Psychiatric hospitals should have a legal obligation to publish investigations into the deaths of detained mental health patients, according to a human rights investigation, which has found “serious cracks” in the detention system.
An inquiry by the Equality and Human Rights Commission said the “non-natural” death of a detained patient should be treated as a serious incident and a mandatory investigation should follow to learn lessons.
In its latest report – Preventing Deaths in Detention of Adults with Mental Health Conditions – the body identified a series of errors that were being repeatedly made, leading to avoidable deaths and near misses.
“We need urgent action and a fundamental culture shift to tackle the unacceptable and inadequate support for vulnerable detainees”
Between 2010 and 2013, 367 adults with mental health conditions died of “non-natural” causes while being detained in police cells and psychiatric wards across England and Wales, stated the report. Of this number, 95% were in psychiatric wards.
It recommended the government should also consider appointing an independent overarching body to investigate all deaths of detained patients in psychiatric hospitals.
The commission said the health sector should follow the police and prison settings, which have independent agencies to investigate deaths in detention and publish reports on common themes.
It noted that NHS England was currently reviewing its guidance to clarify how trusts should carry out investigations following the death of a detained patient.
“An increasing use and turnover of agency staff may be resulting in some unsafe practice due to a lack of training”
The investigation also highlighted evidence indicating that “an increasing use and turnover of agency and NHS in-house agency staff may be resulting in some unsafe practice due to a lack of training and knowledge about risk and assessments”.
Regular mental health training should be a requirement for all frontline staff in psychiatric hospitals, prisons and police custody cells, and compliance with this should be inspected by regulators, the inquiry recommended.
Other problems highlighted from the inquiry include the continued existence of ligature points, which the commission said should not be tolerated, and the use of restraint being a direct or indirect cause of some non-natural deaths.
Poor communication between staff to learn lessons and a failure by hospitals to involve families in, and support them, through investigations were also identified.
Mark Hammond, chief executive 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” he said.
He added: “The improvements we recommend aren’t necessarily complicated or costly. Openness and transparency and learning from mistakes are just about getting the basics right.”
The inquiry reviewed evidence on detention procedures and spoke with organisations including the Care Quality Commission, Department of Health and Healthcare Inspectorate Wales, as well as families of patients who died in detention.