Question to the Department of Health and Social Care:

To ask the Secretary of State for Health and Social Care, how many children died while receiving inpatient mental health care in each year since 2010; and what steps his Department is taking to help ensure that (a) these deaths are properly (i) recorded and (ii) investigated and (b) future deaths are prevented.

Answered by Zubir Ahmed - Parliamentary Under-Secretary (Department of Health and Social Care)

Since 2013, there has been a total of 40 deaths of young people aged under 18 years old in contact with Tier 4 inpatient children and young people’s mental health services, including those on home leave, or who had absconded. We are unable to provide the information broken down by year as requested, as the annual data held by NHS England includes a small patient count of fewer than five cases which could lead to the identification of individuals. Data is not available prior to 2013.

All deaths of children and young people under the care of Tier 4 services are routinely reported to the Department via NHS England. Such deaths are also notified to the Care Quality Commission and the National Confidential Inquiry into Suicide and Safety in Mental Health.

With regards to investigating inpatient deaths, the NHS Patient Safety Incident Response Framework (PSIRF), introduced in August 2022, promotes four core principles to inform learning from safety events: compassionate engagement; systems-based learning; proportionate responses; and supportive oversight. While PSIRF represents a significant improvement to the way that the National Health Service responds to patient safety incidents, it does not alter the requirements set out in the National Learning from Deaths policy framework. These require a patient safety incident investigation to be undertaken into any event where problems in care are thought more likely than not to have led to the death of a patient.

To help ensure that future deaths are prevented, NHS England has radically redesigned the children and young people’s inpatient model of care, working in partnership with hundreds of children, young people, and their families. One of the key recommendations from working with families through the Quality Transformation Programme was to change the service model to enable families to stay overnight at inpatient services to maintain the connection with their loved one and, critically, to ensure that the delivery of care at a point during a crisis is seen as being delivered to the young person, as well as their family and support network. These recommendations have been built into the new service model. NHS England is in the process of testing the new service model through the use of a development service specification.

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