OnWednesday 11 February, in parliament, INQUEST launched “Deaths in MentalHealth Detention: An investigation framework fit for purpose?”- a report based on INQUEST’s work with families of those who have died inmental health settings and related policy work. It identifies three key themes:
1.The number of deaths and issues relating to their reporting and monitoring.
2. The lack of an independent system of pre-inquest investigation as comparedto other deaths in detention.
3. The lack of a robust mechanism for ensuring post-death accountability andlearning.
Itdocuments concerns about the lack of a properly independent investigationsystem unlike deaths in prison and police custody which are independentlyinvestigated pre-inquest and the consistent failure by most Trusts to ensurethe meaningful involvement of families in investigations.
Ultimately,it highlights the lack of effective public scrutiny of deaths in mental healthdetention that frustrates the ability of NHS organisations to learn and makefundamental changes to policy and practice to protect mental health in-patientsand prevent further fatalities and argues for urgent change to policy andpractice.
Deborah Coles, Co-Director of INQUEST said: “Thereare an alarming number of deaths in mental health settings that are not beingproperly investigated because of the lack of transparency and independence inthe current investigation process. Bereaved families and the wider public canhave no confidence in a system where Trusts investigate themselves over deathsthat may have been caused or contributed to by failures of their own staff orsystems.
“Itis anomalous that these investigations into deaths of extremely vulnerablepeople are less rigorous than those in other forms of detention. INQUEST iscalling for a new fully independent system for investigating these deaths. Amore open and learning culture could help to safeguard lives in the future.”
Michael Antoniou, husband of Janey Antoniou who died in mentalhealth detention in said: “Icould never have gone through the investigation and inquest process on my ownwithout the support of INQUEST. The trust was more concerned about deflectingcriticism than establishing the truth. My experience since Janey’s death hasmade it crystal clear that there is an absolute need to have independentinvestigations.”
Lord Patel of Bradford, former chair of the MentalHealth Act Commission said: “Deathsin mental health settings, including a number of child deaths, is worryinglyhigh. I believe that we must do a great deal more to address the needs ofpeople who suffer from mental health problems to protect vulnerable adults andchildren, and to prevent deaths in mental health detention. Therefore, Isupport INQUEST’s commitment to promote change and fight for improvements topolicy and practice, to safeguard the most vulnerable in our society.”
Mark Winstanley, CEO of Rethink Mental Illness said: “Thisreport highlights really serious issues about the lack of transparency andaccountability. The high number of deaths put down to ‘natural causes’, whichare not being investigated full stop is a major issue. Our concern is that asthings stand, it is impossible to tell how many of these deaths are resultingfrom preventable physical health conditions, which might have been avoided ifpeople had received proper medical treatment in inpatient care.
“We need a fully independent system for investigating all deaths in thesecircumstances, so that any failures in care can be exposed and acted upon. Thefamilies of people who have died in inpatient care deserve nothing less.”