Fatal incidents in English secondary mental health services reported via NRLS September 2017 to September 2020

By Dr Minh Alexander NHS whistleblower and former consultant psychiatrist

The reporting and investigation of serious incidents in the NHS, especially in mental health services remains a serious problem.

The 2015 Mazars investigation into deaths at Southern Health NHS Foundation Trust revealed appalling failure to investigate hundreds of mental health deaths, a failure either not detected or reported by the Care Quality Commission in a preceding inspection.

Independent review of deaths of people with a Learning Disability or Mental Health problem in contact with Southern Health NHS Foundation Trust April 2011 to March 2015

Today a parliamentary debate takes place on mental health deaths under the care of Essex Partnership NHS Foundation Trust, as a result of a petition by Melanie Leahy seeking a public inquiry into the disturbing death of her son Matthew, in the context of many other similar deaths and a concern that the trust failed to learn from these deaths.

Debate on e-petition 255823, relating to deaths in Mental Health care 30 November 2020

NHS trusts report patient safety incidents to NHS England/ Improvement under the National Reporting and Learning System.

The most dishonest trusts may not report all serious incidents.

Occasionally, for example, even homicides may not be reported as serious incidents or externally investigated according to NHS policy.

Specialist mental health services report higher levels of fatal incidents compared to acute trusts.

I have extracted fatal incident data September 2017 to September 2020 for NHS trusts with specialist mental health services from the following annual NRLS reports:

NRLS monthly report 2017-2018

NRLS monthly report 2018 -2019

NRLS monthly report 2019 -2020

I found 8632 fatal incidents had been reported in trusts with specialist mental health services between September 2017 and September 2020

The spreadsheet of extracted data can be found here:

NRLS reported fatal incidents  September 2017 to September 2020 in English NHS trusts with specialist mental health services

It is a rough exercise as some mental health trusts have merged with non-mental health trusts during the past three years.

Even allowing for differences in trust size and deprivation in catchment areas, a rough glance raises questions about wide variation in the number of fatal incidents reported.

Are some trusts with specialist mental health services reporting less honestly than others?

Are some trusts wrongly reporting some deaths as “incidents”?

Are some trusts not learning as much as they should from deaths and if so, why?

How much is due to structural problems such as chronic underfunding and neglect of mental health services?

This is a table of the trusts with specialist mental services with the highest number of reported fatal incidents in the last three years:

For completeness, I compared the number of reported fatal incidents during the pandemic (March to September 2020) – 1634, to the number over a similar period (March to August 2019) the year before – 1376.

(I could not find NRLS data for September 2019).

The most vulnerable patients are entitled to safeguarding of their best interests, but sometimes they are failed precisely because they are vulnerable and unable to speak up for themselves.

This includes systemic failure to learn where such patients suffer serious harm.

Real parity of esteem for psychiatric patients is still a long way off.

We have seen over decades that little changes and mental health scandals recur, with similar failures. The political failures underlying this are complex and refractory.

Importantly though, we still have no real NHS investigator.

Instead, patients and bereaved families are faced with an expensively ineffective labyrinth, which leaves questions unanswered after years of endless processes.

Yet in the case of mental health deaths of people where Article 2 Right to Life is engaged and the State has a particular responsibility, it is especially important that this changes and that effective investigation takes place expeditiously.

Please support this petition for independent pre-inquest investigation into all unexplained mental health deaths:

Require pre-inquest investigation into all unexplained NHS mental health deaths

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