A MOTHER is calling on government ministers to launch a public inquiry into the “unnecessary death” of her son after a report found significant failings had been made.

Matthew Leahy, 20, was found hanged at the Linden Center in Chelmsford in November 2012, after a short seven day inpatient stay.

Since, his mum, Melanie, has been campaigning to “find the truth” - with a petition gaining thousands of signatures.

In a highly critical report, the Parliamentary and Health Service Ombudsman said the former North Essex Partnership University NHS Foundation Trust (NEP) had “missed opportunities” to ensure the safety of two young men.

The ombudsman said the men and their families had been “badly let down” by the Trust, which had failed to make improvements following their deaths.

The PHSO investigated the death of Mr Leahy.

It also looked at the case of another man, identified only as Mr R, who died at the unit in December 2008.

In its report published last week, the PHSO found that NEP had not adequately planned its care for Mr Leahy, who had previously been diagnosed as having delusional disorder.

He was also not adequately observed, did not have an allocated keyworker and there was an inadequate response when he reported being raped, the report said.

The PHSO said NEP’s own investigation into Mr Leahy’s death was not robust enough and found the Trust was “not open and honest” with his family about steps being taken to improve safety at the Linden Centre.

The Ombudsman also concluded that NEP did not adequately respond to Mr R’s threats to harm himself, failed to adequately manage his ward leave and did not properly assess and manage risk.

Melanie said: “The journey to get this far has been such a battle. I have been working with the PHSO for over four and a half years needing to prove to them everything I already knew to be true.

“Every point mentioned in this report I have had to give clear evidence. Whilst I understand the Ombudsman has called for a review. I am calling on ministers to launch a public inquiry into the death of Matthew, now.

“Time is of the essence. There is a mass of evidence available and there have been enough reviews of this case.”

Following the Ombudsman’s investigation into Mr R’s case, the trust paid his family £1,250 and wrote to them to apologise.

The PHSO also recommended that within two months the Trust should send a written apology to Mrs Leahy and pay her £500 for the distress caused by the receipt of inaccurate information about safety changes in February 2015.

In November last year, police dropped an investigation into 25 deaths at NEP-run facilities since 2000. Investigators found “clear and basic failings” in care, but insufficient evidence for corporate manslaughter charges. A Health and Safety Executive investigation into how NEP managed its mental health wards is still ongoing, with the Ombudsman saying there remained a “possibility” of criminal charges being brought against the Trust. Visit petition.parliament.uk/petitions/255823Click