Latest data on deaths under the Mental Health Act must be a catalyst for enhanced patient safety and informed learning

Our research shows that people detained under the MHA have the highest mortality rate across all places of detention, including three times higher than prisons.

Worryingly, the ethnicity of nearly one in six patients who died in 2022/23 was recorded as unknown – a serious concern the Panel has raised for a number of years. The absence of high-quality and disaggregated data means it is much harder to draw meaningful learning to better understand inequalities and prevent deaths across different population groups. We are pleased to see that better data is an area of focus for the CQC and we remain keen to support this work.

We welcome the Government’s commitment, made yesterday in response to the rapid review into mental health inpatient safety, to bring together stakeholders to identify improvements to the timeliness, quality and availability of deaths data. This has been an issue for too long, and the Panel is eager to support this work to ensure meaningful improvements are delivered quickly and effectively.

Further, by comparison to deaths in prisons, police custody and immigration detention, there remains a troubling deficit in independent investigation into these tragic, and often preventable, deaths. Instead, deaths are often investigated by the same trust responsible for the patient’s care, rather than an independent investigator, prior to an inquest.

The concerningly high number and rate of deaths each year demands independent scrutiny be placed on detention under the MHA. The Panel’s priority focus is to provide advice and recommendations to the Government and senior health leaders on addressing the significant gap in learning and accountability and drive improvements to patient safety, informed by the collation of high-quality data.