Guide to inquests for mental health patients

What is an inquest?

An inquest is a public court hearing held by a coroner in order to establish who died and how, when and where the death occurred.

By law, a coroner must undertake an investigation into a death and hold an inquest if they have reason to suspect that:

• The deceased died a violent or unnatural death.
• The cause of death is unknown.
• The deceased died in custody or otherwise in state detention.

When will an inquest be held for a deceased mental health patient?

Patients detained in hospital under the Mental Health Act (MHA)

Will an inquest be held? Yes

• Patients detained under the MHA are considered to be in 'state detention' and so an inquest is mandated by law, no matter what the cause of death.
• Where there is an argument that Article 2 of the European Convention on Human Rights (the right to life) has been breached, the inquest will be more complex since it must examine “in what circumstances” the deceased came by their death.
• However, if the medical cause of death is natural, and there are no circumstances that make it unnatural, the inquest will likely be straightforward and look only at the immediate circumstances of the death. The inquest may be documentary only, i.e. no witnesses need to be called.

Informal patients and community patients

Whether an inquest will be held depends on the circumstances of the death:

• If the death is violent or unnatural, or if the cause of death is not known, then an inquest will be held.
• Violent deaths involve an injury of some sort and include those by self-harm, suicide, a fall, road accidents or being deliberately killed by another.
• If the cause of death is natural and known, and has not been caused by any violence, then there will be no requirement to hold an inquest.

Patients subject to a deprivation of liberty authorisation or order 

Patients subject to a deprivation of liberty authorisation or order are not considered to be in 'state detention' and so there is no automatic requirement to hold an inquest.

Whether an inquest will be held depends on the circumstances of the death – see the notes in the 'informal and community patients' section.

When will a jury be called?

An inquest is usually heard by a coroner sitting alone. However, in certain circumstances, the law mandates that an inquest must be held with a jury.

An inquest must be held with a jury if the coroner suspects that:

• The deceased died in state detention and either the death is violent or unnatural, or the cause of death is not known.
  • A patient is in state detention if they are compulsorily detained under the MHA.
  • 'Violent' deaths include those by self-harm, suicide, a fall, road accidents or being deliberately killed by another.
  • For example, where a patient detained in hospital under the MHA has died as a result of suicide, the inquest must be held with a jury.
• The death resulted from an act or omission of a police officer or a member of a service police force.
  • This applies to any category of mental health patient.
• The death was caused by a notifiable accident, poisoning or disease.
  • This applies to any category of mental health patient.

A jury may also be summonsed if the coroner thinks that there is “sufficient reason” for doing so. When deciding whether to exercise this discretion, the coroner will take into account the following:

• The wishes of the family – whether they want a jury to hear the inquest or not.
• Whether the facts of the case bear any resemblance to the types of situation where a jury is mandated.
• The circumstances of the death.
• Any uncertainties in the medical evidence.