Mental Health Bill [ Lords ] (Ninth sitting)

Josh Dean Excerpts

Committee stage
Tuesday 24th June 2025 Public Bill Committees

[Natasha Irons (Croydon East) (Lab)]

I beg to move, That the clause be read a Second time.

The new clause seeks to ensure that if a patient dies while in detention under the Mental Health Act, an independent inquiry into their death will be required. Unlike deaths in prison or police-related deaths, deaths while a person is detained under the Mental Health Act are not automatically investigated independently. Currently, if a person dies while detained under the Act, the trust responsible for their care should carry out an internal investigation into their death to find out what happened and whether lessons can be learned. Those investigations, known as serious incident investigations or root cause analysis, do not have any independent oversight and can vary a lot from trust to trust.

Inquest, the only charity in England and Wales providing expertise on state-related deaths and their investigation, has found that the current system for investigating such deaths is not fit for purpose. In its statement to the Lampard inquiry, it outlined an anonymised case from 2010 in which there was a stark contrast between the findings of the NHS trust that investigated the death of a patient detained under its care and the inquest that took place two years later. The trust found very few failings in care, whereas the jury at the later inquest were critical of the patient’s treatment, which directly led to their death. The question we must ask ourselves is why we would allow deaths while in detention under the Mental Health Act to be investigated by those in charge of custody, when deaths in any other setting would not be. We do not allow the police to judge their own actions if a death occurs in custody, so why should it be any different for those detained under the Mental Health Act?

[Josh Dean (Hertford and Stortford) (Lab)]

My hon. Friend is making a fantastic speech. In the really dire circumstances of a death in detention, we are dealing with the most difficult and, for family members and loved ones, the most devastating circumstances. Given that, does she agree that it is important to make sure that the circumstances are reviewed thoroughly and independently?

[Natasha Irons]

My hon. Friend is absolutely right. This is about transparency and providing answers for the families of patients when the very worst happens.

Independence has allowed investigations into deaths in places of custody to improve significantly. As outlined by the independent advisory panel on deaths in custody, patients detained under the Mental Health Act now have the highest mortality rate across all places of custody. Indeed, the rate is three times higher than in prisons, when taking into account estimates of time in custody and the number of people in each setting. Behind each of these tragedies are families who have unanswered questions and who have had to fight to find out what happened to their loved ones, and vulnerable people who should have received better care.

In my constituency, there is the story of Catherine Horton, who died in 2017 while in the care of the South London and Maudsley NHS trust. The inquest into her death found that the risk assessment was not properly updated, with no formal risk assessment conducted, and no care plan on her arrival or while at the facility. There is also the story of Tia Wilson, who died in 2021 in the care of the same trust. The inquest into her death found that there were multiple failures in managing her risk, which contributed to her death. Then there is the story of the brother of one of my constituents, who absconded from his care, went missing, and was later found dead in a wooded area a stone’s throw from her home.

For each of those cases, we know that internal reviews will have taken place and assurances of improvements will have been made, and yet issues with risk assessments remain and families are left pushing for answers. This is not unique to south London; the internal review process is failing to deliver the necessary improvements across the country. Without embedding independence into the process, we risk undoing a lot of the good work that the Bill seeks to achieve. Adding independence into the investigation of these incidents where the very worst things happen gives trusts a genuine space to learn the lessons. It would improve patient safety and provide families with the transparency they need.

Although we must all acknowledge the incredible work that trusts do across our country to provide care for people at their most vulnerable, we must also provide a proper framework for challenge and improvement. The new clause is an opportunity to treat the deaths of people detained under the Mental Health Act with the same seriousness and care as deaths in other custody settings, to embed transparency, and to make the meaningful improvements that all patients deserve.

--- Later in debate ---

[Jen Craft (Thurrock) (Lab)]

I beg to move, That the clause be read a Second time.

I will speak briefly to the new clause, which was tabled by my hon. Friend the Member for Sheffield Hallam (Olivia Blake). Its aim is to close a loophole in the current framework by which use of restraint is recorded. Currently, the use of restraint is governed by the Mental Health Units (Use of Force) Act 2018, which mandates that where force or restraint is used in a mental health unit, that must be recorded and reported. There are, however, a number of patients who are treated outside mental health units and therefore do not fall within the scope of the Act. My hon. Friend the Member for Sheffield Hallam has spoken about the issue, to which her attention was particularly drawn in the context of the treatment of patients with eating disorders. This happens quite often, either where there is a shortage of beds in a mental health unit or where the patient in question has co-occurring physical health conditions that require treatment outside such a unit.

Restraint is used regularly and often on patients with eating disorders, by which I mean restraining them to force them to eat, but there is currently no mechanism by which its use must be recorded. If a patient, particularly a young person, who is in hospital but is not in a mental health unit is subject to this restraint, which may be deemed necessary to preserve life and in their best interests, there is currently no mechanism by which that is recorded.

[Josh Dean]

We touched earlier on the safeguards around electroconvulsive therapy. Does my hon. Friend agree that when someone with an eating disorder is restrained, particularly in circumstances that involve the administration of nasogastric tube feeding, such safeguards are really important because of the invasive nature of the treatment and the potential restraint used in delivering it?

[Jen Craft]

My hon. Friend is absolutely right. The crucial purpose of the new clause is to ensure that the use of restraint is recorded at all times, as well as highlighting that quite often the restraint may be carried out not by a member of the medical staff, but by hospital security, for example. I think we can only imagine the real horror and force involved in that.