‘Catastrophic collision of failures’ revealed in mental health services

An exclusive Channel 4 News investigation has uncovered an 800% increase over the past five years in coroners issuing official warnings about cases involving mental health issues.

In England and Wales, the number of coroners ‘Prevention of Future Death Reports’ (PFDs) classed as mental health related has risen from 16 in 2017 to 126 in 2021. In the first five months of this year there have already been 52.

Prevention of Future Deaths Reports are produced when coroners wish to put on record their specific concerns arising from inquests. Channel 4 News analysed the data around PFDs published on the Department of Justice website.

Charities and mental health professionals say delays in care and support are risking even more lives.

Paul Farmer, Chief Executive of Mind, told Channel 4 News: “This isn’t just a yellow warning light, this is a red flashing light saying people have died unnecessarily and systems must be improved in order for those deaths not to reoccur.”

A Department of Health and Social Care spokesperson said: “Everyone should have access to safe, appropriate mental health care – which is why we are investing an extra £2.3bn per year to transform NHS mental health services by 2024.

“We are also investing £57m in suicide prevention through the NHS Long-Term Plan and last year provided £79m to enable around 22,500 more children and young people to access mental health support in communities, schools and colleges.

“We are asking members of the public, including those with experience of mental ill health, for their views to inform a new 10-year plan for mental health and wellbeing.”

The report also features cases where family members believe their loved ones would still be alive today if they’d received the urgent mental health care they needed.

During lockdown Josh Adey-Rennard, 33, suffered from depression and had psychotic episodes. He was sectioned and sent to Darlington and then Colchester, nearly 200 miles from his home in Sheffield. He took his own life in September last year while awaiting further treatment.

At the inquest Josh’s death was recorded as suicide but the coroner also wrote a PFD, warning delays in mental health care are risking lives.

His mother, Gillian Adey, told Channel 4 News North of England correspondent, Clare Fallon: “Something has to be done because our lives have been changed forever by this and other people shouldn’t have to suffer.”