1. All mental health deaths should be fully and independently investigated – so that every possible lesson is learnt to prevent deaths in future
- Legal aid should be available to families for all inquests into potentially preventable mental health deaths
- The Chief Coroner should be given the power and resources to ensure lessons are learnt and implemented nationwide
2. Across the country, everyone should have access to properly funded NHS mental health services, funded at the same level as services for physical health
- Mental health patients and their families should have access, across the country, to a 24/7 NHS mental health crisis phone line – staffed by call handlers who have had full risk assessment training
- Funding for mental health care should be increased to match funding for physical healthcare
See below for more detail on each of our policy asks –
Legal aid should be available to families for all inquests into potentially preventable mental health deaths
For any mental health death investigated by an inquest (either in a mental health hospital or in the community), families should have an automatic right to non-means tested legal aid. Inquests should not have to be classified as Article 2, or meet the current high bar for wider public interest for families to receive this.
Why are we asking for this?
Families need a lawyer at mental health inquests.
At an inquest, mental health trusts (and other similar organisations) will almost always have legal representation.
This means that when each witness is called, they will be questioned both by the coroner, and also by the lawyer representing the mental health trust.
These lawyers will be highly skilled; they know exactly the types of questions they can ask a witness and the way in which to ask them.
Because they are directed by their client (the mental health trust), the questions they ask and how they ask them will always be trying to get the best outcome for them.
Conversely, while families can question witnesses themselves, they are not trained. They will often ask the wrong sort of questions, or miss important issues. The process can also be very upsetting for family members.
Although a coroner tries to be neutral – how can anyone be neutral after hearing several well thought out questions from one side (designed to protect the mental health trust), and nothing or poorly formed questions from the other? Could you maintain a neutral stance after listening to just one side of a story for hours on end?
And even if it doesn’t change the outcome of the inquest, lines of questioning from a family’s lawyer can help to bring issues to light in mental health care which wouldn’t otherwise have been noticed.
This happened in Julie’s case. Her family sent a transcript of the inquest to one of the Trust’s involved in Julie’s care – including a section where a member of the Trust’s staff was questioned about their risk assessment procedure. After reading this, the Trust involved have changed their practices. This will keep other patients safer – but would never have happened if Julie’s family had not paid for a lawyer themselves.
This system is broken. Some families pay thousands of pounds themselves for legal representation to bring to light systemic problems which could affect any of us.
All families at inquests into mental health deaths should receive non-means tested legal aid.
The Chief Coroner should be given the power and resources to ensure lessons are learnt and implemented nationwide
Inquests are going on looking at potentially preventable deaths up and down the country every day.
Many of those inquests will result in prevention of future (PFD) death orders – an order made when the coroner feels more needs to be done to stop other people dying in the same way in future (although too often, these orders aren’t even issued when families feel they should have been – in part due to a lack of adequate legal representation for families).
But even if they are, there is no central system to make sure these findings are actually being put in place.
“While the Chief Coroner is expected to oversee the issuing of PFD reports and does publish annual reports based on coroner findings, he does not have the resources to ensure recommendations are followed up and that institutions adhere to them. ” – INQUEST
A very large number of previous PFDs are related to a lack of communication between individuals and agencies before someone dies by suicide – as was the case for Julie. Without a central system making sure these orders are acted on and learnings are implemented across the country, more people will die unnecessarily in the way Julie did.
Mental health patients and their families should have access, across the country, to a 24/7 NHS mental health crisis phone line – staffed by call handlers who have had full risk assessment training
In the weeks leading up to her death, Julie repeatedly called the emergency phone number for her local mental health team – but on many occasions was only able to speak to an ‘un-registered practitioner’ – an employee who was not qualified as a mental health nurse, and had no formal risk assessment training. These unregistered practitioners would carry out ‘informal risk assessments’ on Julie, and in doing so – prevent her from reaching further health services.
While by no means perfect – call handlers for NHS 111 (the phone services for physical health problems which do not require immediate life saving action from 999) are given a considerable amount of training, as well as being required to ask a clear, pre-set of questions to determine which care pathway is correct for a patient (which very quickly escalate to a nurse or doctor if the call handler cannot be sure the patient is safe).
This is in stark contrast to the situation for mental health patients – who face a postcode lottery. Some areas don’t even have a crisis line, while others – like Julie’s – are staffed by unregistered practitioners with very little training, and no set guidance on how to help patients. In Julie’s case, unregistered practitioners would sometimes staff the line alone, and not have immediate access to a trained mental health nurse or doctor.
We welcome the government’s recent commitment to integrate mental health crisis care into NHS 111 – but we need to see real action on this quickly – matched by adequate funding and risk assessment training for call handlers.
Funding for mental health care should be increased to match funding for physical healthcare
We welcome the government’s recent announcement to increase mental health spending by £2bn per year by 2023/24 – but it is still no where near enough.
There is also a real need for more mental health nurses – during Julie’s time with mental health services, nurses were too often overworked, and didn’t have time to do core parts of their job – like reading through notes from her previous calls. The King’s Fund have estimated there has been a 13 per cent reduction in full-time equivalent mental health nurses between September 2009 and August 2017. Targeted recruitment and retention programmes are needed to ensure everyone who needs them can access trained mental health nurses.