Mr Carter paid tribute to the hon. Member for Hartlepool and highlighted a petition signed by 185 people in his constituency about deaths in mental health care. He detailed Hannah's tragic case, highlighting communication failures between ward staff, management, and her family leading to her untimely death while a detained patient at Hollins Park Hospital. Mr Carter emphasised the need for stronger steps regarding prosecutions of those who lead care settings, improved local investigations, and a zero-suicide policy.

Barbara Keeley highlighted the tragic case of Matthew and called for a public inquiry into the failures at the Linden Centre that led to his death. She cited multiple incidents where patients were found hanging, despite repeated inspections, indicating systemic issues in Essex mental health services. Asked the Minister to refrain from stating that Matthew took his own life, suggesting instead to use the phrase 'he was found hanging' as the inquest recorded an open verdict. Barbara Keeley expressed concerns about the independence of the inquiry chair, suggesting that families like Melanie Leahy's support is crucial. She also questioned whether it would be appropriate to revisit inquests with new evidence.

The MP thanked Deborah Coles, the chief executive of INQUEST, for her briefing paper on mental health cases. She highlighted Seni's law and called for a proper inquiry into deaths due to police restraint or mental health services issues, advocating for better communication, data accessibility, staff training, inspections, and oversight at the national level. Catherine West highlighted the ongoing costs and challenges faced by individuals in long-term social care, urging for interim learning from the inquiry to prevent further deaths.

The Chair reminded Members of the new rules in Westminster Hall, including sanitising microphones, following a one-way system for entering and exiting the Chamber, and adhering to intervention protocols.

Paid tribute to Matthew Leahy's mother who has campaigned for years through pain, and highlighted the case of Richard Wade. He stated there is strong evidence that when Richard Wade was found hanging, still alive, clinicians either panicked or left him, allowing crucial minutes before resuscitation was given. Cartlidge also mentioned another death by ligature in the same bathroom three months earlier, questioning why it was not reported initially. James Cartlidge intervened to support the call for an inquiry into the case highlighted by Hollinrake, suggesting it should ideally take place as soon as possible. James Cartlidge argued for the rapid establishment of an inquiry to find the truth, emphasizing that time is critical for affected families like the Wades.

The MP expressed concern about the lack of funding for mental health services in Lewisham, highlighting that a local unit was not built to cater to people with mental health problems. She raised the case of Kevin Clarke who died following police restraint and an excessive response from officers, calling for a strategy of care involving all professionals to prevent fatal incidents.

Asked if modernising facilities and improving training for staff could help prevent such tragedies from happening when helping people with mental and psychiatric issues who need in-patient care. Jim Shannon highlighted the importance of helping individuals with mental health issues within the existing system, citing a case involving a young man named Michael who was homeless and in need of support. He praised various government bodies for their assistance but argued that more must be done to update mental health facilities to provide better privacy, longer visiting hours, and organised activities such as therapy gardens.

These are terribly tragic cases; sometimes they cannot be avoided, but at times they are due to the performance of the trust and perhaps of the management of that trust. The leadership of those organisations must be held to account for their performance. Kevin Hollinrake highlighted the case of Andrew Bellerby, who was under the care of Sheffield Health and Social Care NHS Foundation Trust. After being seen by untrained nurses using a triage assessment tool, he was released into the community where he took his own life. The trust denied responsibility and it cost £100,000 in legal costs before an admission that Andrew's suicide was preventable. Hollinrake criticised the lack of training and accountability within the trust, noting there are 47 breaches of legal requirements. Kevin Hollinrake asked about potential sanctions for those found culpable within management if the independent inquiry finds them responsible.

Paying tribute to Matthew Leahy and his family, Kim Johnson highlighted the serious care failings at the Linden Centre that led to Matthew's death. She called for an independent review of these tragic deaths between 2008 and 2015, emphasizing the need for substantive change rather than superficial reviews.

Supporting the call for improvements in mental health care services, Peter Gibson echoed concerns about the tragic death of a patient at West Park Hospital in his constituency. He emphasized the importance of leadership and management changes beyond financial investment to improve outcomes and avoid further deaths.

Philip Hollobone read out a letter from his constituent, Mrs Marian Coles, whose son died by suicide while an inpatient at Kettering. She expressed the need for independent investigations into such deaths and criticized the current system's inability to adequately address staff misconduct or system neglect.

In support of the case, Robert Halfon highlighted a similar incident in his constituency where someone died under circumstances akin to Matthew Leahy's death at the same institution.