Mental healthcare failings kill | Letters

The Guardian investigation of deaths of patients in mental health detention (Report, 6 March ) exposes the current accountability gap in post-death investigations and inquests. Inquest has long called for a fundamental overhaul of the way in which deaths of mental health patients are investigated. Our casework with bereaved families shows that many deaths are preventable and arise as a result of repeated, systemic failings in care.

There is no independent body for investigating these deaths as soon as they occur. Generally they are investigated by the same institution in which they occur. These internal investigations are shrouded in secrecy and are not in the public domain. This stands in stark contrast to the investigation of deaths that occur in other forms of state detention, where the investigations are independent, reports are published, and thematic areas of concern disseminated.

The lack of statutory enforcement and oversight of safety recommendations reported by coroners is putting lives at risk. They are under-utilised, and there is no follow up or audit of what action has been taken in response. For many years Inquest has called for an effective national oversight mechanism to collate, analyse and monitor recommendations from investigatory bodies and coroner’s courts after all state-related deaths. Recent reviews by Bishop James Jones and Dame Elish Angiolini have underlined the need for these reforms and the government must act now to guarantee recommendations are acted upon and future lives protected.

The stark fact that deaths of mental health patients continue to rise shows the urgent need for action. This is the least that bereaved families deserve.
Deborah Coles
Director, Inquest

As a teenager in 1979 I took an overdose and was subsequently a sectioned mental hospital inpatient for 16 months, on the grounds of risk to myself. In those days psychiatric nursing was a job for life. The nurses, (and the cleaners, and the caterers) worked as in-house teams. Nobody was making a profit out of their work, or out of high interest payments for hospital buildings. Staff turnover was non-existent. Three good psychiatrists were, vitally, attached to the hospital, but the nurses provided the day-to-day vital familiarity, consistency and calm. Psychiatric nurses had excellent thorough training, were well supported through their pay and internal structures, and got to know their patients well. There were enough beds then for this service; suicides, although they did happen, were rare.

I am forever grateful not to have been released until I was no longer an active danger to myself. Forty sane and productive years later, I cannot understand what was so wrong with this system that it had to be so thoroughly dismantled. But a clue as to what has changed is in the fact that the good hospital, where I and countless others had their then valued lives saved, was decanted and closed in the wake of Thatcher’s market-based “reforms”, and today is Kingseat Business Park.
Sushila Dhall

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