At least 271 highly vulnerable mental health patients have died over the last six years after failings in NHS care, a Guardian investigation has found.



Coroners have been so alarmed at the lapses in care that emerged during inquests that they issued legal warnings to 136 NHS bodies, mainly providers of care, between 2012 and 2017. They included mental health trusts, acute hospitals, ambulance services and GP surgeries.

Mental health campaigners said the findings were shocking and claimed that many of the deaths were avoidable and constituted a “tragedy”.

“It is not acceptable that some trusts fail in some of the most fundamental requirements of providing care, with catastrophic consequences,” said Paul Farmer, chief executive of the mental health charity Mind.

“Every one of these deaths is a tragedy, and it must be deeply difficult for families already having to come to terms with losing a loved one to learn that their death could have been prevented,” added Farmer, who chaired NHS England’s taskforce in 2015-16 on improving mental health care.

A Guardian investigation has established that coroners in England and Wales have served “a prevention of future deaths notice” (PFDNs) on one or more NHS bodies in 271 cases. The coroners identified problems including errors, misjudgments, flawed processes, a lack of staff or beds and poor training.

Coroners are obliged under the Coroners and Justice Act 2009 to issue a notice if they believe shortcomings by a person, organisation or public body such as a hospital trust, council or government department, are so serious that other people may die unless urgent action is taken to tackle them.

The Guardian’s analysis of all the notices issued between 2012 and 2017 involving people receiving NHS care for mental health conditions uncovered a total of 706 failings across the 271 deaths. In many cases patients took their own lives.

The disclosures follow growing concern about the NHS’s ability to cope with the fast-rising demand for mental health care, especially among children, young people and older people, and fears that some patients are facing long delays in accessing treatment and receiving inadequate care when they do.

Bodies such as the Commons health select committee, NHS Providers, mental health staff organisations and charities have warned that NHS services have too few staff. There are 6,000 fewer mental health nurses in England than in 2010 and the number of psychiatrists for children and adolescents is also falling.

Many of the notices examined by the Guardian cited inadequate supervision of someone who was a clear suicide risk, or NHS staff ignoring families’ fears that their loved one would take their own life. In dozens of cases, staff made mistakes with the patient’s medication, or failed to properly assess the risk that the patient would take their own life.

The notices also included:

• Forty-five cases in which patients were discharged too soon or without adequate support.

• Seventy-two instances of poor or inappropriate care.

• Forty-one cases in which treatment was delayed.

In two of the most shocking cases, an acutely distressed patient died after NHS staff looking after them made what the coroners found were 12 different types of mistakes on each occasion.

One of those involved was Michael, a 50-year-old teacher who had bipolar disorder and died in July 2013 after his car hit a tree on the Wirral in Merseyside. Michael, whose full name the Guardian is withholding at his family’s request, was described by coroner André Rebello as “respected [and] high-achieving”. Rebello found that Michael had intentionally killed himself but that “the cause of death was aggravated by neglect”.

The prevention of future deaths notice said the “real and immediate risk” to the teacher’s life was not recognised as a result of “failings [by the Cheshire and Wirral Partnership NHS foundation trust] to take steps which might have been expected to avoid that risk”.

It added: “His death was facilitated and enabled in part by the fact that the poor state of his mental health [the day before Michael died] had not been fully appreciated, his care, treatment and supervision was not adequate and he was not listened to.”

Rebello then listed 26 separate instances of failings he called “all more than minimally or trivially contributory factors to a lesser or greater degree [in] Michael’s death”.

Labour said the government should hold an inquiry into the deaths, given Theresa May’s call for the NHS to improve mental health care as part of her crusade on “burning injustices”.

The Liberal Democrat MP Norman Lamb, a mental health campaigner and former health minister, said the inquests had revealed “wholly unacceptable loss of life. I will be writing to Jeremy Hunt [the health and social care secretary], highlighting the Guardian’s analysis, and urging him to look at how the system can be reformed to ensure that every notice issued by a coroner is tracked so that lessons are always learnt.”



The Guardian’s analysis found two trusts with notably high numbers of deaths. Avon and Wiltshire Mental Health Partnership NHS trust and Camden and Islington NHS foundation trust in London each had 14 such deaths across the six years.

Two of the PFDNs sent to the Avon trust related to the death in 2014 of Charlotte Bevan, who fell to her death from Avon Gorge in Bristol four days after giving birth to her daughter Zaani Malbrouck, who was in her arms. The case attracted widespread publicity after CCTV footage emerged of Bevan, who had schizophrenia, leaving St Michael’s hospital carrying Zaani.

Dr Rebecca Eastley, the Avon trust’s medical director, said: “Every death by suicide is a tragic loss of life and reducing the number of people who take their own lives in the area we cover is a priority for our trust. Preventing suicide is a complex task and we are committed to learning lessons from every case.” Improvements in care made since 2012 have cut the trust’s suicide rate by 31%, she added.



In a statement Camden and Islington trust said that it “provides care in an area of London with one of the highest demands for complex mental health support in the NHS. The death of any service user is a source of great concern and sadness for all the staff involved in that individual’s treatment. Our clinicians review every death in line with national guidance and examine any failings, where appropriate, in the quality of care provided.”

The total number of deaths in which the NHS was found to be at fault would be higher than 271 if deaths of inmates in jail where health service staff provided the medical care were included.

Hunt made clear that NHS trusts should implement in full recommendations made by coroners to reduce the risk of further fatalities.

“Every preventable death is a tragedy, bringing unimaginable distress both for families and staff, so where coroners recommend specific steps to prevent future tragedy, I expect NHS bodies to act without delay,” he said.

“The prime minister and I have made mental health services a personal priority: from record spending, to our zero suicide ambition, to the new law on parity of esteem, we are seeing progress, but there is still more to do: any avoidable harm is simply unacceptable.”

• In the UK the Samaritans can be contacted on 116 123. In the US, the National Suicide Prevention Lifeline is 1-800-273-8255. In Australia, the crisis support service Lifeline is 13 11 14. Other international suicide helplines can be found at www.befrienders.org.



Additional reporting: Sarah Marsh and Sabine Gurol