A newly released report by the Health Services Safety Investigations Body (HSSIB) has shed light on significant systemic issues within mental health services, highlighting a persistent culture of fear and blame, and a lack of patient and family involvement, which obstruct effective learning from inpatient deaths.
The HSSIB report scrutinises how mental health providers learn from deaths occurring in inpatient units and within 30 days post-discharge. The investigation reveals multiple processes involved in learning from deaths, including the Learning from Deaths Framework, coroner's inquests, and investigations following patient safety events.
The report indicates that there are substantial challenges in maintaining safety, conducting effective investigations, and ensuring system-wide learning. It identifies that investigations and patient safety event analyses, although intended to promote transparency and learning, often suffer from variable quality. Local investigations frequently lack comprehensive information and fail to observe clinical work practices in real-time, hindering a complete understanding of care delivery.
A critical revelation of the investigation is the prevalent culture of blame within mental health services. Patients, families, and organisations often fear safety investigation processes, which are perceived as punitive rather than educational. The report underscores that patient safety investigations rarely account for the emotional distress experienced by those involved, leading to compounded harm. Bereaved families have reported feeling marginalised and excluded, describing the investigation process as a "tick box exercise" devoid of transparency and accountability.
The HSSIB report also highlights the experiences of mental health service staff, who expressed that effective investigations are those where individuals feel safe to communicate openly. Nonetheless, there exists a pervasive belief that someone must be held accountable for inpatient deaths resulting from self-harm or suicide, contributing to a tense and adversarial environment during inquests.
Furthermore, the investigation reveals significant inconsistencies in reporting deaths and near-misses, with varied definitions and methods across mental health providers. This lack of standardisation hampers the identification of patterns or risks and undermines meaningful change implementation.
As part of her review of the report, HSSIB Senior Safety Investigator Nichola Crust said:
“This report has been published at a crucial time for reform in the NHS and we would expect the findings of this report to contribute to the government’s long term plans in relation to mental health settings. Whilst the report does paint a sobering picture, it also does pinpoint the opportunities for improvement, through our findings and safety recommendations.
“We emphasise areas that should be prioritised to remove the barriers and limitations to learning – only then will the system see an improvement in patient safety, a reduction in compounded harm and ultimately a reduction in deaths in inpatient care.”
The report brings to light gaps in discharge planning, crisis service accessibility, and access to community therapy, all of which potentially contribute to poor patient outcomes. Variability in therapeutic engagement and a lack of personalised care have left patients feeling disconnected and hopeless. Families have voiced their frustrations over restricted involvement in care decisions, which they believe hampers their ability to support their loved ones.
To address these issues, the HSSIB emphasises the need for a systemic approach to safety investigations, focusing on collaboration, transparency, and oversight. The report calls for a shift from procedural practices to a culture rooted in empathy, person-centred care, and active family involvement. It outlines five key safety recommendations aimed at supporting high-quality and transparent investigations, better oversight of recommendations, balancing safety with therapeutic environments, and developing consistent data on patient deaths.
NHS Providers Interim Chief Executive Saffron Cordery responded to the report saying:
“The NHS knows it must do more to improve how it learns from the deaths of mental health patients.
“This hard-hitting report sets out in stark detail that far too often, families and carers are being let down by inconsistencies and variations in practice across the NHS and within trusts.
“Opportunities to both learn from deaths and improve quality of care are being missed. Shortfalls in tackling systemic issues are further compounding these challenges.
“When someone dies under NHS care, it is essential that bereaved families and carers are treated with honesty, respect, and compassion.
“Families need to know, and be confident, that the NHS will recognise and act on any failings in care and deliver meaningful change to help prevent them happening again.”
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