Missed opportunities: What lessons can be learned from failings at the North Essex Partnership University NHS Foundation Trust


This report highlights two cases which, although four years apart, when taken alongside the wider timeline we have developed show serious failings in the North Essex Partnership University NHS Foundation Trust (NEP) over a period of more than a decade. 

In each case a young man, first Mr R and then Mr Matthew Leahy, was admitted to the Linden Centre in Chelmsford, part of the NEP at the time. Within a short time of their admission, both tragically died.

We found a series of significant failings in both cases. In Matthew’s, these were compounded by an insufficient Serious Incident Investigation.

Based on the timeline we have established and related evidence such as the CQC’s inspection reports, the learning from these incidents does not appear to have prevented mistakes from reoccurring. It is this broader picture that has led to us producing this report. 

The timeline in the next chapter highlights a range of additional evidence that should have acted as a warning signal to the Trust’s leadership that there were serious failings that needed to be addressed. These are not issues that we have looked at through our own investigations, which are limited by the scope of the individual complaints we receive. 

However, we believe that in an organisation committed to learning and improvement, the evidence from these cases should have prompted immediate action led from the very top of the Trust with senior accountability for delivering and evidencing improvement. Instead, it appears there was a systemic failure to tackle repeated and critical failings over an unacceptable period of time.

An example of the wider evidence that is available but that sits outside the scope of our investigations can be seen in the May 2017 response to the review of an Freedom of Information (FOI) request dating back to September 2016 for the number of attempted suicides at the Linden Centre since 2006.

The response to this sets out that, ‘A review of all attempted suicides that were transferred to A&E would require a manual trawl of records and the cost of compliance would exceed the appropriate limits. The Trust is therefore applying section 12 exemption to this part of your request.’

Given the failures of treatment that had been highlighted at the Linden Centre and more widely across the Trust, it is surprising that the NEP’s leadership team had not requested that such information was recorded and made available to it. This would have given better visibility about what incidents were taking place and whether mistakes were reoccurring. 

The response to this FOI request suggests such information could not be pulled together without many hours work, if at all. If this information was not readily available, it invites the question about what was being recorded and monitored to facilitate a culture of learning across the Trust, and to ensure mistakes were not repeated. Such matters sit outside the scope of our investigations into individual incidents, but suggest further scrutiny about what happened at the systemic level in the Trust during this period would be useful.  

As was recently highlighted in the NHS Long Term Plan , ‘evidence shows that the quality of care and organisational performance are directly affected by the quality of leadership and the improvement cultures leaders create.’ Mistakes will always be made, but they must also be learnt from. As the Long Term Plan suggests, the drive for this must be visibly led from the very top of an organisation. 

In this case, the broader evidence we have seen indicates that there were serious deficiencies in the culture of learning and improvement across NEP. In addition, although recent evidence suggests the situation has improved since the creation of EPUT, according to the CQC’s most recent inspection report there remains work to do. 

We believe there could be valuable learning taken from a more fundamental review of the approach to leadership, learning and improvement at NEP and why the pace of change only seemed to improve following the merger to create EPUT. It is important that the opportunity to do this is not lost.