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Like-minded organisations in pursuit of restraint-free services

Investigating deaths in mental health units and NHS Trusts


Panorama aired a programme in early April highlighting the lack of consistency surrounding the recording of deaths that occur in mental health units. Research by the charity Inquest (who work with people bereaved by a death in custody and detention) referred to their own casework plus 238 separate Freedom of Information requests and suggested that at least nine young people have died as “in-patients”. In an answer to a written parliamentary question on the topic last year, Care Minister Alistair Burt MP said that only one death had been recorded by the Care Quality Commission (CQC). When interviewed by the programme, Mr Burt stated that he did not know the true figure and accepted that more research was required.

The Restraint Reduction Network share the concern of many professionals, service users, families and advocacy groups that the real issue is one of corrupted organisational cultures. Commissioners, providers and regulators have a clear responsibility to ensure those people who are less able to advocate for their rights and who are more likely to be subject to care and support that does not meet their needs (especially when such care and support is poor, neglectful or abusive) require services that are well-governed and transparent. This includes clear recording and reporting procedures and a robust and open reveiw of critical incidents that result in harm.

Too often it appears that organisations repeat the failings that others have made in previous years. Having some centralised process to share mistakes so that others can learn is desperately needed.

Also this month, the CQC announced that they would be launching a review into how NHS trusts “identify, report, investigate and learn from deaths of individuals using their services.” The investigation has been launched as the result of a request from the Secretary of State for Health, following the inadequate response to the deaths of people with a learning disability or mental health problem in contact with Southern Health NHS Foundation Trust.

The review will focus on the “quality of practice” in relation to “identifying, reporting and investigating” any deaths of individuals using a service managed by the NHS, whether in a hospital setting, care in community or living at home. Professor Sir Mike Richards, CQC’s Chief Inspector of Hospitals, said ‘every year thousands of people under the care of NHS trusts die prematurely because their treatment or care has not been as good as it could have been.’ He added ‘it is essential that, when this happens, NHS services identify and investigate the circumstances of these deaths so that staff can learn from them and reduce the likelihood of a similar event happening in the future.’ The findings are expected to be released by the end of the year.