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Many deaths of mentally ill in custody 'avoidable'

4:00pm Monday 23rd February 2015 content supplied byNHS Choices

The Commission wanted to establish the extent to which there has been compliance with Article 2 (the right to life) and Article 14 (the right to non-discrimination) of the European Convention on Human Rights. It wanted to see whether improved compliance with these civil rights rules could reduce deaths in psychiatric hospitals, prisons and police custody.


What did the inquiry find about deaths in detention?

From 2010 to 2013, there were 367 deaths from non-natural causes of adults with mental health conditions while detained in psychiatric wards and police custody. A further 295 adults died in prison, many of whom had mental health conditions.

The inquiry found that the same mistakes are being repeated across prisons, police cells and psychiatric hospitals. This includes, for example, the failure to appropriately monitor patients and prisoners at serious risk of suicide, even in cases where their records recommend constant or frequent observation. It also includes failure to remove "ligature points" in psychiatric hospitals, which are known to be often used in suicide attempts.

According to the inquiry report, psychiatric hospitals are an "opaque system". The Commission found it difficult to access information about non-natural deaths in psychiatric hospitals, such as individual investigation reports. This contrasts with prisons and police settings, where there is an independent body in charge of investigating deaths and ensuring that lessons are learnt.

The Commission also found misplaced concerns about data protection, leading to failures to share important information, such as concerns of other professionals about mental health, or suicidal tendencies not being passed on to prison staff. Similarly, failure to involve families to support the person being detained make it difficult for the family to pass on information that might have prevented deaths. Poor communication between staff, including lack of updates on risk assessments after self-harm or suicide attempts, was also highlighted.

Other significant findings included:

  • The availability of drugs, including "legal highs", in prison.
  • Evidence of bullying and intimidation in prisons in the lead-up to someone talking their own life. This can result in a person being locked up alone in a cell for their own safety, because there is nowhere else for them to go. This can lead to deterioration of the person's mental state.
  • Inappropriate use of restraint in people with mental health conditions, including "face-down" restraint. There were also increasing reports of police officers being called out to restrain people on psychiatric wards.
  • A high number of deaths occurred shortly after a person ended a period of detention, suggesting insufficient mental health support and follow-up.


What does the EHRC recommend?

The EHRC recommends:

  • Structured ways of learning from deaths and near misses in all settings where people with mental illness are detained, to ensure that improvements are made.
  • Individual prisons, hospitals and police settings should focus more strongly on meeting the basic responsibilities of keeping detainees safe. It recommends better staff training, and for the inspection regimes to explicitly monitor this. 
  • The Commission wants more "transparency", to allow services to be scrutinised and held to account. The Commission suggests that the "statutory duty of candour", which is being introduced in April 2015 and applies to all NHS bodies in England, could help to achieve this.


What happens next?

Mark Hammond, the EHRC's chief executive says: "This Inquiry reveals serious cracks in our systems of care for those with serious mental health conditions. We need urgent action and a fundamental culture shift to tackle the unacceptable and inadequate support for vulnerable detainees.

"The improvements we recommend aren't necessarily complicated or costly: openness and transparency, and learning from mistakes are just about getting the basics right. In particular, by listening and responding to individuals and their families, organisations can improve the care and protection they provide."

The Commission says it is now going to follow up its recommendations with the relevant organisations.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.


"Hundreds of deaths in mental health units 'were avoidable'," says a report on the front page of today's Independent. The Guardian highlights 662 mentally ill detainee deaths from 2010 to 2013...

Links to Headlines

Mental health deaths in detention 'avoidable'. BBC News, February 23 2015

Hospital psychiatric detainees more at risk of preventable death. The Guardian, February 23 2015

Too many deaths in custody are preventable but staff lack mental health expertise, says human rights body. The Independent, February 23 2015

Useful Links

Further Readings

Equality and Human Rights Commission.�Preventing Deaths in Detention of Adults with Mental Health Conditions (PDF, 486kb). Published February 23�2015

Press release

Equality and Human Rights Commission.�Deaths in detention of hundreds of people with mental health conditions could have been avoided, new Inquiry finds. Published February 23�2015

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