Deep failings in care across the country’s mental health services have led to avoidable deaths

The report, ‘Preventing Deaths in Detention of Adults with Mental Health Conditions’, suggests that repeated 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.

Main findings from the Inquiry include:

• Basic mistakes are being repeated, such as failing to monitor patients who are at a high risk of suicide.
• There is a lack of transparency and robust investigation, with virtually no information collated centrally about the deaths and no independent body to ensure that effective, independent investigations take place, with families feeling excluded from investigations.
• Poor communication between staff and services means that vital records are lost leading to subsequent poor care which may lead to avoidable deaths.

The report outlines recommendations including more rigorous systems and processes, a stronger focus on basic responsibilities to keep people safe and greater transparency in investigations.

Responding to EHRC’s report, our Chief Executive, Katherine Rake said:

“The EHRC’s findings identify some deep failings in care right across the country’s mental health services which may sadly have led to avoidable deaths; unfortunately these findings fit with what we have been hearing from local Healthwatch.

“In particular the lack of any consistent independent investigation into deaths in psychiatric hospitals is leaving families without answers and means that lessons aren’t being learnt when things go wrong.

“We support the recommendations from the Inquiry and look to the Government to take them on board and create a system that offers everyone compassionate, safe and high quality care.”