Deaths in the NHS: Mental Health Trusts
Caring for the most vulnerable
Following a death investigation, coroners send reports to organisations to take action to prevent similar fatalities. However, no one is responsible for understanding who receives these reports, whether they respond, if action is taken, nor is there any systematic use of these reports to support national learning. The Preventable Deaths Tracker is changing this, the only platform that provides real-time analytics on coroners’ reports and their responses.
I’ve previously shared an analysis of reports sent to Ambulance Trusts. So today, I collate the data for Mental Health Trusts - the services that care for some of the most vulnerable people in our communities.
824 coroners’ reports
There are 49 Mental Health Trusts in England following recent mergers. Collectively, 824 reports were sent to Mental Health Trusts to take action following a death between July 2013 and 08 December 2024. However, this is likely an underestimate.
An investigation by the Preventable Deaths Tracker (PDT) found that at least 92 reports are missing from the Judiciary website. There were also at least 89 reports that Mental Health Trusts could not locate, questioning their use of these potentially life-saving reports.
After a series of Freedom of Information (FOI) requests, only one Mental Health Trust, Humber Teaching NHS Foundation Trust, accurately matched the information published by the Chief Coroners’ Office, likely because they’ve not yet received a report.
Twenty Mental Health Trusts initially refused to share any information, citing that it was already available on the Judiciary website. But as shown above and previously written, the PDT knows this often isn’t the case. Nine (18%) Mental Health Trusts continued to refuse to provide any useable data, including:
Responses to coroners
Every organisation that receives a coroners’ report must respond by law. Tavistock and Portman NHS Foundation Trust had the best response rate, with one response published, followed by Leicestershire Partnership NHS Trust, which had nearly 90% published. No responses were published for Northamptonshire Healthcare NHS Foundation Trust and Cambridgeshire and Peterborough NHS Foundation Trust.
Trends over time
Most reports for Mental Health Trusts were published in 2024, and the year isn’t over yet.
The Verdict
The current email-based “system” for sharing and publishing coroners’ reports and responses is a mess - it’s inefficient, inadequate, and certainly can’t prevent future deaths. The solution? A national centralised database of all inquests that is routinely used by a dedicated and independent unit of experts (i.e. epidemiologists and social scientists) who can directly advise and support policymakers. In the short term, the Chief Coroner’s Office and all 77 Coroner Areas should audit the publication of their reports and responses, including historical cases, to ensure this information is accurately published.
As with Ambulance Trusts, there is no mechanism for Mental Health Trusts to collectively learn from these 824+ reports nor any process for national learning. We shouldn’t wait until the concerns amount to another statutory inquiry.
National organisations, such as the Department of Health and Social Care and NHS England, are only aware of the coroners’ reports that they receive directly. Both national organisations and NHS Trusts would benefit from regular epidemiological and thematic analyses of all health and social care concerns raised by coroners so actions can be systematically implemented across all relevant organisations to prevent future deaths. Until then, the Preventable Deaths Tracker will keep tracking.