Equality and Human Rights CommissionHundreds of people with mental health conditions detained in psychiatric hospitals, prisons and police cells in England and Wales have died of non-natural causes in recent years, with repeated basic errors, a failure to learn lessons and a lack of rigorous systems and procedures all contributing to this, according to an Inquiry.

The Inquiry by the Equality and Human Rights Commission covered 2010-13, during which 367 adults with mental health conditions died of non-natural causes while detained in psychiatric wards and police cells and another 295 adults died in prison, many of whom had mental health conditions. 

The Commission is the first body to examine how the human rights of detainees with mental health conditions are protected across the health, prison and police settings. It consulted with organisations including the Care Quality Commission, Healthcare Inspectorate Wales, Her Majesty’s Inspectorate of Constabulary, Her Majesty’s Inspectorate of Prisons, the Independent Police Complaints Commission and the Prisons and Probation Ombudsman. Evidence was also gathered from family members. 

The Inquiry found failures by institutions to bring in processes to learn from lessons and implement recommendations. As a result, the Commission has, for the first time, created an easy-to-follow Human Rights Framework, aimed at policy makers and frontline staff across all three settings, which includes 12 practical steps to help protect lives.

Main findings

Main findings from the Inquiry included:

Basic mistakes being repeated: such as failing to properly monitor patients and prisoners at serious risk of suicide, even when their records recommended constant or frequent observation; and failing to remove ‘ligature points’ within psychiatric hospitals despite the knowledge that they are commonly used to attempt suicide

A lack of transparency and robust investigations: 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. Staff do not feel they can speak out openly and families feel excluded from investigations

Misplaced concerns about data protection: causing a failure to share important information, such as concerns raised by professionals in court not being passed to prison staff, or prison healthcare staff not telling officers on the prison wing that an inmate had suicidal tendencies

A failure to involve families in support for detainees, making it more difficult for them to pass on information which they feel might have prevented deaths – such as previous treatment plans or trigger points for self-harm like anniversaries of bereavement or relationship difficulties. Detainees were refused contact with their family members at a time when they were particularly vulnerable, or unable to see them because they were held a long distance away from the family home

Poor communication between staff: leading to crucial information being lost or delayed during the transfer of prisoners; a failure to update and share patients’ risk assessments following self-harm or suicide attempts; and leading to crucial information being missed

Widespread evidence of bullying, threats and intimidating behaviour in the run-up to someone taking their own life: research showed 20% of prisoners aged 18-24 experienced bullying in the month before their death. Conversely, inmates with mental health conditions were frequently held in segregation for their own safety or the safety of others, leading to a deterioration in their mental state

Inappropriate detention in police custody: every year a large number of people with mental health conditions are detained in police stations for their own safety. In 2013/14 alone, there were 6,028 occasions when people were locked up in police cells as a place of safety because there was nowhere else for them to go

Inappropriate and disproportionate use of restraint on people with mental health conditions, including ‘face-down’ restraint - which can lead to suffocation - and the use of Tasers. In addition, there were concerns about an increasing call-out of police officers to restrain detained patients on psychiatric wards

A high number of deaths shortly after leaving detention, raising questions about whether the appropriate follow-up mental health support is put in place.  

Mark Hammond, CEO of the Equality and Human Rights Commission called for urgent action and a fundamental culture shift to “tackle the unacceptable and inadequate support for vulnerable detainees.

“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.”

“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’s Inquiry makes recommendations in four key areas. They are addressed at government, regulators and inspectorates and the leaders and managers of individual institutions.

In terms of learning lessons and creating rigorous systems and processes, the report says organisations need to be better at learning lessons from previous deaths in their own are and other institutions.

Also, prisons and hospitals should set up 'trigger systems' to alert staff to events or dates which could prompt self-harm such as anniversaries of bereavement, family breakdown and  imprisonment.

It also recommends mandatory follow-up support and referrals to mental health services within seven days for those leaving prison.

Another recommendation is for a stronger focus on meeting basic responsibilities to keep detainees safe, such as regularly refreshed training in mental health awareness should be mandatory for all frontline staff in prisons and police custody cells as well as psychiatric hospitals. Compliance with this should explicitly be part of the inspections carried out by regulators.

Also, each police force should have a mental health liaison officer embedded in its operations for each area or division to ensure learning is implemented and appropriate training takes place;

To create greater transparency and robust investigations, the report says the government should consider appointing an independent body to investigate all deaths of detained patients in psychiatric hospitals rather than rely on internal investigations by hospital trusts.

Also, there should be a statutory obligation on all institutions, including psychiatric hospitals, to publish investigations and to respond to recommendations, including committing to action plans. If it is found to be effective, the new ‘statutory duty of candour’ should be expanded to prisons and police detention as well as the NHS, to help increase transparency, accountability and involvement of families.

It also recommends much more involvement for families in decisions about care.

Finally, it recommends the EHRC Human Rights Framework be adopted and used as a practical tool in all three settings. This sets out practical steps to prevent deaths including a duty to put in systems to protect lives; an obligation to investigate any death for which the state may have some responsibility; freedom from bullying, neglect by staff and unlawful use of physical restraint; effective risk assessments and; appropriate medical and mental treatment and support. 

A parallel research exercise was conducted in Scotland. This research did not find the same concerns as are evident in England & Wales but the report makes recommendations about the greater integration of human rights principles, better training and support to staff and better data collection. The research also recommends that the forthcoming review of Fatal Accident Inquiries considers these matters.