Inquiry finds hundreds died ‘non-natural’ deaths following detention

Disabled activists have backed the findings of a major inquiry that concluded that serious flaws within the mental health and criminal justice systems were responsible for the deaths of hundreds of service-users in detention.

They spoke out after the Equality and Human Rights Commission (EHRC) published its report into the “non-natural” deaths of 367 people with mental health conditions who had been detained in psychiatric hospitals and police cells in England and Wales, and another 295 adults – many of whom had mental health conditions – who died in prison.

The commission concluded that the biggest problems were with the detention of people in psychiatric hospitals.

The inquiry found basic mistakes were repeated, a lack of transparency and “robust” investigations, an unwillingness to share important information because of misplaced concerns about data protection, a failure to involve families in providing support for detainees, and poor communication between staff.

The inquiry also found that people were locked up in police cells inappropriately on more than 6,000 occasions because there were no places available for them in the mental health system.

Some of these people subsequently died, often due to inappropriate restraint by police.

The inquiry also found an “inappropriate and disproportionate” use of restraint of people with mental health conditions, including “face-down” restraint – which can lead to suffocation – and Tasers.

And it found a high number of service-users had died shortly after leaving detention, raising questions about the quality of follow-up mental health support.

The Mental Health Resistance Network (MHRN), whose members are all survivors of the mental health system, said there was a need for sweeping improvements.

An MHRN spokeswoman said the number of non-natural deaths reported by the commission “did not surprise me at all. It saddens, but it doesn’t surprise me.”

The network called for independent investigations of all deaths and serious incidents in psychiatric hospitals, which would go further than the inquiry’s recommendation for the government to consider appointing an independent body to investigate all deaths of detained patients in psychiatric hospitals.

The MHRN spokeswoman said: “Certainly in psychiatric hospitals, it is our experience that any investigation that takes place into a serious incident invariably becomes a litigation-avoiding exercise by the NHS.

“There is no question that psychiatric hospitals should not be investigating any serious incidents themselves, because their concern is about avoiding litigation.”

She said the shortage of beds meant that most people in psychiatric hospitals have been sectioned, which meant “a lot of very, very distressed and disturbed” people being treated in a “medical model” way by staff who put them on drugs, but offer insufficient day-to-day talking-based support.

The often “adversarial” relationships on wards meant that it was difficult to create a “trusting dialogue” with staff, she added.

She said: “When a person is suicidal they are put on maximum observation. They just sit there until someone attempts to do something, and then they restrain them.”

She added: “It is a well-known fact that if you go into a psychiatric ward and you have a physical health problem, that physical health problem will not be dealt with.”

And she said there was “no way somebody with a mental health problem should be detained in a police cell. It is traumatic, it is degrading, and you feel like you have committed a crime.”

The EHRC inquiry made recommendations in four areas: in learning lessons and “creating rigorous systems and processes”; a stronger focus on meeting basic responsibilities to keep detainees safe; more transparency and robust investigations; and the adoption of a new human rights framework across hospitals, police cells and prisons.

The human rights framework sets out practical steps to prevent deaths, including a duty to put in systems to protect lives, and to investigate any death for which the state may have some responsibility; freedom from bullying, staff neglect and unlawful physical restraint; effective risk assessments; and appropriate treatment and support.

Parallel research in Scotland did not find the same concerns as in England and Wales, although the inquiry did make recommendations on integrating human rights principles into the system, improving training and support to staff, and for better data collection.

Mark Hammond, chief executive of the EHRC, said the inquiry showed “serious cracks” in the mental health system, which needed “urgent action and a fundamental culture shift” to tackle “unacceptable and inadequate” levels of support.

He said that recommendations on “openness and transparency and learning from mistakes” were about “getting the basics right”.

A spokeswoman for the government, in a cross-departmental response, said: “It is vital that all services — NHS, prisons and the police — are honest and open when things go wrong, and work with families and staff to prevent further tragedies.

“Many of these deaths could have been prevented with the right care and support.

“The government is working with NHS England and the Care Quality Commission to improve the way these deaths are investigated and we’ve launched a zero suicide ambition for the health service.

“We are reviewing the way we care for high-risk prisoners and already work closely with police forces, the Independent Police Complaints Commission and other partners to prevent deaths in custody and to take action to minimise the risks to all detainees.”

Among the measures the government has taken is a national review of case-notes to work out the percentage of avoidable deaths in different hospitals.

The Ministerial Council for Deaths in Custody, which oversees deaths in police custody, considers lessons to be learnt following a death and is responsible for developing a “legislative and policy framework to help prevent deaths in any state custody setting”, the spokesman said.

News provided by John Pring at

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