Deaths in Mental Health Settings

Charles Walker Excerpts

Friday 27th February 2015 Commons Chamber

[Mr Charles Walker (Broxbourne) (Con)]

I rise to congratulate Deborah Coles and INQUEST on publishing an extremely important document entitled “Deaths in Mental Health Detention: an Investigation framework fit for purpose?”. INQUEST’s report focuses on the deaths of those detained under the Mental Health Act 1983. There are two sad truths. First, too many people are dying in mental health detention—on average more than 300 people a year in each year between 2003 and 2013. Secondly, there is no mechanism for independent investigation of those deaths.

Mental health patients have an absolute right to life, and that right must not be forgotten, abused or cast aside. That absolute right to life extends to the state having a positive duty to safeguard those patients from taking their own life. When there is a death in custody, the police have the Independent Police Complaints Commission to investigate it. The Prison Service has the prisons and probation ombudsman to investigate, but the NHS has nothing that could be classed as independent.

The Coroners and Justice Act 2009 clearly states that deaths in mental health detention that are “violent or unnatural” or cases in which

“the cause of death is unknown”

should be scrutinised at inquests before a coroner sitting with a jury. However, in almost all cases in the NHS, the relevant trust or care provider is the investigating agency, so we have the NHS investigating itself when someone dies while in its care. There are many problems with that.

One of the main problems is that coroners are reliant on the reports provided by the NHS body that is investigating itself when someone dies in its care. Also, families are too often excluded from the investigation processes conducted by NHS trusts, and the length of time that an inquest can take is enormously variable. Some can be done very quickly, resulting in families feeling railroaded; others can take years. One anomaly that needs to be addressed is that any inquest that takes a year and a half or more is deemed to have taken a year and a half. So an inquest can wait to be heard for five years, yet for the purpose of statistics it has been waiting for only a year and a half—that is unacceptable.

As I have said in this place on numerous occasions, there is inequality in representation: the agents of the state are represented by QCs funded by the taxpayer, whereas the families are pretty much left to their own financial devices. I shall return to that issue later. There is also a desperately poor collation of statistics on the type, number, frequency and features of these deaths—there is no transparency. INQUEST observes in its report that its

“experience is that the practice of NHS Trusts in investigating these deaths, and the issues raised by them, is consistently falling short of the existing guidance”.

INQUEST reports that over the past five years it has been unable to identify a single independent investigation at the evidence-gathering stage following a self-inflicted death.

INQUEST goes on to cite the following deficiencies in the process: a lack of family liaison with trusts following a death; families not being provided with any information about the investigation process or informed of their right to be involved in that process; no information being provided to families as to where they can find independent advice and support; families having little, if any, opportunity to raise concerns or questions; families not being provided with the terms of reference of an investigation; trusts refusing to provide families with the final versions of reports; and trusts failing to pass on a copy of the final report to the coroner. This situation is absolutely devastating for families and its impact on their morale cannot be overstated. It is wrong and something needs to be done. Sadly, the list I have read out is incomplete, but time prevents me from adding further points.

More generally, the superficial nature of investigations and the speed at which some cases move to the inquest hearing stage leave many families without any meaningful chance of establishing the circumstances of their relative’s death and, crucially, whether the death was preventable. As I said a few moments ago, there is another option for trusts keen to avoid their responsibility or owning up to their responsibility. One option is to push the investigation through extremely quickly, railroading people, but the other option is to drag its feet. As I said, an investigation that took five or six years to complete would still be deemed to have taken a year and a half when the coroner’s court reported. That is unacceptable.

Why is robust investigation so important? It is because our coroners generally rely on other agencies to gather relevant evidence before an inquest hearing, and have limited resources and powers to direct any initial investigations. So a coroner’s court will only be as good as the evidence provided to it. Therefore, it is currently the case that the rigour and thoroughness of inquests into deaths in mental health detention are ultimately dependent on the internal hospital investigation—the NHS investigating itself. The shortcomings in the current process mean that highly relevant evidence is often not identified, gathered and preserved, or, even worse, that the evidence-gathering process is influenced by those who have both control of the material and an interest in the outcome. INQUEST states:

“This incomplete or tainted evidence then flows through the inquest system and is effectively ‘fruit of the poisonous tree’”.

So if we are to continue with the current discredited system—I hope we are not—at the very least NHS trusts and health care providers need clear guidance, not just on the form of their investigations, but on who is responsible for undertaking them. Ultimately, what we need is the independent investigation of deaths, along the lines of the investigations undertaken by the Independent Police Complaints Commission and the prisons and probation ombudsman. We need an independent investigation that involves the families of the deceased, which, at its conclusion, produces a rigorous investigation report that is published and made widely available. That and only that will allow for robust inquests that get to the truth.

At these inquests there must be equality of representation. As I said earlier, it is simply not acceptable for the agents of the state to be represented by QCs funded by the taxpayer, while the families of the deceased are means-tested to see what they can afford. Quite simply, if someone is in the care of the state, the state has a duty of care.

If we are to have the proper investigation of deaths in mental health settings, we need greater investigatory independence matched to a coherent data set on the number of deaths in mental health settings. These data should record age, gender, ethnicity, the location of the death and the type of death—for example, whether it was self-inflicted, restraint-related or from natural causes. As death rates by individual units or clinical commissioning groups are not published, the statistics currently available in the public domain do not enable identification and analysis of where deaths in mental health settings take place. Again, this lack of transparency must be addressed.

The lack of publicly available data is particularly concerning in relation to ethnicity, where there are significant concerns about the continued over-representation of black people in mental health settings and the coercive use of force that features in some of their deaths. I would like to take this opportunity to briefly congratulate and thank Matilda MacAttram of Black Mental Health UK on her fantastic campaigning in this important area. I see that the Policing Minister is on the Front Bench; I am sure that he will pass on his congratulations to Matilda as well.

[The Minister for Policing, Criminal Justice and Victims (Mike Penning)]

indicated assent.

[Mr Walker]

Perhaps most worryingly, it is difficult, if not impossible, to identify from the current statistics the number of children who have died in mental health settings. This is simply not good enough. Children are detained in mental health settings and sadly, on occasions, some of those children are dying while being detained. We really need to minimise that occurrence as a matter of utter urgency.

The Minister replying to this debate will know that deaths in custody—or, more accurately, deaths while in the care of the state—is the topic of much debate at the moment, with the Equality and Human Rights Commission publishing its paper and concerns earlier this week. That paper was launched in the House of Commons. There is growing concern, and it is clear that there is a demand from many quarters, across the United Kingdom—people with a stake in this issue—for decisive action to be taken. Although for the past 10 years the overall trend has been downwards, deaths in mental health settings still account for 60% of all deaths in state custody.

More than half the deaths in mental health settings are ascribed to natural causes, but this in itself is a cause of concern, because the descriptor “natural causes” may mask deaths where contributing factors include the side effects of high-dose, multiple medication on the individual’s physical health. There is too much uncertainty hidden under the heading of “natural causes”, and it will stay that way until in-house investigators are replaced by independent investigators and independent oversight; because in an ideal world, where there is a violent death —a death that involves suicide, the use of force or restraint—the default position should be for an independent investigation. In cases where natural causes are suspected, an independent body could review the initial findings of the NHS trust before accepting them or asking for more information, with a view to mounting a formal investigation.

Seeing that the Policing Minister is here, I cannot let this occasion pass without saying that there is still widespread concern that on too many occasions police officers are being called to mental health wards—NHS environments—to restrain patients. Police officers are not trained to do that. I know this is causing the Minister concern; I know it is causing police officers concern. It should cause us all concern.

In conclusion, there is much work to be done to ensure that where a tragedy does occur in a detained mental health setting, there is a robust, independent system of investigation that gets to the truth, provides both closure and reassurance to grieving families and, through initiating changes in existing processes and procedures, prevents future deaths. I met some of the families last week who attended the launch of the INQUEST paper. It was a very sobering experience. These are good people who are seeking answers as to why husbands, wives—people they love—have lost their lives while in the care of the state. We need to be better at providing those answers.

--- Later in debate ---

[Jane Ellison]

Yes, he is wearing both hats today. He has confirmed that he will take this matter forward in the Ministry of Justice, and I am grateful to him for that. The fact that, in the last Adjournment debate of the parliamentary week, the two Departments most closely involved in responding adequately to these matters are represented by Ministers shows how important they are.

My hon. Friend the Member for Broxbourne might wish to raise his concerns about the robustness of inquests directly with the Office of the Chief Coroner. However, let me tell the House about another way in which the better use of data is helping in this situation. I understand that the Care Quality Commission is undertaking analysis of the information available from coroners’ investigations and inquests, along with other information it already receives on expected and unexpected deaths, which should help it to target requests from coroners better.

The Care Quality Commission is also working with the Coroners Society of England and Wales and the Office of the Chief Coroner to establish a memorandum of understanding, with the aim of achieving better working relationships and sharing of information. I am sure that my hon. Friend, having had the chance to highlight the importance of this issue today, will want regularly to ask questions, presumably in the next Parliament, about how this work is progressing and what the timetable is. Indeed, the Minister for Policing, Criminal Justice and Victims has heard his request for vigour and energy behind that work.

In conclusion, it is absolutely right that we should seriously consider how to improve the investigation of deaths in mental health settings.

[Mr Charles Walker]

The reason independent investigation is so important is that people can be detained against their will under the Mental Health Act 1983. There needs to be some oversight of their welfare, and they need to be safeguarded, but it is difficult if that is provided only by the NHS, the organisation that is responsible for detaining them. That is why independent oversight and safeguarding is needed.

[Jane Ellison]

I absolutely understand that point, which my hon. Friend has made with some power. I certainly undertake to speak with my colleague the Minister of State, the right hon. Member for North Norfolk (Norman Lamb), who leads on mental health matters in the Department, and ensure that he is aware of my hon. Friend’s strength of feeling about the issue. I will refer him to the Hansard report of this debate. I am sure that my hon. Friend will continue to press the case. I hope that the issues I have touched on in my response give him some sense that work is in train to look at this. The seriousness of the issue is very much acknowledged in both the Department of Health and the Ministry of Justice.

It is important that we set out clear requirements for rigorous, transparent and timely investigations of serious incidents, including deaths, and for all those affected, including the families, to be involved throughout those investigations. We must continue to seek to improve the overall process of learning from deaths to prevent further avoidable tragedies. The Department of Health, NHS England and the CQC continue to look at ways of improving the system, along with colleagues in other Departments, particularly in relation to transparency and ensuring that lessons are learned. I congratulate my hon. Friend once again on bringing these important matters to the attention of the House.

Question put and agreed to.