The deaths in custody of hundreds of people with mental health problems could have been avoided, according to an inquiry.
Repeated basic errors, poor communication and a lack of rigorous procedures were found to have contributed to deaths in police cells, prisons and psychiatric hospitals.
The Equality and Human Rights Commission (EHRC) examined the period from 2010-13, during which it said 367 adults with mental health conditions died of non-natural causes in psychiatric wards and police cells, while 295 adults died in prison, many of whom had mental health conditions.
The EHRC has recommended a framework aimed at policy makers and front-line staff to help protect people in custody.
Professor Swaran Singh, lead commissioner on the inquiry, said: “Human rights are for all of us and nothing is more fundamental than our right to life.
“When the state detains people for their own good or the safety of others it has a very high level of responsibility to ensure their life is protected.
“For people with mental health conditions that is a particular challenge with a large number of tragic cases over the past few years where that responsibility has not been met.
“The commission, as Great Britain’s national human rights institution, carried out this inquiry in consultation with other expert bodies to examine what lessons can be learned and how to prevent further unnecessary and avoidable harm and heartbreak.”
The report found basic mistakes were repeated, such as failing to properly monitor patients and prisoners at serious risk of suicide, and not removing ligature points in psychiatric hospitals despite their common use in suicide attempts.
Misplaced concerns about data protection were blamed for prison healthcare staff not telling officers on the wing that an inmate had suicidal tendencies. A failure to update patients’ risk assessments was also criticised.
A central record is kept of the deaths of people with mental health issues in prisons and police stations, but not in hospitals. The EHRC noted that there is no independent body charged with ensuring that effective investigations take place in the latter, and claimed some staff feel they cannot speak out openly.
The commission made a number of recommendations such as setting up trigger systems to alert staff to events or dates which could prompt self-harm, such as the anniversary of a bereavement, and embedding a mental health liaison officer in each police force.
Inspector Michael Brown, co-ordinator for mental health at the College of Policing, said: “There is a growing demand on front-line police officers and staff in helping those of us suffering mental health difficulties.
“While the police service should not be filling gaps in mental health services we need to ensure that we give front-line officers and staff basic training in identifying signs and symptoms.
“Officers and staff also need to be equipped with the knowledge of where to divert vulnerable people into a healthcare setting so that they can receive expert care. That means not using police cells as a place of safety for those detained in distress.”