there had been a series of significant failings in the care and treatment of two vulnerable young men who died shortly after being admitted to North Essex Partnership University NHS Foundation Trust before it was merged with South Essex Partnership Trust to become Essex Partnership University NHS Foundation Trust.

Sir Rob said: ‘There was, in summary, a near complete failure of the leadership of this trust certainly before it was merged.'

The former ombudsman praised Melanie Leahy the mother of 20-year-old Matthew Leahy who died in 2012.

He said: ‘She was an exemplary complainant. She had her own views, she was very well prepared for every meeting, she was courteous but assertive, she knew what she wanted out of an investigation and, given the tragedy that she had been through, it was a remarkable contribution to public life that she performed over many years.'

Sir Rob said the way some doctors spoke about another patient, identified as Mr R, who died in 2008 had been ‘staggering' and ‘patronising'.

He said: ‘In their view, he didn't have mental health problems at all and that he had been admitted because he wanted somewhere to live because he was homeless.'

The former ombudsman said it was possible some incidents had fallen ‘through the gaps between the various bodies' and not been investigated.

‘I have no confidence that people trust the system because they don't know where to go when they want to make a complaint,' he added.

Sir Rob said Essex was not ‘exceptional', adding: ‘My sense is that all the issues which have  come out of the cases which I looked at you can see in other places, not necessarily in exactly the same way, but, just thinking about it, the absence of leadership, the failure to use the duty of candour, not communicating effectively with patients, the safety  issues around ligature points, the failure of the serious incident review and the absence of training and development. These are still issues which the NHS has to address general.'

Paul Scott, chief executive of Essex Partnership University NHS Foundation Trust, said ‘As the Inquiry progresses there will be many accounts of people who were much loved and missed over the past 24 years and I want to say how sorry I am for their loss.

‘All of us across healthcare have a responsibility to work together to improve care and treatment for all and to build on the improvements that have already been made over the last 24 years.'