Equality and Human Rights Commission (EHRC)
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Deaths in detention of hundreds of people with mental health conditions could have been avoided, new Inquiry finds

Repeated basic errors, a failure to learn lessons and a lack of rigorous systems and procedures have contributed to the non-natural deaths of hundreds of people with mental health conditions detained in psychiatric hospitals, prisons and police cells in England and Wales, according to a major new Inquiry by the Equality and Human Rights Commission.

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 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’s Inquiry team consulted with organisations including the Care Quality Commission (CQC), Healthcare Inspectorate Wales (HIW), Her Majesty’s Inspectorate of Constabulary (HMIC), Her Majesty’s Inspectorate of Prisons (HMIP), the Independent Police Complaints Commission (IPCC) and the Prisons and Probation Ombudsman (PPO). 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 front-line staff across all three settings, which includes 12 practical steps to help protect lives.

Professor Swaran SinghLead 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. For people with mental health conditions that is a particular challenge with a large number of tragic cases over the past few years where that responsibility has not been met.

The Commission, as Great Britain’s National Human Rights Institution carried out this Inquiry, in consultation with other expert bodies, to examine what lessons can be learned how to prevent further unnecessary and avoidable harm and heartbreak.

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.

Access to drugs: including the increasing availability in prisons of 'legal highs' which can increase the risk of mental health crises.

Widespread evidence of bullying, threats and intimidating behaviour in the run-up to someone taking their own life: research showed 20 per cent 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 -16 times a day - when people were locked up in police cells as a place of safety because there was nowhere else for them to go. Some of those locked up for this reason have subsequently died, often following the use of restraint.

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 HammondCEO of the Equality and Human Rights Commission said:

This Inquiry reveals serious cracks in our 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.

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 including:

Learning lessons and creating rigorous systems and processes

  • Organisations need to be much better at learning lessons from previous deaths and near misses of people in their own care, as well as experiences from other institutions.
  • Prisons and hospitals need to 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;
  • There should be mandatory follow-up support and referrals to mental health services within seven days for those leaving prison
  • Every prison should have a dedicated expert responsible for implementing lessons from past investigations and preventing future deaths.

A stronger focus on meeting basic responsibilities to keep detainees safe

  • Regularly refreshed training in mental health awareness should be mandatory for all front-line 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;
  • 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;
  • The Government’s proposed improvements to mental health services in prisons must be matched with sufficient resources.

Greater transparency and robust investigations

  • 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;
  • 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;
  • There should be much more involvement for families in decisions about care.

The EHRC Human Rights Framework should 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. Adopting it as an overall approach as well as ensuring compliance with each individual element could reduce non-natural deaths and should help to inform and shape policy decisions.

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.

For further information please contact the Commission’s media office on 0161 829 8102, out of hours 07767 272 818.

Notes to editors

The Commission’s report - Preventing Deaths in Detention of Adults with Mental Health Conditions: An Inquiry by the Equality and Human Rights Commission - can be found at:


The Equality and Human Rights Commission is a statutory body established under the Equality Act 2006. It is an independent body responsible for protecting and promoting equality and human rights in Great Britain.  It aims to encourage equality and diversity, eliminate unlawful discrimination, and promote and protect human rights.  The Commission enforces equality legislation on age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, sexual orientation. It encourages compliance with the Human Rights Act 1998 and is accredited by the UN as an ‘A status’ National Human Rights Institution.   


Channel website: https://www.equalityhumanrights.com/en

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