Deaths in mental health detention: an investigation framework fit for purpose?


This much anticipated and evidence based report: Deaths in Mental Health Detention: An investigation framework fit for purpose?  draws on findings from INQUEST’s work with families of those who have died in mental health settings and its associated policy work.

The report identifies three key themes:

   1. The high number of deaths in mental health settings and issues relating to their reporting and monitoring

   2. The lack of an independent system of pre-inquest investigation as compared to other deaths in detention

   3. The lack of a robust mechanism for ensuring post-death accountability and learning.

Despite the high number of deaths in mental health settings, the report discusses the lack of a properly independent investigation pre-inquest, following these deaths. This is contrasted with a death in prison and police custody where an independent body is able to establish the facts of a death pre-inquest and highlight key concerns for the prevention of future fatalities. Moreover the report findings highlight the consistent failure by most Trusts to ensure the meaningful involvement of families in investigations.

Ultimately the report argues that due to the lack of public scrutiny of deaths in mental health detention, this frustrates the ability of NHS organisations to learn and make fundamental changes to policy and practice, which can protect mental health in-patients and prevent further deaths. To safeguard the lives of an extremely vulnerable group, INQUEST argues for urgent change to policy and practice.

Deborah Coles, Co-Director of INQUEST said,

“There are an alarming number of deaths in mental health settings that are not being properly investigated because of the lack of transparency and independence in the current investigation process. Bereaved families and the wider public can have no confidence in a system where Trusts investigate themselves over deaths that may have been caused or contributed to by failures of their own staff or systems.
It is anomalous that these investigations into deaths of extremely vulnerable people are less rigorous than those in other forms of detention. INQUEST is calling for a new fully independent system for investigating these deaths. A more open and learning culture could help to safeguard lives in the future.”

Michael Antoniou, husband of Janey Antoniou who died in mental health detention in said,

“I could never have gone through the investigation and inquest process on my own without the support of INQUEST. The trust was more concerned about deflecting criticism than establishing the truth. My experience since Janey's death has made it crystal clear that there is an absolute need to have independent investigations.”

Lord Patel of Bradford, former chair of the Mental Health Act Commission said,

"Deaths in mental health settings, including a number of child deaths, is worryingly high. I believe that we must do a great deal more to address the needs of people who suffer from mental health problems to protect vulnerable adults and children, and to prevent deaths in mental health detention.  Therefore, I support INQUEST’s commitment to promote change and fight for improvements to policy and practice, to safeguard the most vulnerable in our society."

Mark Winstanley, CEO of Rethink Mental Illness said,

“This report highlights really serious issues about the lack of transparency and accountability. The high number of deaths put down to ‘natural causes’, which are not being investigated full stop is a major issue. Our concern is that as things stand, it is impossible to tell how many of these deaths are resulting from preventable physical health conditions, which might have been avoided if people had received proper medical treatment in inpatient care.

“We need a fully independent system for investigating all deaths in these circumstances, so that any failures in care can be exposed and acted upon. The families of people who have died in inpatient care deserve nothing less.”

The report is available to download here:

Deaths in Mental Health Detention: An investigation framework fit for purpose? (PDF)

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