Shine A Light

The case for independent investigation of deaths in mental health institutions

When someone dies in a mental health unit in England or Wales, there is currently no obligation to carry out an independent inquiry.

Ayesha Carmouche Deborah Coles
17 May 2015
Annesley House.jpg

Annesley House, run by mental healthcare provider Partnerships in Care

Rebecca Overy was just 18 when she was found collapsed with a ligature around her neck on 23 June 2013 in Annesley House, a privately-run adult secure hospital in Nottinghamshire.

Rebecca had a history of mental health problems and self-harm, and had been receiving treatment in hospital since the age of 13. She was initially detained under the Children’s Act and later the Mental Health Act. 

As she approached her 18th birthday, she was making progress at a private hospital in Woking, Surrey.


Rebecca OveryPlans were being made for her eventual release. She had secured a college place to study animal welfare and her mother had found her voluntary work at an animal charity. Rebecca liked making jewellery. In her room at the unit she listened to music; she had posters on her wall.

On the day after she turned 18, Rebecca was immediately transferred 150 miles north to Nottinghamshire, to a facility for adults: Annesley House. (It’s run by Partnerships in Care, part of the for-profit Acadia Healthcare Group based in Franklin, Tennessee.)

Over the following weeks, the family watched in desperation as Rebecca’s spark disappeared.

Late last year the inquest into Rebecca’s death revealed multiple failures: a long history of suicide and self-harm which escalated after her speedy transition to adult mental health care, and reduced observations which gave Rebecca the opportunity to prepare a ligature. (The Coroner’s Report to Prevent Future Deaths is here).

At the inquest’s conclusion Rebecca’s mother and step-father said:

“…healthcare professionals have all moved on with their lives, but we will not … Unfortunately, for us they obviously had lessons to learn so they took away our beautiful daughter, our future family, our future grandchildren and our world will always be a darker place because of what they did NOT do for our precious Rebecca.”

Rebecca’s death was not an isolated incident; she was one of many vulnerable individuals who have died in mental health settings since 2000. According to the monitoring body, the Independent Advisory Panel on Deaths in Custody, 60 per cent of deaths in detention — including prisons, immigration removal centres, police custody — occur in mental health institutions.

Deaths in other forms of state detention, such as police or prison custody or immigration removal centres, are investigated by (nominally) independent bodies. The Prison and Probation Ombudsman (PPO) investigates deaths in prisons and immigration removal centres, and the Independent Police Complaints Commission (IPCC) investigates deaths in police custody or following police contact. Coroners rely on their inquiries to inform the findings of an inquest into a death.

Both the PPO and the IPCC have been rightly criticised for their ability to hold prison and police authorities to account. Still, the stated purpose of their investigations is to understand what happened, to learn lessons and encourage change that might prevent future deaths. 

They are required to involve bereaved families in the investigation and to separate themselves from the bodies they are scrutinising. 

Despite the disturbingly high number of people who die, no such ‘independent’ investigation follows the deaths of people in mental health institutions. Instead NHS Trusts, which are responsible for providing mental health care, investigate themselves via internal reviews.

INQUEST is a charity which provides help to people bereaved by a death in custody or detention in England and Wales. Earlier this year we published a report on mental health deaths, drawing upon our work with families, and our statistical monitoring and policy work.

The single most important factor highlighted by this report was the absence of a pre-inquest investigation mechanism. Reliance upon the NHS Trusts’ internal inquiry has often been problematic, since the death may have been caused or contributed to by the failures of the hospital’s staff or procedures.

Without the pre-inquest support of an independent investigatory body coroners may be unable properly to investigate systemic failings or to provide insight or guidance on the prevention of future deaths.

Bereaved families often struggle to be involved in the internal investigations and face barriers to disclosure of basic information and relevant documents. Families have described an atmosphere of “them against us” and “a battle to the end”. It does not inspire family or public confidence when an organisation investigates itself over a death in which it may be implicated.

In the past year political parties have amplified their commitments to improving mental health care. The Conservatives and Liberal Democrats have called for mental health conditions to be given equal priority to physical health, while Labour has vowed to invest in child and youth mental health services. And last year a statutory duty of candour placed a legal duty on health and social care providers to be open with patients or their families when things go wrong.

All this is welcome. The starting point must be a post-death investigative framework that is independent.

The average number of self-inflicted deaths of detained patients has remained relatively stable since 2000, at about 48 such deaths a year, which may have led to some complacency. This is perhaps rooted in an assumption that such deaths will happen, because some patients are at high risk of self-harm.

But individuals suffering from acute mental health symptoms may be admitted into mental health institutions for their own protection. Staff receive information about a patient’s vulnerabilities and have control over a person’s treatment and welfare.

Avoidable deaths are more likely to be prevented if investigation holds institutions to account and if lessons are learned and acted upon. The newly elected government must recognise the value of independence and transparency as a necessary means to establish the facts, protect the vulnerable, and to uphold the rights of bereaved families who are longing for answers.



INQUEST’S evidence-based report, Deaths in mental health detention: An investigation framework fit for purpose? (February 2015) can be ordered here.

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