Enquiry finds 662 avoidable deaths while in police custody


An enquiry conducted by the Equality and Human Rights Commission has found that between 2010 and 2013 there were 662 deaths from non-natural causes of adults with mental health conditions.

The inquiry found that the same mistakes are being repeated across prisons, police cells and psychiatric hospitals. This includes, for example, the failure to appropriately monitor patients and prisoners at serious risk of suicide, even in cases where their records recommend constant or frequent observation. It also includes failure to remove “ligature points” in psychiatric hospitals, which are known to be often used in suicide attempts.

According to the inquiry report, psychiatric hospitals are an “opaque system”. The Commission found it difficult to access information about non-natural deaths in psychiatric hospitals, such as individual investigation reports. This contrasts with prisons and police settings, where there is an independent body in charge of investigating deaths and ensuring that lessons are learnt.

The Commission also found misplaced concerns about data protection, leading to failures to share important information, such as concerns of other professionals about mental health, or suicidal tendencies not being passed on to prison staff. Similarly, failure to involve families to support the person being detained make it difficult for the family to pass on information that might have prevented deaths. Poor communication between staff, including lack of updates on risk assessments after self-harm or suicide attempts, was also highlighted.

Other significant findings included:

•The availability of drugs, including “legal highs”, in prison.

•Evidence of bullying and intimidation in prisons in the lead-up to someone talking their own life. This can result in a person being locked up alone in a cell for their own safety, because there is nowhere else for them to go. This can lead to deterioration of the person’s mental state.

•Inappropriate use of restraint in people with mental health conditions, including “face-down” restraint. There were also increasing reports of police officers being called out to restrain people on psychiatric wards.

•A high number of deaths occurred shortly after a person ended a period of detention, suggesting insufficient mental health support and follow-up.

The EHRC recommends:

•Structured ways of learning from deaths and near misses in all settings where people with mental illness are detained, to ensure that improvements are made.

•Individual prisons, hospitals and police settings should focus more strongly on meeting the basic responsibilities of keeping detainees safe. It recommends better staff training, and for the inspection regimes to explicitly monitor this.

•The Commission wants more “transparency”, to allow services to be scrutinised and held to account. The Commission suggests that the “statutory duty of candour”, which is being introduced in April 2015 and applies to all NHS bodies in England, could help to achieve this.

AHPN welcomes this enquiry into unnecessary deaths while in police custody, as it serves as a reminder about the deaths of BAME people while being detained in custody. Many people from BAME backgrounds have died while in police custody one of the most famous examples of this is the death of Sean Rigg where a jury found that police used unnecessary force while trying to restrain him. Lessons need to be learned and rigorous investigations need to be conducted for every death that occurs while in police custody and psychiatric hospitals.