The criminal justice system is failing people with a mental illness. At every stage, their needs are being missed and they face unacceptable delays in getting support. Not enough progress has been made since our last joint inspection 12 years ago to put right these critical shortfalls.

– Chief Inspector of Probation Justin Russell, speaking on behalf of all six inspectorates

17 November 2021

A major inspection conducted jointly by six inspectorate bodies has found that the criminal justice system is failing people with mental ill health in England and Wales. INQUEST has responded calling for transformative change in a system that has proved itself incapable of reform.

Inspectors investigated the work carried out across policing, liaison and diversion services, prosecution and court, probation, and prisons and resettlement services in six regions of England and Wales.

Their report details the experiences of individuals with mental ill health at different phases of their journey through the system, from their first contact with the police to release from prison. The conclusions are deeply concerning and reflective of long term issues.

Inspectors identified a myriad of failings and stated that too little progress had been made since the last review in 2009. In particular, they highlighted the poor exchange of information between and within each element of the criminal justice system; the lack of training of staff on mental health issues; and the lack of timely, accessible, and adequate mental health support.

The report describes the information exchange arm of the criminal justice system as ‘broken’ and concluded that the shortage of mental health support leads to ‘unacceptable delays’ for individuals accessing services.

They cited the lack of a common definition of mental ill health as an underlying issue, meaning that ‘nobody has an accurate picture of the numbers of people with mental health issues in the criminal justice system, or the collective needs or risks posed by these individuals.’

The findings of the report resonate profoundly with INQUEST’s experience. After decades working with families whose relative’s deaths are at the sharpest end of these failures, INQUEST believes that a criminal justice response is fundamentally inappropriate for people with mental ill health.

INQUEST has repeatedly observed how being held in police custody can have traumatic, detrimental, and sometimes fatal consequences for people with mental ill health. This is reflected in the experiences of Sammy, who is quoted in the report:

It’s only reflecting back I realised how bad it was ... It traumatised me for a long time, how I was handled (in the police station) and treated ... I was disassociated, detached and suffering psychosis and anxiety. How they didn’t notice ... they interviewed me anyway. For months after I’ve had panic attacks and nightmares

Imprisonment can also induce and exacerbate existing mental ill health and increase the likelihood of self-harm and suicide. In the report Fergus articulated their experience of prison:

Heartbreak that manifested itself physically, triggering muscle weakness, exhaustion, insomnia and anxiety attacks. And the feeling you’re going to die... Distressed to the point that made you sob in the shower or under the blanket where the segregation staff couldn’t hear my desperate sobs and gasps.

INQUEST’s own report on deaths in prison called the repeated preventable deaths and suicides in prison a national scandal, with a person taking their life in prison every four days.

The inspectorate report also highlighted the overrepresentation of Black, Asian and minority ethnic groups at every stage of the criminal justice system and found they are at higher risk of experiencing mental ill health. INQUEST’s understanding is that this overrepresentation is reflective of structural racism in society, which results in the heightened criminalisation, policing and incarceration of people from racialised groups.

Inspectors highlighted the ‘shortage of specialist services for ethnic minority people’. This finding points to the clear need for culturally sensitive mental health support based on principles of care not coercion. 

The report also examined the specific experiences of women, 70% of whom report mental ill health in prison (compared to 48% of men). Inspectors found women were particularly likely to be put in prison as a ‘place of safety’ during a mental health crisis. Primarily because suitable alternative accommodation was not available.

There is no national data on this misuse of prison, but senior managers at one women’s prison counted 24 such incidents in the previous 12 months. The report concludes this practice as inhumane and inappropriate and called for the government to do more to find or fund beds elsewhere.

INQUEST’s research and work with the families of women who have died in prison has exposed similar issues, as well as the consistent failure of criminal justice bodies to safeguard and divert women in need of care and support. 

Time and time again, INQUEST have witnessed the trauma experienced by the families of people who die in police or prison custody as the result of a harmful system.

Despite the countless reports, critical inquests and reviews over the years, there has been insufficient change. INQUEST continues to support families whose relatives die preventable deaths. The criminal justice system has proved itself incapable of reform.

In order to remedy the crisis of mental ill health in the criminal justice system, systemic change is needed. In the short-term, urgent action must be taken to ensure that individuals in the system have access to appropriate mental health support, treatment and can be diverted to healthcare settings.

In the long-term, it is vital that we end the criminalisation of people with mental ill health, drastically reduce the prison population, and holistically invest in our communities. Only a transformative approach will ensure the prevention of future harms and deaths of people with mental ill health.