Investigating deaths under the Mental Health Act: The need for independence and parity

DHSC sponsors the establishment of a new independent mechanism, utilising existing resources and organisations, to conduct investigations into deaths occurring under MHA detention. This could be set up as part of one distinct body, or through collaborative work across existing investigative bodies within detention and healthcare services.

All deaths in MHA detention be investigated – both ‘non-natural’ and ‘natural’.* As part of this, we recommend that a ‘panel’ approach (as explored more below) be adopted to ensure appropriate clinical resources are allocated to each investigation.

The investigative mechanism draws on existing expertise to help shape the clinical review structure and training for clinical reviewers for the investigation of these deaths, collaborating with bodies such as the Parliamentary and Health Services Ombudsman (PHSO) and HSSIB.

Clinical leadership is embedded within the independent investigative mechanism itself. At the very least, this mechanism should have its own clinical leadership to direct, oversee, and quality assure externally commissioned clinical advice. Further scoping may be needed to ensure that the process for obtaining clinical advice is appropriately structured to ensure sufficient independence, quality, and proportionality of investigations.