Work of the IAP

  1. Home
  2. Work of the IAP
  3. Archive
  4. Deaths of Patients Detained under the Mental Health Act (MHA)

Deaths of Patients Detained under the Mental Health Act (MHA)

Mental Health

Panel member Simon Armson initially undertook scoping work to identify the key work priorities for the IAP in relation to the deaths of those detained under the MHA, to take forward as part of the longer-term work programme.

Deaths of detained patients account for approximately 60% of all deaths in state custody. The Panel recognises the work that has already been undertaken to reduce suicide in this patient group, including the development of the National Suicide Prevention Strategy. In this context, the Panel decided to focus on natural cause deaths, particularly those that could be viewed as premature.

Natural cause deaths of detained patients

The panel presented findings and recommendations about how to address evidence of poor physical health of mental health patients to the Ministerial Board in March 2011, and worked with DH, CQC and other stakeholders such as the Health and Social Care Information Centre to explore the reasons for the high number of deaths from myocardial infarction (MI) and pulmonary embolism (PE).

The Panel continued efforts to encourage CQC to work with the Health and Social Care Information Centre (HSCIC) to access data from the Mental Health Minimum Data Set in order to look further into the apparently high number of deaths due to PE and MI. In 2014, CQC gained access to the relevant data.

It has since been agreed that instead of a standalone analysis, the CQC will embed this topic into their system of Intelligent Monitoring of mental health providers by developing an indicator of premature mortality that will inform risk based inspections. This will ensure that they will be alerted to Trusts where the level of expected mortality due to natural causes (such as MI and PE) is exceeded. The CQC would then undertake regulatory action, if required.  The CQC is working in collaboration with NHS England to develop the indicator.

Although the original recommendation was for a re-analysis of the data, the Panel is hopeful that embedding an indicator into CQC Intelligent Monitoring will have an ongoing impact on improving physical healthcare of detained patients. The Panel welcomes this development and the positive relationship they have developed with CQC in pursuing improvements to reduce deaths of detained patients.

Mental Health Literature Review

The Panel identified a need to review how mental disorder amongst detainees relates to self-inflicted and natural cause deaths in all custodial settings. As part of its contract to provide research and analysis for the Panel, the University of Greenwich commenced work on a literature review in 2013 with the aim of identifying priorities for future work.

The University advised that although there were many reports on the prevalence of mental health problems amongst offenders and those in prison and police custody; and some evidence to show the relationship between those mental health problems and deaths in custody, the relationship was complex and could not be systematically broken down to inform specific actions to improve risk management. In order to take the work forward, the Panel asked the University of Greenwich to explore the small amount of literature they had found on staff knowledge and attitudes towards mental health and the extent to which this led to improved care for detainees. The Panel’s report and the literature review can be found here.

The Panel decided, given the complexity of the relationship between mental health and deaths in custody, that a first step would be to take action on the link between improving staff attitudes to mental health and improved care. As a result, they hosted a roundtable discussion with key organisations in March 2015 to discuss staff training and how to support their own mental wellbeing. The key issues covered at the roundtable were:

  •  There was a consensus that supporting staff mental wellbeing was crucial.
  •  There were a range of initiatives aimed at supporting staff to work effectively with detainees who were vulnerable due to their mental health (e.g. Five Minute Intervention and the Vulnerability Assessment Framework).
  • Supervision opportunities for staff could help build their resilience and enable them to operate effectively despite the difficult experiences common to their working environments. This would need to be habitual and part of their role rather than an ‘initiative’.
  • More could be done to work with vulnerable individuals before they come to attention of the CJS and it would be vital to invest in that to prevent a negative cycle. This was costly in economic terms as well as to the lives of individual detainees.


The Panel will be considering the outcome of the discussions and next steps at their next meeting.

Terms of Reference

Review the statistics on the number of deaths of detained patients over the last ten years in order to gain an understanding of the scale of the issue and identify any common themes.

  • Undertake a short analysis of relevant data and information sources including narrative verdicts and Rule 43 Reports, data from the Care Quality Commission (CQC), the National Patient Safety Agency (NPSA) and the Confidential Enquiry into Suicides and Homicides by People with Mental Illness to identify any gaps and priority areas for the work of the IAP.
  •   Seek the views and advice of relevant organisations and individuals with experience of dealing with deaths of this nature.
  •   Use the findings of this work to produce outline recommendations for the preparation of advice and guidance for those responsible for the care of detained patients, which will be developed as part of the IAP’s longer-term work programme.



Last updated July 2015

*/ ?>