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What is a Westminster Hall debate? Westminster Hall debates give Members of Parliament (MPs) an opportunity to raise local or national issues and receive a response from a government minister. Any MP can take part in a Westminster Hall debate. Essex Mental Health Independent Inquiry Vicky Ford MP opened this debate by raising concerns about the Essex Mental Health Independent Inquiry. This centred on a recent open letter from the inquiry's Chair, Dr Geraldine Strathdee, who stated that as a non-statutory inquiry she felt they would be unable to fulfil their terms of reference, due to extremely low engagement from staff at Essex Partnership University NHS Foundation Trust. She had highlighted that, of the 14,000 members of staff whom the inquiry had written to, only 11 had agreed to give evidence. In the debate it was noted that Vicky Ford MP, Sir James Duddridge MP, Priti Patel MP and Sir John Whittingdale MP were now all calling for the Essex Mental Health Independent Inquiry to be converted into a full statutory inquiry, which will compel witnesses to give evidence, to ensure full transparency and greater public scrutiny of its progress. This debate was responded to on behalf of the Government by Neil O’Brien MP, Minister for Primary Care and Public Health. He noted that the Secretary of State for Health and Social Care had recently met with Paul Scott, Chief Executive of Essex Partnership University NHS Foundation Trust, to ask about the actions the Trust is taking to encourage staff engagement with the inquiry and to seek assurance that the Trust will provide all the evidence and information requested by the inquiry. Regarding the potential of converting this into a statutory inquiry, he stated that: “Our view is that a non-statutory inquiry, if it is possible, remains the most effective way to get to the truth of what happens. It is quicker, and potentially involves not having to drag clinicians through the public processes of a statutory inquiry. When my right hon. Friend the Member for Witham was Home Secretary, she used the non-statutory process to protect those who did not want to be named and dragged through a statutory process. It is faster and more flexible, which is why it was chosen in the first place. Although statutory inquiries can compel witnesses to give evidence under oath, that does not necessarily mean that it will be easier to obtain the evidence we want. However, all that turns on people co-operating with a non-statutory inquiry, and we now need to see a quantum leap in the level of co-operation. We will not hesitate to move to a statutory inquiry if we do not see a dramatic increase in the level of co-operation. Given how long this has gone on, we cannot wait for a long period for a transformation in the level of engagement. While the approach remains non-statutory for now, we will not hesitate to change that approach if we do not see the change we need rapidly.”

The coroner raised the following matters of concern: Jeesal Cawston Park (JCP) Jeesal Akman Care Corporation was the care provider for JCP and closed in 2021. However, Jeesal Holdings Ltd, Jeesal Residential Care Services Ltd (JRCSL) and possibly other linked companies with the same directors, continue to provide residential care to persons with mental health illness, learning disabilities, complex needs and physical disability. The concerns raised at the inquest could apply to residential care offered by these companies and unless such concerns are addressed there is a risk that future deaths may occur. It is not known if the directors of these companies are directors of other companies providing care for persons with learning and other disabilities. CCTV was shown at the inquest which revealed Ben King had been assaulted in the hours prior to his death and also that 1 to 1 observation was not carried out in accordance with the Observations Policy. CCTV is a reliable means of ensuring that staff comply with Policies and residents are treated with dignity. CCTV is not available in many if not all of the residential homes owned by JHL and JRCSL. Basic dietary advice and guidance provided was not followed by staff. The use of the Dietician in training of staff was reduced in 2017 from one day’s training to an hour’s power point presentation. Important records were not completed by staff, eg Food intake, Exercise, Weight and vital observations. Evidence was heard that exercise was not regularly offered to Ben King and when the Sports Instructor was absent for lengthy periods of time, there was no replacement Multi-Disciplinary Team (MDT) Meetings were not held every 4 to 6 weeks as required. At MDT meetings which did take place, out of date weight measurements were recorded and relied upon for Ben. His increasing weight gain was not discussed at these meetings and weight loss was not set as a desirable or essential goal. JCP used the Pandora software system, (company Directors for Pandora are the same as for JHL and JRCSL) which is still used at the residential homes owned by JHL and JRCSL. Concerns were raised at the inquest in respect of this software system in that not all policies and documents were available to staff on the IPads provided, some of the documents were unwieldy and difficult to read (for example, Personal Healthcare Plan), the Dietician recommended use of paper records in respect of Food and Fluid intake as these would be more accessible to staff and encourage the documents to be completed or in the alternative providing for the records on Ipads to be more easy to access and complete. The internal investigation carried out following Mr Ben King’s death did not capture the concerns raised at inquest. Evidence was heard that no substantive changes have been made at the residential homes owned by JHL and JRCSL following the death of Ben King and the closure of JCP to deal with these concerns. Norfolk and Norwich University Hospital (NNUH) Guidance was sought by Emergency Department (ED) when Ben King attended on 10 July 2020 from a Respiratory Consultant, who was not made aware that Ben King had attended some 6 hours earlier with the same symptoms. The Respiratory on call consultant was not contacted when Mr King returned to NNUH two days later on the 12 July 2020 with the same symptoms. At the time of Ben King’s attendance at NNUH, Ben King was under the Respiratory Team and had been seen a few days earlier, on 3 July 2020. The Respiratory Team was not made aware of Ben King’s attendances at ED on 9, 10 or 12 July 2020 with respiratory problems. Advice given on discharge appears to be unclear and contradictory. The expert Respiratory Consultant referred to the advice as being “inadequate, unclear and inaccurate” On the Discharge Form provided on 9 July 2020 it is noted “Plan – home as Ben is back to normal, self, red flags and safety netting covered, to return in the event of any difficulty.” On discharge from ED on 10 July 2020 (second occasion) the hospital record states that Ben King is to return home, encouraged to lose weight, fluids are to be encouraged and “with no need to monitor his sats unless clinically unwell with sats in 60s%”. Not all of this information was included in the Discharge Form on 10 July 2020: The Discharge Form provided under “Other” - “seen by respiratory team, they are happy to send him home, they have clerked their advice on the paper. CPAP and O2” On 12 July 2020 the Discharge Plan provided “Home”. The advice from the Respiratory Consultant seen on 3 July 2020 was for CPAP to stop. Evidence was heard from the Care staff at JCP that they were unclear as to what the plan was with regard to Ben and specifically as to when Ben was to be returned to Hospital. One of the Doctors at JCP contacted the ED, NNUH to try to ascertain what the advice was and was unable to get any substantive response. Email contact was made with the Respiratory Team but no response was received until after Ben King’s death on 28 July 2020. The section headed “Drug History” was not completed on the Discharge Form on Ben King’s attendances on 9 or 12 July 2020. On 10 July, it states “nil significant”. This is despite Ben King being prescribed Promethazine, a sedative medication, affecting the respiratory system. Evidence was heard that not all prescribed medications could be expected to be included in “the small space” provided. That this is a medication where consideration would have been given to a risk/benefit analysis but there was no evidence of any such analysis. Regulation 28 evidence was that not all medication can be listed; only “pertinent” medication. Promethazine would appear to be such a medication. Arterial and venous blood gas samples were taken from Ben King on his attendances on 9 and 10 July 2020, which the Respiratory Consultant said in evidence were incomparable (although this was not the evidence of the Expert Respiratory Consultant). No blood gas samples were taken on the 12 July 2020. A copy of this report was sent to: The Chief Coroner Clinical Commissioning Group Norfolk Safeguarding Adults Review Group Care Quality Commission Department of Health Healthcare Safety Investigation Branch (HSIB) Healthwatch - Norfolk

Yvonne had experienced mental health problems since childhood and was considered originally to have a personality disorder. She was treated by mental health services for many years and had several inpatient admissions, some of which were compulsory. After a period of self-neglect and refused admission, Yvonne was finally detained under the Mental Health Act on 27 January 2020 at Park House Psychiatric unit, Manchester. On admission she was found to be significantly malodorous and have several long-standing serious deep infected ulcers. She had to be transferred to the acute hospital for assessment and treatment where her condition gradually improved and she was given prophylactic venous thromboembolism (VTE) medication until she was medically fit enough to be discharged back to the psychiatric unit on 12 February 2020. When she was readmitted, despite discharge information from the acute hospital stating that she had been treated with VTE prophylaxis and despite Yvonne fulfilling several trigger criteria, a VTE risk assessment was not undertaken in accordance with the detaining authorities’ policy. There was a failure to monitor her condition and make appropriate records or an action and management plan and she did not have further mental capacity assessments. On 19 February 2020 she was again detained and on the morning of 23 February 2020, she had a cardiorespiratory arrest and was resuscitated for a brief period of time before being taken to the emergency department of North Manchester General Hospital. Further attempts at resuscitation proved unsuccessful and she was pronounced dead due to a pulmonary thromboembolism. The Greater Manchester Mental Health NHS Foundation Trust (GMMH) serious incident investigation failed to establish: whether the responsible clinician, junior doctors or nursing staff were aware of the trusts VTE policy and if not, why not. if they were aware of it, why was it not complied with. whether there was an awareness and compliance with the policy Trust wide. It also failed to identify, acknowledge or be aware of the death of a patient in 2016 from a VTE at Park House unit. In their report, the Coroner raised the following matters of concern: There was a lack of appropriate safeguarding review, Senior clinical oversight as well as necessary MDT meetings and actions to be completed. It did not appear that all permanent or locum clinical and nursing staff Trust-wide were aware of the VTE policy and how it should be implemented including initial assessments and reassessments of the risks as well as consequent medical management. There was no regular audit of compliance with the VTE policy. There was no training programme to ensure familiarity and compliance. A copy of the report was sent to the Chief Coroner.

In this statement the Minister sets out that the rapid review will: Focus on data and evidence currently available to healthcare services, including information provided by patients and families. Consider how this data and evidence can be used more effectively to identify patient safety risks and failures in care. Be chaired by Dr Geraldine Strathdee, who is also the Chair of the Essex Mental Health Independent Inquiry. The review will be separate from, but complementary to, the Essex Inquiry.