A new report from the Independent Advisory Panel on Deaths in Custody has been published (Oct ’25), calling for independent investigations after Mental Health Act deaths which occur whilst someone is detained.
The report highlights that 225 people died whilst detained under the MHA meaning this is the highest rate of death in any custodial setting. But unlike police, prisons or immigration detention, there is no independent mechanism to investigate such deaths. The scale of this is perhaps revealed for us all by the public inquiry being held now in Essex where a significant number of unexplained and unexpected deaths are under review amidst considerable controversy. Some of us will remember the inquiry which took place in Hampshire in to a mental health provider who was linked to 1,400 unexplained and unexpected deaths over a 5yr period which involved the Secretary of State for health ordering an independent investigation.
INVESTIGATIVE EQUIVALENCE
Given the scrutiny we see on policing, prisons and immigration, it has always been very surprising to me we see no independent body to investigate MHA deaths. The argument against it has often been that many of those who die whilst detained under the Act die of natural causes and that’s fair comment where it’s true, but we have a problem with two parts –
- We know some deaths under the MHA have been labelled ‘natural causes’ when they actually aren’t; and we know the NHS don’t always do an internal investigation so the scale of this problem isn’t well understood, best I can tell.
- And even if that were handled well, it still leaves enough unexplained and unexpected deaths to mean an independent mechanism is a legitimate idea, worthy of serious consideration.
LAUGHING BOY
The death of Connor Sparrowhawk in 2013 is one incident which made me realise I need to think more carefully about deaths under the MHA. The whole business of what went on only really came to light because of campaigning by Connor’s mum, Professor Sara Ryan – it was as tireless as it was impressive to see how she took on the NHS claims about Connor’s death over many years, including various investigations, the inquest and professional conduct proceedings.
After his admission under the MHA to hospital, Professor Ryan had warned staff Connor should not be allowed to bathe unsupervised, because he suffered from epilepsy and there was a real risk his head could fall beneath the water during a seizure. So obviously, staff left him unsupervised during bathing and after a seizure, he drowned in the bath. This was not immediately reported to the police and cause of death was initially given as “natural causes” which I hope sounds as ridiculous to you reading this as it did to me when I first read reports.
Sara’s campaigning and the struggle to secure proper insight in to what went wrong in Connor’s case is captured beautifully in her book “Justice for Laughing Boy” and it all lead to the wider inquiry in to Southern Health and the resignation – eventually – of the trust’s Chief Executive Katrina Percy. The Health Secretary ended up on his feet in Parliament talking about 1,400 unexplained, unexpected deaths.
CHANGE IS DUE
We already have three public inquiries in to the state of mental health care – in Essex, Nottingham and recently announced, Teeside. The Health Services Safety Investigation Branch also undertook an inquiry in to emergency departments and the Health & Social Care select committee recently published a report in to community mental health services, to which the government responded, shortly afterwards.
We’re entering the second quarter of the twenty-first century so we probably should create conditions where unexplained and unexpected deaths are better scrutinised and independently investigated where necessary. The IAPDC report is a good start and it’s worth reading but it will take a world of work to get things from there to the creation of new oversight and investigation mechanisms which, at least in principle and on paper, compare to those for policing, prisons and immigration.
The biggest challenge of all, probably relates to culture. I’ve always been fascinated how we regularly hear about the difficulties with police culture and academics have written whole books about “canteen culture” in policing – we rarely hear similar things for NHS professions and when we bear in mind what has been revealed by investigations such as the Francis Review (in to Mid-Staffs Hospital), it’s a real wonder. Wider NHS culture towards oversight, investigation and accountability for incidents which may raise legal and professional conduct questions, is something we might wonder would be resisted in the way so many things in the NHS are.
That said, we might also wonder whether the proposals would actually deliver the benefits we usually suppose they will – lessons learned, policy and training development, different outcomes in the future. I’m busy researching those kinds of ideas for mental health police contact deaths and it’s already obvious, we can easily question whether those assumptions are valid.
Read the report linked at the top of the post – it’s very worth while, but loads of work to do to get anywhere close to it.
Awarded the President’s Medal, by
the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
All opinions expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown, 2026
I am not a police officer.
I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current. Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.
Government legislation website – www.legislation.gov.uk
Mental Health Cop 