A recent report commissioned by NHS England and discussed by The Health Service Journal suggests that hundreds of patients, who died, whilst being detained under the Mental Health Act 1983, may have been denied inquests.
The main issue here is that all deaths in state detention, whether that is within the initial stages at police detention, within the prison service or whether detained under the Mental Health Act should, by law, be examined by a coroner. It is then up to the coroner to decide, upon evidence, if an Inquest is necessary within the public interest.
The concerns raised in this report show huge inconsistencies between official data of deaths reported to the coroner and reports sent to NHS trust regulators, suggesting that coroners are not always aware of a death in custody. If a coroner is not made aware then simply an Inquest can not be opened.
The reporting figures provide an alarming picture of the extent of this problem. According to Ministry of Justice figures between 2011 and 2014 a total of 373 deaths of people detained under the Mental Health Act were reported to coroners in England and Wales. In contract the figures supplied by the Care Quality Commission show a total of 1,115 deaths. This suggests that only a minority of deaths occurring whilst in detention have been investigated, as the law requires, by a coroner and 742 deaths have not been investigated.
By law all deaths in detention should be investigated and the Department of Health have accepted that it could not rule out the real risk that patients and families have been denied inquests.
The shocking and very sad impact of this is that families who have lost a family member may never know why their loved one died whilst in the care of the state. The state has a duty of care to ensure that people who are detained in their care are in fact cared for and when a person does die it is essential that events surrounding their death are investigated. The investigation should answer questions for the family but also provide ways to prevent further deaths.
The figures are shocking and it is obvious that more needs to be done to ensure there is an openness surrounding deaths in custody. There is no independent framework for this area and coroners are simply not resourced to conduct investigations themselves. The system is reliant on reviews and reports by already strained NHS trusts. Even so each case requires investigation because the state has deprived someone of their liberty and they have died whilst under detention. Fundamentally if you are not learning about what is causing deaths in custody you are limiting the ability to prevent further ones. When a person’s liberty is taken away it should not mean that if they die the family are not entitled to answers.
If incidents are failed to be reported or appropriately examined then lessons can not be learnt to avoid further deaths. It is clear that when a loved one dies families deserve an explanation of why their loved one has passed away under NHS care. A death should be reported, examined and lessons should be learnt from it.
The Care Quality Commission is currently undertaking a review of the quality and robustness of NHS investigations into deaths of people detained under the Mental Health Act. It is with hope that this review will provide a system which is robust, independent and transparent so that no family is left without answers.
If you or your family are faced with the unfortunate and difficult task of trying to represent yourselves in the inquest into the death of a loved one and feel you would benefit from legal assistance, please contact us – we offer a free initial consultation and represent families across the country. We are experienced in applying for exceptional funding and are able to provide legal representation at inquest for a fixed fee.
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