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Hundreds of mental health deaths in detention ‘avoidable’

Basic errors and a failure to learn have contributed to the deaths of hundreds of people suffering from mental health conditions detained in psychiatric hospitals, prisons and police cells in England and Wales, according to a new Inquiry. 

Carried out by the Equality and Human Rights Commission (EHRC), the Inquiry covered the period 2010-13, during which 367 adults with mental health conditions died of ‘non-natural causes’ while detained in psychiatric wards and police cells. A further 295 adults died in prison, many of whom had mental health conditions. 

The Inquiry found that there was a failing to properly monitor patients and prisoners at serious risk of suicide, even when their records recommended constant or frequent observation. This was a basic and repeated mistake. 

Also, there were failures to remove ‘ligature points’ within psychiatric hospitals, despite the knowledge that they are commonly used to attempt suicide. 

On top of this, a lack of transparency and robust investigations was identified. The Commission noted that unlike prisons and police stations, virtually no information is collated centrally about the deaths of people with mental health conditions in hospitals and there is no independent body charged with ensuring that effective, independent investigations take place. 

Professor Swaran Singh, lead commissioner on the Inquiry, said: “Human rights are for all of us and nothing is more fundamental than our right to life. When the state detains people for their own good or the safety of others it has a very high level of responsibility to ensure their life is protected.” 

As a result of the Inquiry, the Commission has, for the first time, created an easy-to-follow Human Rights Framework, aimed at policy makers and front-line staff across all three settings, which includes 12 practical steps to help protect lives. 

These include the right to freedom from physical abuse by staff or other detainees; freedom from bullying, threats and disrespectful treatment by staff and other detainees; and the requirement to provide effective risk assessment before initial detention or as soon after as is reasonably practicable. 

There is also a call for detainees to have the right to treatment for drug and alcohol abuse and protection from access to them. 

A Department of Health spokesman said: “It is vital that all services – NHS, prisons and the police – are honest and open when things go wrong and work with families and staff to prevent further tragedies. Many of these deaths could have been prevented with the right care and support. 

“The government is working with NHS England and CQC [Care Quality Commission] to improve the way these deaths are investigated and we’ve launched a zero suicide ambition for the health service.” 

Last year, the DH funded nine pilot schemes in which mental health nurses work closely with police on patrol and in call centres to reduce the number of people being detained under the Mental Health Act. PSE’s sister title National Health Executive highlighted the early success of the pilots

Mark Hammond, CEO of the EHRC, added that the Inquiry reveals “serious cracks” in the country’s 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,” he said. 

“While the Commission welcomes recent government announcements to address some of these issues, we are also mindful there have been a number of false starts in the past. It will be critical that words are matched by actions and appropriate resources.” 

Michael Brown, College of Policing national co-ordinator for mental health Inspector, noted that there is a growing demand on frontline police officers and staff in helping those suffering mental health difficulties.  

“While the police service should not be filling gaps in mental health services we need to ensure that we give frontline officers and staff basic training in identifying signs and symptoms,” he said. “Officers and staff also need to be equipped with the knowledge of where to divert vulnerable people into a health care setting so that they can receive expert care. That means not using police cells as a place of safety for those detained in distress.” 

Brown added that the College of Policing is leading a review nationally of police standards and training, including looking at the issue of restraint, as highlighted in the EHRC report. 

Vicki Nash, head of policy and campaigns at the mental health charity Mind, told PSE she welcomed the attention that this report brings to the worrying number of people with mental health problems who lose their lives in preventable circumstances while being detained. 

“For the lessons of these tragic deaths to truly be learnt it is vital that we see the introduction of robust, meaningful and independent investigations in all settings where detention of people with mental health problems takes place, as well as real investment in preventing them happening in the future,” she said. 

“The aim, of course, is to avoid ‘non-natural’ deaths in these settings all together, which will only be achieved through early intervention, adequate crisis care services and ensuring that patients are listened to. However, when things do go wrong, the need for a robust investigation process which ensures mistakes are leant from is crucial.” 

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