Independent investigations into Mental Health Act deaths are essential for transparency, learning and accountability, says IAPDC in new report
This report warns that the absence of independent investigations of deaths under the Mental Health Act (MHA) risks critical learning being lost, undermining efforts to prevent future deaths and leaving bereaved families without answers.
This article contains reference to suicide and deaths in detention settings. If you or someone you know is affected, please contact Samaritans on 116 123 or visit samaritans.org for support.
The report recommends establishing an independent investigative mechanism, drawing on current expertise and resources across detention settings. This should include clinical leadership and collaboration with expert organisations such as the Parliamentary and Health Service Ombudsman, the Health Services Safety Investigations Body and regulators like the Care Quality Commission (CQC).
Establishing an independent mechanism would ensure parity with other detention settings, with independent investigations for deaths in police custody, immigration detention, and prison already established for several years. Independent investigations would also support coroners in fulfilling the UK’s obligations under Article 2 of the European Convention on Human Rights (ECHR) – the right to life – while providing vital data to monitor and prevent deaths.
Between 2023 and 2024, 225 people died while detained under the MHA. The Panel’s latest statistical analysis of deaths in custody found that patients detained under the MHA have the highest rate of death across all detention settings – three times higher than in prisons. Yet, unlike deaths in prisons, immigration detention, or police custody, deaths arising whilst detained under the MHA are not automatically investigated by an independent body prior to an inquest.
Reviews into the safety of care within the healthcare landscape have continued to identify significant challenges, including the recent review conducted by Dr Penny Dash. There will no doubt be significant changes to be made following the government’s implementation of the review’s recommendations and the implementation of the 10-year plan for the NHS. This is one reason why the Panel’s report does not precisely prescribe a specific mechanism or body to remedy the issues it identifies. However, the consistently high number and rate of deaths in MHA detention highlight why this is so important.
The upcoming Mental Health Bill presents a critical opportunity to embed lasting reform, but the Panel urges the government to go further. Strengthening the investigation process will enhance transparency, improve patient safety, help provide answers for bereaved families, and build public confidence in mental health services.
Jake Hard, Panel member, said:
“We are calling for the establishment of an independent mechanism to investigate all deaths occurring whilst detained under the MHA, bringing these into line with the investigation of deaths in prisons, police custody, and immigration detention. This approach will help to ensure improved quality and consistency of investigations and provide greater transparency and accountability of the organisations responsible for the person’s care at the time of their death. Furthermore, this approach will contribute to a better understanding and analysis of the factors relevant to deaths across different detention settings.”
Lynn Emslie, Chair, said:
“Families deserve answers, transparency, and accountability when a loved one dies in state detention. The current system of investigations commissioned by NHS and provider trusts is not independent or transparent and there needs to be improved, consistent data collection and reporting – the consistently high number and rate of deaths in MHA detention highlight why this is so important. We urge the government to act now to ensure all deaths in custody are investigated equally, with the same rigour and independence.”
Read the full report here.