The Care Quality Commission (CQC) has said it was wrong to approve the Bradgate Unit as being compliant with national care standards.
The charity Inquest has called for a system to ensure independent investigations into all suicides of mental health in-patients.
The Mental Health Act 1983 allows for mental health patients to be ‘sectioned’ if they are judged to be at high risk of committing violent acts, including suicide.
The Bradgate Unit has been criticised repeatedly by the local coroner over the deaths of high-risk patients in what should have been a ‘secure’ environment.
The CQC has admitted that it failed to properly inspect some mental health units, including Bradgate.
Following the death of Kirsty Brookes, aged 19, Leicestershire coroner Catherine Mason commented: “Despite the known existence of a real and immediate risk to Kirsty’s life from self-harm, she had been able to abscond due to not being observed and detained in accordance with her needs and care plan.”
Mason also noted that evidence given at the inquest contradicted a previous statement by Leicestershire Partnership NHS Trust that staffing levels at the unit were adequate.
Deaths in psychiatric units are not independently reviewed, and the CQC has no power to investigate individual cases.
Norman Lamb, Care and Support Minister, said: “NHS England and the CQC are reviewing how they can further tighten up the system and ensure that all deaths of mental health in-patients are reviewed and lessons for patient safety are identified.”