“It is a pleasure to serve under your chairmanship, Mr Stringer, and to have the extra few minutes, which allows me to speak about a constituency case. I want to put on record how moving the speech by my hon. Friend the Member for Hartlepool (Mike Hill) was, and how many wonderful speeches there have been today, to give this desperate situation the attention it deserves.

I declare my interest as a patron of Mind in Haringey. I want to put on record my thanks to Deborah Coles, the chief executive of INQUEST, who wrote this important briefing paper and represents, sadly, hundreds of families who face a similar case to Melanie Leahy. They are desperate. They want to know the reasons and what happened prior to losing their child. I hope that at the end we will have a positive statement from the Minister about a proper inquiry and recommendations to be followed as a result of it.

The Minister may well remember Seni’s law, which was introduced by my hon. Friend the Member for Croydon North (Steve Reed), as a result of his campaign with Seni’s family. Seni died as a result of police restraint due to his having a very serious mental health problem but not getting the correct care under the mental health services. This Friday I have a constituency meeting with a constituent who has tragically lost her son in similar circumstances. This is not an isolated incident and it is wonderful to have this debate.

I want to focus on the findings from INQUEST and some of the other experts who have looked carefully at the similarities in these cases. We know that between 2013 and 2016 there were 71 deaths similar to the one that we are talking about today. Despite several recommendations made by the coroner following each one of these to prevent further deaths in similar circumstances, as the hon. Member for South Suffolk (James Cartlidge) said, the lessons simply are not being learned. Are we doing a read across from similar conditions in the prison service, where, I think, the deaths have come down and the lessons have been learned to some degree? I wonder if there can be shared learning across different services.

We know that in November 2020, INQUEST, the voluntary sector organisation that helps families, looked into 20 recent cases of deaths in adult in-patient mental health settings and found the same issues repeated: lack of staff training, poor record keeping, a failure to involve the family in the care of the patient, a lack of local specialist units and staff shortages.

We know that as a result of covid-19, as other hon. Members mentioned, we have an opportunity to do things differently. We know that we can do much better in terms of accessible data on the number of deaths and how people have died. We know that we can do much better in training our mental health professionals. At Care Quality Commission level, we could do much better in terms of inspections, so that this appalling area is cleaned up once and for all.

We also know that there is failure of communication at crucial times, so that for months and months the family are left not knowing what is the next step and what will happen as a result. That is why it is crucial, as we have all said today, that we have the correct oversight at the national level to monitor the learning and implementation, but also that we have a statutory public inquiry. It can be into Essex mental health services, but what matters is that whatever it is, it is generalised across every single mental health setting.

In the context of covid, where we know there will be at least 20% more people suffering from mental health conditions—including more young people, who are disproportionately affected by covid—there is a real urgency to this work. I hope that we as Members can put more pressure on the Department of Health and Social Care to tackle the problem once and for all.”