Systemic issues identified within mental health services

A new report from 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.

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Source: National Health Executive, 30 January 2025