An investigation has discovered that hundreds of patients detained under the Mental Health Act may have been denied inquests to which they are entitled.
Any death of a patient considered mentally ill should be reported to a coroner for further investigation.
But official figures indicate that of 1,115 cases recorded by the NHS over the last three years, approximately one-third were in fact reported as should be requisite.
Charities and politicians have been scathing regarding the figures, with many suggesting that it shows a fundamental failing in the health service.
Official Ministry of Justice figures indicate that between 2011 and 2014, only 373 deaths of people detained under the Act were reported to coroners in England and Wales.
With the authorities being condemned for this oversight, health watchdogs have begun to examine NHS investigations into the death of patients, amid concern that those with learning disabilities have not been adequately examined.
Brian Dow, from the charity Rethink Mental Illness, suggested that the report represents a crisis, and would prevent progress from being made in this area.
“If incidents are not being appropriately referred and examined then lessons can’t be learnt about how to avoid further tragedies in the future. We owe it to people detained under the Mental Health Act and their families to ensure this. We want to see a robust, independent and transparent system for investigating deaths in mental health settings, so no more families are left without answers.”
Diane Abbott, shadow health secretary, was extremely critical of the figures, suggesting that the government was letting both the public and the mentally ill down badly.
“These figures are shocking. If the state has deprived someone of their liberty and they then die under detention, their death must be reported to a coroner. If you are not learning about what is causing the deaths, you are limiting the ability to learn for the future. What is more alarming is that if this data is accurate, only a minority of deaths in state detention have been investigated by a coroner. These are deaths of people who are owed a duty of care by the state.”
Commenting on the issue, a Department of Health spokesman acknowledged that all such deaths should be investigated adequately, but also suggested that the alarming nature of these figures could be partly explained by aberrant methods of recording.
“Families deserve an explanation if their loved ones pass away under NHS care and we expect every death in detention to be investigated thoroughly to make sure lessons are learnt. The Care Quality Commission is reviewing the quality and robustness of NHS investigations into deaths under the Mental Health Act; however, there is no evidence of significant under-reporting.”
The Care Quality Commission continues to inspect 12 NHS trusts in the wake of the unfortunate, and widely publicised, passing of Connor Sparrowhawk.