Medical practice

Many deaths of mentally ill in custody 'avoidable'

“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.

What did the EHRC investigate?

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:

  • Psychiatric hospitals. Detention in hospital means being held under the Mental Health Act, which is sometimes referred to as being “sectioned”. In 2012/13, there were said to be over 50,000 such detentions and the number has since been increasing.
  • Police custody. The Mental Health Act allows for a person “in crisis in a public space” to be held in police custody as a “place of safety” when there is insufficient other health-based support available. In 2012/13, there were reported to be 7,761 occasions when the Act was used to hold an individual in police cells.
  • Prisons. The prison service does not record the number of imprisoned people who have mental health conditions; however, they are likely to affect a large proportion of inmates. The most recent data – from 1997 – reported that 92% of male prisoners were suffering from psychosis, neurosis, personality disorder, alcohol misuse or drug dependence.

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.

NHS Attribution