“We have a lot of Incidents”: Why the Investigation Process for Mental Health Deaths Must Change
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The phone call
“Unfortunately I’ve got some bad news about Sophie,” my mum said over the phone. I knew my sister had been in a mental health facility in London for nearly two weeks. She had a diagnosis of schizophrenia but was generally well and lived an independent life. I prepared myself for the worst. Perhaps there was some bad news about her health, or she needed to stay in the hospital longer than expected.
“She’s passed away,” my mum said.
In just seconds, those three words sucked all the reason and logic out of the universe. Sophie couldn’t be dead. Just a couple of months before, we had spent the day together in London. We had visited the Sherlock Holmes Museum, eaten overpriced avocado on toast, and saw the Food: Bigger than the plate exhibition at the Victoria and Albert Museum.
Sophie had been full of life and a talented artist, having studied at some of the most prestigious art colleges in the UK. Though unable to be in paid employment for much of her adult life, she was constantly producing artwork and working towards either a course (completing an MA in Public Sculpture) or her own projects. She was an active member in a local arts organisation for people with mental health challenges, acting as both a trustee and volunteer. I was 35. She was 37.
“Was it suicide?” I asked. It was the only explanation I could think of. Sophie was physically healthy, she didn’t smoke, played ping-pong, and did yoga.
“Suicide…no.” My mum sounded surprised. She said the hospital had told her there would be a full internal and external investigation. The cause of death was not known.
Sophie and me together in London, a couple of months before her death
Investigation?
I held onto the idea of a full internal and external investigation throughout the following month. In that time, I flew back and forth between China, where I had been living, and the UK, three times. I spent Christmas with my UK family; the empty space at the table far more gaping than the lack of presents under the tree. But throughout it all we could, at least, focus on finding out the truth of what had happened.
In late January, we visited the City and Hackney Centre for Mental Health in London. We found out from the clinical director that no investigation into Sophie’s death had started after nearly five weeks. No witness statements had been taken, no one had been interviewed. Her death had merely been recorded in the notes, as if it was a normal incident.
Sitting in that stark white room, filled with grief and disbelief from my brother, my mum, and me, and the appeasing expressions and evasive remarks from the clinical director, a thought crossed my mind: Is this a normal incident?
“How many people die unexplained in your hospital?” we asked.
“We have a lot of incidents,” was the answer.
What is an incident?
The word “incident” was repeatedly used as a euphemism for Sophie’s unexplained death. When the NHS investigation into Sophie’s death eventually started (it still hasn’t finished), it was called an SI Review or Serious Incident Review.
If the clinical director wouldn’t tell us how many deaths happened in the hospital, perhaps the media would give us some context. Later, it didn’t take us long to find the following:
Guardian: NHS to look into deaths of more than 100,000 mental health patients a year
Guardian: Hundreds of mental health patients died after NHS care failures
BBC: NHS trust ‘failed to investigate hundreds of deaths’
Telegraph: Hundreds of mental health deaths may not have been investigated
Telegraph: NHS ‘failed to investigate 1000 deaths’
Community Care: NHS trust investigated ‘too few’ deaths of mental health and learning disability patients
From the moment we started trying to get answers about Sophie’s death, I had the feeling that it was as if she had died in prison. After all, had she died suddenly and unexpectedly outside of state detention, it would have been the job of the police to check that her death was not suspicious, and investigate it if it was.
The mental health centre where Sophie lost her life
How are deaths in mental health facilities investigated?
When an unexpected death happens in a mental health facility, the process is largely as follows (this is what should happen, but media reports confirm internal investigations do not always take place):
- The death is recorded in the notes by the hospital staff.
- The death is reported to the coroner.
- Post-mortem results are collected and sent to the coroner.
- NHS conducts internal “Serious Incident Review”. Results of Serious Incident Review are sent to the coroner.
- Coroner conducts inquest.
Even prisons don’t investigate themselves
A robust mechanism for pre-inquest investigation matters because the results of the investigation are what is presented as evidence, along with the post mortem, at the coroner’s inquest. Only objective and accurate evidence can facilitate an objective and accurate verdict.
While putting together this petition, I discovered that there are actually independent bodies who investigate deaths in prison and police custody. The Prisons and Probation Ombudsman is responsible for investigating prison deaths before the inquest. No such mechanism exists for deaths in mental health facilities.
Previously, I had been thinking “It’s almost as if she died in prison.” After reading this report I started thinking “It’s worse than if she died in prison.”
Why are mental health patients treated in this way? Mental health facilities should be safe places where patients are respected and can receive effective treatment.
Mental health facilities cannot pretend to offer effective treatment if they cannot offer safety. And the NHS cannot claim to offer a safe environment if unexpected deaths are not independently investigated. Please share this story or sign this petition to change the system so all mental health deaths are properly investigated.
