Between 2010 and 2013, 367 adults with mental health conditions died of non-natural causes while in state detention in police cells and psychiatric wards. Another 295 adults died in prison of non-natural causes, many of these had mental health conditions. Since 2013 that number has risen considerably. Each of them left behind loved ones who have suffered as a result of these deaths.
Our Inquiry reveals that despite many reports and recommendations, serious mistakes have gone on for far too long. The same errors are being made time and time again, leading to deaths and near misses.
We received evidence from individuals and organisations affected by the topic of our Inquiry. In the course of this Inquiry, the team was able to spend time talking to some of the families of those who died in detention and their experiences are central to our report. We would like to thank all of those involved, in particular the family members, for their help and support. We would also like to thank the Commission’s Inquiry team for their hard work.
We hope that this report provides valuable insights and recommendations which can bring about real change in the way that adults with mental health conditions are treated in detention. Our aim is to help prevent further unnecessary tragedies.