Missed opportunities is our report on the Ombudsman’s investigations into the deaths of two vulnerable young men. We found a series of significant failings in their mental health care and treatment.
Both of their families suffer the ongoing injustice of knowing that their sons did not receive the standard of care they should have done. This has has caused them unimaginable distress.
We are publishing the report and our recommendations to alert parliament to systemic problems in care and treatment of patients with acute mental health problems at former North Essex Partnership University NHS Foundation Trust.
NHS Improvement has agreed to establish a review in line with our recommendations and will share any learning it identifies across the NHS as needed.
The North Essex Partnership University NHS Foundation Trust (now merged into the Essex Partnership University NHS Foundation Trust) has accepted the recommendations. The Trust has committed to continuing to work with us to put things right.
It is important the NHS understands why this happened and what lessons can be learned to prevent it happening again.
We also published the final investigation report into one of the young men, Matthew Leahy, in January 2020.
This is to inform the review that NHS England and NHS Improvement will be carrying out into what happened at North Essex Partnership University NHS Trust.
You can download this report and Rob Behrens' letter about the review to the Public Administration and Constitutional Affairs Committee (PACAC) below.