In every suspected death caused by an intentional act, there will be an inquest. This covers not just deaths found to be caused by suicide (a legally defined term requiring proof of intention by the individual to end their life) but also other unnatural deaths of people receiving mental health care.

The inquest, taking place in front of a coroner and/or jury, is the forum where these deaths can be fully investigated and there is a legal obligation on coroners to consider risks to future lives during the process and publish a Prevention of Future Deaths report if such a risk is identified and steps can be taken to minimise it. In short, this is where lessons can really be learnt.

The problem is that the inquest system is broken, leading to missed opportunities to make changes and prevent future deaths, including through suicide. On top of this the lack of availability of legal aid and the postcode lottery that exists regarding how coroners conduct inquests can often compound the grief and pain of a bereaved family.

For bereaved families of individuals who were under the care of a community mental health team (as opposed to when a person dies as an inpatient in a psychiatric hospital), the issue is particularly stark.

It is beyond doubt that where a person dies while an inpatient, the coroner must investigate not only how the death occurred but how and in what circumstances. This is because the right to life, protected by Article 2 of the European Convention on Human Rights, requires a wider investigation in these circumstances and in many such inquests, legal aid will be available to bereaved families to allow them to be represented during the inquest (even to those outside the usual financial eligibility limits). Although this does not necessarily lead to exactly the investigation or conclusion a bereaved family seeks, the inquest process has a solid chance of fulfilling its function with the bereaved family able to participate effectively.

Where a person has died under the care of a community mental health team, although it is my view that a wider investigation is still required, the law is a little less clear.

I have faced many coroners on behalf of bereaved families who decide Article 2 is not engaged in circumstances where a person is in receipt of mental health care in the community, even if they are receiving multiple visits per day from the Crisis Resolution or Home Treatment (“CRHT”) team and/or the bereaved family believe their loved one required admission to a psychiatric hospital and/or should not have been discharged from the CRHT. This decision by a coroner to refuse to hold a wider investigation into the circumstances of the death, not only deprives the bereaved family of proper public scrutiny of the mental health care their loved one received, but also means legal aid is highly unlikely to be available to fund legal representation for them.

To make matters worse, NHS mental health trusts facing potential criticism in an inquest are, in my experience, highly likely to be legally represented for the inquest process. The inequality in arms is immense. NHS trusts’ lawyers will usually seek to persuade a coroner that a narrow investigation is lawful at an early stage in the inquest process and often go to great lengths to argue that there is no need for a coroner to make a Prevention of Future Deaths report.

The chances of lessons being learned and a bereaved family in these circumstances feeling they have been at the heart of the inquest process are phenomenally low. By requiring inquests into the deaths of people receiving community mental health care to look at the circumstances of the death rather than the narrow issue of how the death occurred, and ensuring legal aid is available for bereaved families for these inquests, there would be a real opportunity to reduce the number of deaths of people in community mental health care. In particular, these changes could help identify meaningful strategies to reduce the “average of 191 deaths per year” of people receiving care from Crisis Resolution/Home Treatment teams.

The Ministry of Justice is conducting a review of legal aid for bereaved families in inquests and I very much hope Jackie Doyle-Price MP, the newly appointed suicide prevention minister, will see this as an opportunity to speak up for bereaved families as she has committed to do and join the call for legal aid to be available to all bereaved families whose loved one died during or following contact with a state agency, including community mental health care, and in particular those under the care of Crisis Resolution/Home Treatment teams.

Another aspect of our broken inquest system which I think could easily be fixed and in doing so could help the new minister deliver a robust and effective “cross-government suicide prevention plan” is the handling of Prevention of Future Deaths reports. Yes there has been a minor improvement in that they are now (mostly all) published online, but they are not easily searchable and I know of no particular body charged with properly disseminating the lessons learned from a local level to a national level. There are 10 pages worth of these reports filed under ‘Suicide’ and a least 100 more in relation to risks to lives of patients in mental health care. Many of these relate to risks which occur not just in a local area, but are replicated, or very similar to, problems across the country.

Given these reports have been published after investigations into previous deaths, I urge the new minister to not only review past reports if she has not already done so, but also to consider a way to ensure risks identified by coroners regarding mental health care and suicides are properly scrutinised (start by making the contents of the report searchable) and that any effective steps taken to address risks locally are disseminated to all relevant service providers nationally so that more lives are better protected, and bereaved families can be more confident that another family will not have to go through the same pain as them as their loved one.