1. Investigating
Deaths
in
a
Mental
Health
Setting
In
February
2016
a
taskforce
set
up
by
the
NHS,
chaired
by
the
Chief
Executive
of
Mind
Paul
Farmer,
produced
a
report
entitled
the
Five
Year
Forward
View
for
Mental
Health.
The
taskforce
gave
a
frank
assessment
of
the
state
of
current
mental
health
care
across
the
NHS,
highlighting
that
one
in
four
people
will
experience
a
mental
health
problem
in
their
lifetime
and
the
cost
of
mental
ill
health
to
the
economy,
NHS
and
society
is
£105bn
a
year.
In
a
wide
ranging
package
of
recommendations,
it
proposes
a
three-­‐pronged
approach
to
improving
care
through
prevention,
the
expansion
of
mental
health
care
such
as
seven
day
access
in
a
crisis,
and
integrated
physical
and
mental
health
care.
One
of
the
most
important
recommendations
is
for
the
introduction
of
an
independent
system
for
scrutinising
the
quality
of
investigations
into
all
deaths
within
in-­‐patient
mental
health
settings.
This
is
particularly
poignant
in
the
wake
of
the
December
2015
Mazars
Report
which
investigated
the
deaths
of
people
with
mental
health
problems
and
learning
disabilities
who
were
being
cared
for
by
NHS
Southern
Health
Trust.
The
report
examined
the
period
between
April
2011
and
March
2015,
and
of
the
10,306
deaths
of
service
users
cared
for
by
NHS
Southern
Health
Trust,
722
were
categorised
as
unexpected;
of
these
deaths
only
30%
were
investigated.
Of
the
deaths
that
were
investigated
64%
did
not
involve
the
family.
Perhaps
most
disturbing
is
that
only
4%
of
all
unexpected
deaths
involving
people
with
learning
disabilities
were
investigated
by
the
Trust.
The
report
found
that
there
was
poor
leadership
of
the
investigation
of
deaths
at
corporate,
director
and
area
level
within
NHS
Southern
Health
Trust.
In
addition,
the
report
found
that
the
Trust
tended
to
interpret
the
criteria
for
what
constituted
a
serious
incident
that
required
investigation
too
narrowly
to
reduce
the
number
of
investigations
required.
Unlike
deaths
in
prison
or
police
custody
there
is
no
independent
agency
responsible
for
investigating
deaths
in
a
mental
health
setting.
When
a
death
in
a
mental
health
setting
occurs
the
cause
needs
to
be
quickly
identified,
properly
categorised,
investigated
and
reported.
This
improves
safety
for
service-­‐users,
providing
the
Trust
learns
from
the
investigation.
The
parents
of
Connor
Sparrowhawk,
who
very
sadly
died
in
a
Southern
Health
Trust
Unit
in
2013,
and
those
who
support
them,
have
been
instrumental
in
bringing
these
issues
to
the
fore
(http://justiceforlb.org),
but
there
is
still
a
really
long
way
to
go.
The
introduction
of
an
independent
system
examining
the
quality
of
investigations
into
deaths
would
add
an
important
level
of
scrutiny,
and
could
save
lives.
Andrew
Spooner,
Paralegal
2016