Background information and links to related work

The inquiry primarily looked at existing evidence across the three sectors from 2010 to 2013, to examine how organisations complied with their obligations under Article 2 of the European Convention on Human Rights (the Right to Life). The evidence was gathered in a range of ways, including consultation with the regulators, inspectorates and advocacy groups, as well as meeting with bereaved family members.

A two page framework based on human rights case law has been produced to assist organisations in meeting their obligations under the law. It identifies what they need to do to prevent loss of life and how to carry out investigations and implement lessons learned.

The Inquiry found that repeated basic errors, a failure to learn lessons and a lack of rigorous systems and procedures have contributed to the non-natural deaths of hundreds of people with mental health conditions detained in psychiatric hospitals, prisons and police cells in England and Wales.

As a result, the Commission has, for the first time, created an easy-to-follow Human Rights Framework, aimed at policy makers and front-line staff across all three settings, which includes 12 practical steps to help protect lives.

We have published 2 reports. They can be downloaded in PDF and Word:

Alternative formats are available upon request.

What is the problem?

Mental health impacts on all of us and people with mental health conditions are the people most likely to be held in detention (as prisoners, in police custody or having been detained under the Mental Health Act). Tragically, a number of people with mental health conditions die while being detained. Figures from England and Wales show:

  • according to the IPCC, fifteen people died in or following police custody in 2012/13. Almost half (seven individuals) were identified as having mental health concerns
  • in 2013, deaths in prison custody rose to 215; the most in any calendar year since records began, 74 were self-inflicted
  • in 2012, there were 98 deaths of non-natural causes of people detained in hospitals under the Mental Health Act (source report, PDF)

Despite efforts from individuals and organisations to prevent these deaths, not all lessons appear to be learnt, and every year deaths occur that are later deemed to have been preventable.

The Commission will analyse the evidence to establish the extent to which there has been compliance with Article 2, and Article 2 together with Article 14, of the European Convention on Human Rights. We will develop understanding about how organisations have implemented recommendations from previous inquiries and reports into non-natural deaths in detention. 

We will do this by examining the evidence about non-natural deaths in detention of adults with mental health conditions in prisons, police custody and hospitals between 2010 and 2013,  and by engaging with individuals from the key organisations in the three settings to determine their perspectives on the protection of detained adults with mental health conditions. Full details of the scope of the Inquiry can be found in the Terms of Reference.

For the purpose of this inquiry the Commission will define a mental health condition as any disorder or disability of the mind. This definition is identical to the definition of a “mental disorder” in section 1 of the Mental Health Act 2007.

The settings for the inquiry are devolved in Scotland and have their own specific legislative frameworks. We will be undertaking an evidence gathering exercise in Scotland though, which will be aligned to the Scottish National Action Plan for Human Rights that will allow us to gather comparable data across Great Britain.

The Commission has a legal power, under section 16 of the Equality Act 2006 (EA2006), to conduct an inquiry into anything relating to its equality, diversity and human rights duties in sections 8 and 9 of the Act.

An inquiry is a means of collecting the evidence we need to gain a clear picture of equality and human rights in Great Britain, and we can carry out an inquiry into any area where we feel there is a benefit to wider society. For this inquiry, the Commission will focus on existing evidence and may also contact organisations to increase its understanding.

For this inquiry, we are focusing on those who are aged 18 and over. This will include some adults in Young Offender Institutions. We recognise that there are specific issues around children and young people and detention and we are planning a separate piece of work in England on this subject.

Serious harm is excluded from the scope of the inquiry, but we will examine the extent to which records are kept about incidents of serious harm in the three settings and how this information is used to learn lessons and to reduce the risk of future deaths. The inquiry is focused on non-natural deaths which fall into one of the following categories: self-inflicted/suicide, deaths caused by another person including homicide, deaths; the cause of which is unknown and accidental deaths.

Why are you only looking at existing evidence?

We are looking at existing evidence to allow us to identify particular trends and systemic issues across the three sectors. We will analyse the evidence to establish the extent to which there has been compliance with Article 2 of the European Convention on Human Rights (ECHR)   and Article 2 together with Article 14. We will also be considering data on protected characteristics to identify any differential outcomes between groups across all three settings, in order to form a view on levels of compliance with Article 2 together with Article 14 of the ECHR.

Will you include the views of families in the report? How will they be able to input to the Inquiry?

We will be considering the views of the families of individuals with mental health conditions who have died while detained in the three settings. 

Further related information

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Last updated: 05 Dec 2017