“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.
Both stories follow an inquiry by the Equality and Human Rights Commission (EHRC) into the deaths of people with mental health conditions while detained in police custody, prisons or psychiatric hospitals.
The inquiry looked at whether people who were detained had been treated correctly according to EHRC guidelines. The inquiry focused on two basic rights: the right to life and the right to non-discrimination.
Over the period 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 identified many areas of concern, including a lack of information sharing between professionals, insufficient involvement of family members, inappropriate use of restraint, and failure to learn from past incidents.
The Commission recommends that rigorous systems are put in place to ensure that any incidents are thoroughly and transparently investigated, and acted upon.
The Commission’s report looked into deaths in detention for those with mental health conditions. The inquiry looked at the period 2010 to 2013 in three detention areas:
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.
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 EHRC recommends:
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.