Deaths in mental health detention: An investigation framework fit for purpose? (February 2015)

Summary

INQUEST's groundbreaking evidence-based report is based on our work with families of those who have died in mental 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 compared to other deaths in detention.

3. The lack of a robust mechanism for ensuring post-death accountability and learning.

Content

The report documents concerns about the lack of a properly independent investigation system, unlike deaths in prison and police custody which are independently investigated pre-inquest, and the consistent failure by most NHS Trusts to ensure the meaningful involvement of families in investigations.

Ultimately, it highlights the lack of effective public scrutiny of deaths in mental health detention that frustrates the ability of NHS organisations to learn and make fundamental changes to policy and practice to protect mental health in-patients and prevent further fatalities and argues for urgent change to policy and practice.