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.

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Published: 2023-10-09
Issue:Online First
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How to Cite
Baker, D., Fidalgo, M. and Harrison-Brant, L. (2023) “Counting and Accounting for Mental Health Related Deaths in England and Wales”, International Journal for Crime, Justice and Social Democracy. doi: 10.5204/ijcjsd.2989.

Author Biographies

University of Liverpool
 United Kingdom

Dr David Baker is Research Lead in the Department of Sociology, Social Policy and Criminology at the University of Liverpool. His work focuses on preventable deaths, death investigation and holding governmental organisations to account. He is the author of two books on police related deaths, the latest of which is ‘Police Related Deaths in the United States’ published in 2021 by Lexington Books. He has published extensively in academic journals and has also appeared on BBC Radio 4’s ‘Four Thought’, in addition to contributing articles to The New Statesman and The Conversation. His latest work focuses on preventable deaths in mental healthcare that occur in inpatient, outpatient, community and criminal justice settings.

 United Kingdom

Marta Fidalgo has previously researched and published about police related deaths in the United States. She holds an MSc in Psychology from the University of East London and has worked as a Mental Healthcare Support Worker at Cygnet Healthcare, Coventry (UK).

 United Kingdom

Lauren Harrison-Brant has previously conducted research on workplace deaths and is currently a Detective Constable with Thames Valley Police (UK).