In this fifth post for the State Violence Research Network blog, Dr Carly Speed, from Liverpool John Moores University, discusses the issues of contentious deaths during psychiatric detention. Carly will be discussing this at the ‘From the State to the Streets’ conference, being held between April 10th and 12th. For information on how to register for the conference, and on how to submit a blog yourself, see the links at the end of the post.
The thought of being detained under the Mental Health Act, whilst it may seem an unlikely prospect, is distinctly more possible than we might imagine. MIND, the leading mental health charity, indicates that one in four people will experience a mental health problem in the UK each year (MIND, 2017: n.p). Furthermore, the number of individuals being detained under the Mental Health Act reached an all-time high in 2015/16, when 63,622 detentions were made under the Act in England (Health and Social Care Information Centre, 2016: 4).1 For some, the use of psychiatric detention provides potentially life-saving and life-changing care and treatment. This should not be forgotten. However, the focus of this doctoral research is the significantly under-researched issue of contentious deaths in psychiatric detention. Between 2000 and 2014, 4,801 patients died whilst detained under the Mental Health Act in England and Wales (Independent Advisory Panel on Deaths in Custody, 2015: 9). More recently, in 2015/16 there were 266 deaths of detained patients in England, and in 2016/17 there were 247 deaths (Care Quality Commission, 2018: 44).
The doctoral study undertook archival research in order to critically analyse the historical response in this area, followed by interviews and questionnaires with bereaved families, coroners and legal practitioners. In addition, an examination of online family campaign websites, established following the death of a relative, was undertaken. Of particular interest was the issue of accountability, alongside problems apparent in the inquest and investigation processes.
The findings of this research highlighted a number of key problematic areas, both historically and contemporaneously. One such theme was the continual inferior response to patients and their families in both life and death. Patients and families had their voices and experiences continuously dismissed and silenced, whilst being blamed for the failings of those who provided inadequate care and treatment. The research also uncovered persistent denials of responsibility and accountability following the deaths of patients. This was particularly apparent within the investigation system following the deaths of detained patients. There is not, nor has there ever been, an independent investigation system in place to examine these deaths. This means that the hospital trusts responsible for a patient’s care and treatment at the time of their death undertake the investigation into the death. This indicates the ‘glaring disparity’ (INQUEST, 2015: 5) between how deaths in psychiatric detention are investigated in comparison with deaths in police and prison custody, where deaths are investigated independently.2 Participants persistently indicated that the lack of an independent investigation system in this area has a detrimental effect on the potential of the true circumstances surrounding deaths. This also minimises the prospect of accountability and the learning of lessons in order to prevent future deaths. The coroners’ court process following the deaths of detained patients is also highly problematic. Participants in the research detailed how families are informed by trusts that they do not require legal representation, only to then enter the court to be faced by the legal teams representing hospital trusts and other interested parties. Coroners themselves also indicated how they felt constrained by the fact that they were unable to follow up or enforce the recommendations made in their courts.
Despite the apparent secrecy, dismissal and marginalisation, there were continuous challenges and contestations displayed both historically and contemporarily by patients, their families, and those who work in this area. These forms of resistance have resulted in much-needed alternative truths and emerging knowledges which directly challenge the repressive structures of power that dominate this issue. The claim that lessons will be learned seemingly follows the aftermath of each death, yet this rarely translates into any meaningful change. Despite this reluctance to radically transform the numerous failing systems identified, the changes needed were startlingly obvious. As such, the themes which emerged from the research resulted in a number of radical alternatives being proposed. These included the application of an abolitionist and social justice approach to this area, the introduction of an independent investigation system, and transforming the way in which the coroners’ court deals with deaths in psychiatric detention.
These radical alternatives will be explored in this paper at the SVRN conference. However, another key radical alternative to focus on in anticipation of the conference is the suggestion that the inferior response to patients and their families, in both life and death, should be viewed as a continuum of harm and violence. As such, the entirely inferior response chronicled through this doctoral research should not simply be viewed as harmful to patients and their families. There is also a legitimate case to view the response to patients and their families as mentally, emotionally and physically violent, all in an attempt to subjugate and silence already marginalised groups. Adopting this approach would cost nothing. It is a change in attitude and would allow the issues faced by these groups to be acknowledged, with an emphasis on how the state, and their agents, can be challenged in order to expose unnecessary suffering and promote justice and accountability for those embroiled within psychiatric detention.
We must endeavour to challenge the misconception that deaths in psychiatric detention are not preventable, as this is often not the case. Whilst we continue to hide behind this misconception, lessons will not be learned following these deaths. Investigations will continue to lack independency, transparency and accountability, and the coronial process will be limited in the follow-up that is currently permitted. Reconceptualising the experiences of patients and their families as not only harmful to them but violent could offer the potential to increase our understanding of the consequences of inadequate care and treatment, as well as the subsequent inferior response following the deaths of patients. When the issue is, as it is in this case, a matter of life and death, radical and meaningful change in this area is urgently needed and long overdue.
Care Quality Commission. (2018) Monitoring the Mental Health Act in 2016/17, Newcastle Upon Tyne: Care Quality Commission.
Community and Mental Health Team NHS Digitial. (2017) Mental Health Act Statistics, Annual Figures 2016/17, Experimental Statistics, (Online) Available From: https://files.digital.nhs.uk/pdf/b/t/ment-heal-act-stat-eng-2016-17-summ-rep.pdf. Date Accessed: 21st April 2018.
Health and Social Care Information Centre. (2016) Inpatients Formally Detained in Hospitals Under the Mental Health Act 1983, and Patients Subject to Supervised Community Treatment, (Online) Available From: http://www.content.digital.nhs.uk/catalogue/PUB22571/inp-det-m-h-a-1983-sup-com-eng-15-16-rep.pdf Date Accessed: 20th December 2016.
Independent Advisory Panel on Deaths in Custody. (2015) Deaths in State Custody: An Examination of the Cases 2000 to 2014, (Online) Available at: http://iapdeathsincustody.independent.gov.uk/wp-content/uploads/2015/12/IAP-Statistical-Analysis-of-recorded-deaths-in-state-custody-between-2000-and-2014.pdf. Date Accessed: 12th January 2019.
INQUEST. (2015) Deaths in Mental Health Detention: An Investigation Framework Fit For Purpose?, London: INQUEST.
MIND. (2017) Mental Health Facts and Statistics (Online) Available From: https://www.mind.org.uk/information-support/types-of-mental-health-problems/statistics-and-facts-about-mental-health/how-common-are-mental-health-problems/#.XFC-n-Q3bIU. Date Accessed: 18th January 2019.
1 Following this year, the way in which these statistics were collated has changed and the number of people detained in 2016/17 appears significantly lower at 45,864 (Community and Mental Health Team NHS Digital, 2017: 2). Due to the changes in the collation process, the 2016/17 statistics are ‘not directly comparable’ with previous years. However, the NHS digital team have estimated that if the statistics were comparable then it would have shown an estimated 2% increase in detentions since 2015/16 (Ibid: 2).
2 It is not to argue that the independent investigation systems in place following deaths in police and prison custody are not problematic, it is to highlight that they have been introduced, unlike deaths in psychiatric detention.
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The opinions and viewpoints contained in this blog post are not necessarily shared by the State Violence Research Network, and publication should not be considered an endorsement.