Norman Lamb

Preventing deaths in detention: Progress review

Follow-up report

This is a follow-up report to our 2015 inquiry into non-natural deaths of adults with mental health conditions who were detained in prisons, police custody or psychiatric hospitals between 2010-13. Our inquiry found that serious mistakes were contributing to the number of deaths, and we developed a series of recommendations for the various organisations involved. This follow-up report examines the steps taken to act on our recommendations over the past year and is based on information provided to us by inspectorates and regulators we worked with, data, reports and other publications on the subject.

Main findings

Fresh analysis of evidence shows that changes are being made in some areas where we had concerns in our inquiry, but some key areas still need to be addressed.

Data on the number of non-natural deaths in the three settings shows that the overall trends are:

  • the number of non-natural deaths is continuing to decrease for detained patients.
  • the number of non-natural deaths has continued to increase year on year for prisons.
  • the number of non-natural deaths is low, but numbers are fluctuating for police custody.
  • Following extensive consultation with other regulators and stakeholders over the last year, we have revised our recommendations for change. These reflect learning from good practice and where urgent changes are required.

New recommendations 2016

All settings

  • The impact of the statutory duty of candour that applies to NHS bodies in England should be formally evaluated by the Government in 2016 so that any recommended improvements can be made and shared across other public service functions, including the prison and police settings. 

Psychiatric hospitals

  • There should be a full Government investigation into whether independent investigations are in fact being carried out into non-natural deaths of detained patients and whether they are of sufficient quality. The work the CQC and MONITOR are undertaking following the Mazars report into Southern Health NHS Foundation Trust should identify whether national learning from investigations into unexpected deaths of detained patients is taking place.
  • The remit of the independent patient safety body Healthcare Safety Investigation Branch (HSIB) should include mental health and incorporate an oversight function of independent investigations into non-natural deaths of detained patients. The Government should also consider whether any other groups with protected characteristics, such as learning disabilities, would benefit from HSIB having specific accountabilities in relation to them.
  • The outcome of the February 2016 seminar on data collection (hosted by the Equality and Human Rights Commission) should be agreement on the responsibilities of each key organisation in this area and an action plan in taking this forward.


  • Urgent changes need to be put in place by the Government to address the root causes leading to the high levels of non-natural deaths in prisons, including greater access to specialist mental healthcare.
  • Data on the use of restraint should be routinely published in the prison setting by the Ministry of Justice to aid transparency and accountability.
  • Data on the number of prisoners with mental health conditions should be collated and this should be routinely published.
  • The changes being made through the review of the Assessment, Care in Custody and Teamwork (ACCT) process used to manage and support prisoners who are at risk of suicide or self-harm, including those to the guidance for staff on risks and triggers, should be the right ones to ensure they are effective. Training should be provided to staff to ensure they know how to use the process.


  • Any changes being put in place for the commissioning of healthcare in police custody must incorporate the planned improvements that were due to be made by NHS England. 

Last updated: 05 May 2016