Deaths in detention of hundreds of people with mental health conditions could have been avoided, new Inquiry finds

Repeated basicerrors, a failure to learn lessons and a lack of rigorous systems andprocedures have contributed to the ‘non-natural deaths of hundreds of peoplewith mental health conditions’ detained in psychiatric hospitals, prisons andpolice cells in England and Wales, accordingto a major new Inquiry by the Equality and Human Rights Commission.

The Inquirycovered the period 2010-13, during which 367 adults with mental healthconditions died of non-natural causes while detained in psychiatric wards andpolice cells and another 295 adults died in prison, many of whom had mental illnesses.

The Inquiry foundfailures by institutions to bring in processes to learn from lessons andimplement recommendations. As a result, the Commission has, for the first time,created an easy-to-follow Human Rights Framework, aimed at policy makers andfront-line staff across all three settings, which includes 12 practical steps tohelp protect lives.

ProfessorSwaran Singh, LeadCommissioner on the Inquiry said: “Human rights are for all of us andnothing is more fundamental than our right to life. When the state detainspeople for their own good or the safety of others it has a very high level ofresponsibility to ensure their life is protected. For people with mental healthconditions that is a particular challenge with a large number of tragic casesover the past few years where that responsibility has not been met.

“TheCommission, as Great Britain’s National Human Rights Institution, carried outthis Inquiry in consultation with other expert bodies to examine what lessonscan be learned in how to prevent further unnecessary and avoidable harm andheartbreak.”

Alun Thomas, Chief Executive of Welsh mentalhealth charity Hafal said: “As a service user and carer-led charity we are very concerned aboutthe findings of the report. Vulnerable people are being gravely let down byservices; every death is a tragedy. It’s essential that the recommendations areacted upon as soon as possible.

“Hafal istackling these issues head-on. Lastweek we announced funding of almost half a million from the Big Lottery to deliverour “Out of the Blue” service which will provide a brand newmental health intervention for offenders and support them to access theservices they need. We are particularly concerned that when aperson is detained under section 136 of the Mental Health Act and they are takento a place of safety, there are insufficient hospital spaces available and oftenthe person ends up in a prison cell. It is essential that people in crisis areprovided with suitable accommodation which meets their care and treatmentneeds.

“Hafal isalso prepared to lead by example. Weare in the process of developing our own in-patient services. Our newservice user and carer-led recovery centre will launch in the coming years and wewill work with the NHS in Wales to establish best practice for hospitalservices, providing a safe, therapeutic and recovery-focused service for in-patients.”

·        Downloadthe Equality and Human Rights Commission inquiry report report at:

·        Findmore information on Hafal’s “Out of the Blue” at:

·        Formore information on Hafal’s Recovery Centre go to: