HSIB launches investigation into community mental health care

The Healthcare Safety Investigation Branch (HSIB) has launched an investigation into community mental health care following the death of a 56-year-old woman.

HSIB has begun examining how patients in crisis with severe mental health needs are assessed by NHS services.

The investigation came after warnings from multiple coroners over the poor assessment of suicide risk in people in mental health crisis in the last year and followed the death of Frances Wellburn, who took her own life in August 2020 while under the care of Tees, Esk and Wear Valleys Foundation NHS Trust (TEWV).

Wellburn had long-term mental health problems but suffered a crisis and was admitted to hospital in September 2019.

Following discharge, she was not referred to a specialist NHS service for people experiencing psychosis because clinicians incorrectly believed she was too old for the service, according to a TEWV investigation report seen by The Independent.

Despite being assessed as a “medium risk”, Wellburn was not contacted by mental health teams for three months. In June 2020, she was admitted to an inpatient unit for three weeks, but her health deteriorated, and she later took her own life.

Separately, coroner warnings in three prevention of future deaths reports published last year found mental health staff failing to risk assess people who later took their own lives.

HSIB’s investigation will look into how patients’ risk is assessed when receiving care in the community and how services interact with families and other health services. It will also examine how mental health services consider menopause when assessing women’s mental health and referrals to early intervention psychosis services.

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Source: The Independent, 27 January 2022