Mental disorders and deaths in custody: Making the case for mental health literacy -University of Greenwich & The Runnymede Trust (link opens as PDF in a new window)
INQUEST: Deaths in mental health detention -an investigation framework fit for purpose? - February 2015 (link opens as PDF in a new window)
Independent review of deaths of people with a Learning Disability or Mental Health problem in contact with Southern Health NHS Foundation Trust April 2011 to March 2015 - December 2015 (link opens as PDF in a new window)
CQC: Monitoring the Mental Health Act 2013/14 - 2015 (link opens as PDF in a new window)
CQC: Learning, candour and accountability - December 2016 (link opens as PDF in a new window)
National Quality Board: National Guidance on Learning from Deaths - March 2017 (link opens as PDF in a new window)
CQC: Opening the door to change: NHS safety culture and the need for change - December 2018 (link opens as PDF in a new window)
CQC: Learning from deaths: A review of the first year of NHS trusts implementing the national guidance - 15 March 2019 (link opens as PDF in a new window)
Parliamentary and Health Service Ombudsman, Missed opportunities: What lessons can be learned from failings at the North Essex Partnership University NHS Foundation Trust - June 2019 (link opens as PDF in a new window)
Rethink: Adult Secure Service User, Family and Carer Feedback Survey during the Coronavirus (COVID-19) pandemic - March-June 2020 (link opens as PDF in a new window)
CQC: Out of sight – who cares? Restraint, segregation and seclusion review - October 2020 (link opens as PDF in a new window)
INQUEST: Westminster Hall debate -"Deaths within mental health care" - 30 November 2020 (link opens as PDF in a new window)
Centre for Mental Health: The future of prison mental health care in England (Dr. Graham Durcan) - June 2021 (link opens as PDF in a new window)
National Confidential Inquiry into Suicide and Homicide: Ligature points and ligature types used by psychiatric inpatients who die by hanging: a national study - January 2012 (opens as a PDF in a new window)
Independent review of deaths of people with a Learning Disability or Mental Health problem in contact with Southern Health NHS Foundation Trust - April 2011 to March 2015 (“the Mazars Review”) - December 2015 (opens as a PDF in a new window)
British Journal of Psychiatry: Patient outcomes following discharge from secure psychiatric hospitals: systematic review and meta-analysis - Seena Fazel, Zuzanna Fiminska, Christopher Cocks and Jeremy Coid, 2016 (opens as a PDF in a new window)
INQUEST: Deaths in Mental Health Detention: an investigation framework fit for purpose? (opens as a PDF in a new window)
NHS: National Guidance on Learning from Deaths: A framework for NHS Trusts and NHS Foundation Trusts on Identifying, Reporting, Investigating and Learning from Deaths in Care - March 2017 (opens as a PDF in a new window)
National confidential inquiry into suicide and mental health, Annual report - 2019 (opens as a PDF in a new window)
Learning from deaths needs much greater priority across the health and social care system. Without this, opportunities to improve care for future patients will continue to be missed.