A group of mental health charities and experts have called for more robust, effective and transparent systems for investigating self-inflicted deaths of detained mental health patients.
The call was made at an event at The King’s Fund and hosted by 20:20 Assurance, entitled ‘Debating the urgent need for independence in investigating Serious Untoward Incidents’. There, INQUEST and Mind joined representatives from NHS England, private health care providers and the Royal College of Nursing to discuss effective investigative mechanisms into self-inflicted deaths within Trusts.
In the 10-year period between 2002 and 2011, 3,197 people in the UK died in mental health detention, equating to an average 320 deaths each year and representing around 60% of all deaths in custody.
A significant part of the discussion focused on whether investigations into Serious Untoward Incidents (SUI) should be carried out independently.
INQUEST co-director Deborah Coles said: “We are extremely concerned about the much neglected area of people who are dying in mental health detention. We have been concerned in particular by the secrecy concerning the number of deaths and the closed nature of the investigations.
“Unlike deaths in prison or police custody, deaths while under mental health section are the only deaths in state detention not to be independently investigated pre-inquest. More rigorous, robust and transparent investigations, with the effective participation of the family, can play a critical role to safeguard the lives of others.”
The current system in the UK allows the Trust responsible for a patient’s care to investigate their own SUIs internally. Such a practice has led to criticism from the families of those who have died whilst in the care of the mental health providers who are then charged with investigating themselves.
Sophie Corlett, head of external relations at Mind, said: “When someone dies in psychiatric care, the investigation that follows must be done in such a way that ensures we fully understand why the death happened and how we can prevent similar incidents in future. This investigation needs to be robust and needs to involve the friends and family of the person who has died, whose insight and evidence can prove invaluable.
“Most importantly, we need to make sure that the findings of any investigation are then acted upon. Too often, trusts don’t learn and we see the same mistakes being made time and time again, with catastrophic consequences.”