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Mentally Ill: Death

Volume 467: debated on Thursday 15 November 2007

To ask the Secretary of State for Health in respect of what percentage of deaths occurring in mental health institutions inquests were held in the last five years. (163930)

[holding answer 13 November 2007]: This information is not collected by the Department.

Deaths of patients who were detained under the Mental Health Act 1983 should be referred to Her Majesty's Coroner (HMC). HMC will hold an inquest where the medical cause of death remains in doubt after a post-mortem examination, or if the cause of death is violent or unnatural or where a death has occurred in such a place as to require an inquest under section 8 (1) of the Coroner's Act 1988.

To ask the Secretary of State for Health what guidance he has issued to mental health trusts on (a) procedures to be followed and (b) inquiries to be made following deaths of patients held under mental health legislation. (163931)

[holding answer 13 November 2007]: The Department issued guidance in 1994 Health Service Guidance (94) 27: “Guidance on the discharge of mentally disordered people and their continued care in the community” which details action to be taken following mental health in-patient deaths. This was followed by further guidance in 2005, “Independent investigation of adverse events in mental health services”, which updated part of the 1994 guidance.

This guidance requires strategic health authorities to commission independent investigations. This involves appointing the investigation team, agreeing terms of reference, publishing and distributing the results and agreeing a local action plan following a homicide committed by a person in touch with mental health services.

The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH) collects data on suicide and sudden unexpected deaths of in-patients and homicides committed by persons in touch with mental health services. NCISH is funded by the National Patient Safety Agency and published its latest report, “Avoidable Deaths”, in December 2006. This reviews homicides in England and Wales between April 1999 and December 2003 and suicides from April 2000 to December 2004.

The Mental Health Act Commission (MHAC) collects data on all detained patient deaths and publishes data on those from non-natural causes in its biennial report. MHAC, under its general remit to keep under review the operation of the Mental Health Act 1983, asks providers to notify it of all deaths of detained patients within three working days.

MHAC reviews the deaths of patients who have died from non-natural causes to establish whether good practice, as defined in the Mental Health Act 1983 Code of Practice, has been followed and whether lessons for future practice and policy need to be learned. This review may include sending a Commissioner to the inquest which considers the circumstances of the death or arranging a visit to the hospital to consider the issues arising.