The NHS trust in charge of the Linden Centre mental health facility at Broomfield has been served warning notices over patient safety by the health regulator.

The news comes just before an independent inquiry into historic deaths at the centre is due to start in February. Maldon mother Melanie Leahy, whose 20-year-old son Matthew Leahy died at the centre in 2012, has said that she believes the proposed inquiry will be "a whitewash". She is campaigning for a full statutory public inquiry, which could compel witnesses to give evidence under oath.

The latest inspection visits to the Linden were made by the Care Quality Commission (CQC) following the death of another young man last year. The CQC carried out the unannounced visits to Finchingfield Ward - a ward for men with acute mental health issues - in October and November after concerns were raised over 'safety incidents' and the 'risk of harm'.

The CQC report on its findings does not specify whether the visits were made in relation to the death on 23 October of a young man who had absconded from the centre. Jayden Booroff, 23, from Chelmsford died after being hit by a train following his escape from the Linden Centre. He had been admitted there just four days earlier.

Essex Partnership University NHS Foundation Trust (EPUNFT) runs the centre, which serves a population of around 1.3million across Essex, Bedfordshire, Suffolk and Luton.

Summary of the CQC's findings:

As the CQC did not carry out a full inspection this time, the previous grading from 2019 of 'requires improvement' remains in place. Instead, the visit focussed on the safety issues and found:

• some staff did not follow the required actions to maintain patient safety. For example, garden areas required staff to observe patients due to environmental risks. An incident recorded on CCTV showed there were no observing staff present, contributing to a patient absconding
• staff did not keep accurate records of patient care and managers did not check the quality and accuracy of notes
• staff failed to correctly record patients' mental health act status and did not always make entries in a timely way.

Within the inspection report, which is published today (Thursday, 14 January), some of the findings make for uncomfortable reading, including:

• "Staff could not record accurately when they observed patients. The service provided staff with observation records that had pre-populated time stamps at on the hour intervals. This meant records showed one staff member observed all patients (17 at the time of inspection) at the same time, on the hour every hour. This was not physically achievable due to patients being in different areas of the ward.
• "The ward ligature risk assessment clearly recorded the need for staff to be physically present in the garden when patients went outside."

The point on ligature risk assessment could raise particular concern as on 12 November last year the trust (EPUNFT) pleaded guilty to a charge under the Health and Safety at Work Act. The prosecution was brought by the Health and Safety Executive (HSE) – following an investigation into how risks from potential ligature points were managed on wards of the former North Essex Partnership University Trust between October 2004 and March 2015. The former trust was absorbed into the current trust (EPUNFT) after a merger in 2017.

Follow-up to the latest inspection visits

Speaking of the outcome of the latest inspection visits, CQC's Head of Hospital Inspection for mental health services said: "We served warning notices to ensure improvements are made around safe care and treatment, staffing and good governance.

"The trust responded quickly to concerns raised during feedback from the inspection and provided assurance on how they intended to address issues. The trust took immediate actions to address some safety concerns, including the removal of garden shelters and increasing security measures.

"Patients gave positive feedback about the ward staff and the hospital environment. The trust ensured there was support available to patients and staff following incidents, this included access to senior leaders and psychologists.

"We have reported our findings to the trust leadership, which knows what it must do to bring about further improvements and ensure it maintains any already made. We will return to check on the trust's progress."