Counting and Accounting for Mental Health Related Deaths in England and Wales

This article examines how mental health related deaths (MHRDs) in England and Wales are counted and accounted for. Data collated by the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) constructs such deaths as being predominantly the result of suicide. This article examines 221 Reports to Prevent Future Deaths (PFDs) issued by coroners’ courts in relation to MHRDs. It establishes that in 49% of cases suicide is not recorded as the sole cause of death. The article also provides thematic findings that emerged from the qualitative analysis of these PFDs and identifies issues with errors or deficiencies in the provision of care (in 72% of cases), communication (55%) and policy (26%). The findings emphasise that organisational and structural issues contribute to deaths of people in connection with mental healthcare and that these deaths should not solely be considered suicides. The article raises significant questions about the accuracy of mortality data and the capacity of public organisations to learn lessons that might prevent future deaths.