Mental health deaths

People with poor mental health are particularly vulnerable, and INQUEST’s casework reveals that mental health is a recurring feature of deaths in custody. Many inquests have revealed frequent shortcomings in the ability of the police and prisons to offer appropriate care to these individuals.


There remain serious issues that need to be addressed around the monitoring of suicidal prisoners: too often vulnerable prisoners fail to receive adequate levels of care.

Self-harming and suicide among young people in prison are of particular concern: the vast majority of deaths of young people and children are self-inflicted. Self-harming among young people in prison is more prevalent than among the adult population. In 2011, prisoners aged 15 to 20 accounted for 11 per cent of the prison population but 21 per cent of all self-harm incidents.

Police custody

Approximately half of all deaths in or following police custody involve detainees with some form of mental health issue.

One way in which people presenting with mental health issues may have contact with the police is when they are in a public place and are believed to be in need of ‘immediate care and control’. In these circumstances individuals can be detained by police under the Mental Health Act 1983 and taken to a place of safety.

Since 1990 it has been government policy that police custody should only be used as a last resort. Yet in 2011-12, nearly 9,000 people taken off the streets by police using emergency powers under the Mental Health Act ended up in police stations rather than hospitals. There continue to be cases where individuals die in police cells following a failure to deliver appropriate care. The use of custody has the effect of criminalising someone in need of medical attention and can exacerbate mental health problems.

Mental health settings

Psychiatric patients are owed a positive duty of protection under human rights law, which means that hospitals must ensure that they take appropriate steps to prevent patients from taking their own lives. However, there continues to be a high number of suicides in psychiatric settings. There is also a high number of deaths of people with mental illness in circumstances involving the use of restraint by police. In 2012, INQUEST opened 67 cases that involved deaths in mental health settings.

Unlike deaths in prison or police custody, there is no independent agency responsible for investigating deaths in mental health detention. INQUEST believes it is unjust that institutions responsible for the care of mentally ill people should not be subject to the same scrutiny given to other forms of detention.


INQUEST has been involved in supporting the families of a high number of mental-health related deaths in custody, from Roger Sylvester’s death in 1999 through to Sean Rigg’s death in 2008 and Olaseni Lewis’ in 2010, and is continuing to monitor these deaths closely. INQUEST believes that the individual and institutional neglect uncovered by recent inquests should prompt the Home Office and Department of Health to review how the police and mental health providers work together to respond to people in crisis.

Related links:

Deaths of children and young people

Statistics of deaths in custody

INQUEST’s Submission to Casale Review of IPCC investigation into death of Sean Rigg (February 2013)


INQUEST's publications Fatally flawed and Dying on the inside: Examining women’s deaths in prison

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