HSSIB investigation report: Mental health inpatient settings: overarching report of investigations directed by the Secretary of State for Health and Social Care (13 May 2025)

Summary

In June 2023 the Secretary of State for Health and Social Care announced that HSSIB would undertake a series of investigations focused on mental health inpatient settings. This overarching report brings together and explores cross-cutting patient safety risks across five individual investigations.

Content

The aim of this report is to examine patient safety risks identified across the following HSSIB investigations:

• Creating conditions for learning from deaths and near misses in inpatient and community mental health services: Assessment of suicide risk and safety planning (12 September 2024)
• Creating conditions for the delivery of safe and therapeutic care to adults in mental health inpatient settings (24 October 2024)
• Mental health inpatient settings: out of area placements (21 November 2024)
• Mental health inpatient settings: Supporting safe care during transition from inpatient children and young people’s mental health services to adult mental health services (12 December 2024)
• Mental health inpatient settings: Creating conditions for learning from deaths in mental health inpatient services and when patients die within 30 days of discharge (30 January 2025)

Findings

Safety, investigation, and learning culture

• There remains a fear of blame in mental health settings when safety events happen. This contributes to a more defensive culture despite staff actively wanting to learn.
• Many recommendations to support learning for improvements in mental health care do not lead to implemented actions. Reasons for this include a lack of impact assessment resulting in unintended consequences, no clear recipient involved in the development of recommendations, and duplicated recommendations across organisations.

System integration and accountability

• The integration of health and social care within an integrated care system currently relies on relationships, with an expectation and hope that they will work well. However, where this is not the case, a lack of clear accountability can result in poor outcomes for people with mental illness and severe mental illness.
• The delivery of care for people with mental illness and severe mental illness is challenging because health and social care services are not always integrated and their goals are not always aligned.

Physical health of patients in mental health inpatient settings

• There are gaps in the provision of physical health care for people with severe mental illness, including inconsistent health checks, poor emergency responses, and misattribution of physical symptoms to mental illness.
• The misattribution of physical symptoms to patients’ mental health was observed and had the potential to contribute to worsened patient outcomes.
• National reports, strategies and research have made recommendations to improve the physical health of people with severe mental illness. However, there is evidence that recommendations are delayed in implementation and people continue to die prematurely.
• Integrated care boards lack the required data and the necessary analytical capability to assess disparities in access, experience and outcomes related to the physical health needs of people with severe mental illness.
• There is variation in how the physical health checks are carried out on mental health inpatient wards, with limitations in processes for following up on patients’ physical health needs.
• There is variation in the knowledge, skills and experience of staff who undertake physical health checks and in the environments in which these checks take place.
• Patients may not always be supported in terms of health education about their physical health risks and modifiable risk factors, for example smoking, dietary advice and physical activity.

Caring for people in the community

• Integrated care boards cannot consistently draw reliable insights from data at national, system or local level, to optimise and improve services, patient care, and outcomes across mental health pathways of care. This results in variability in service provision which does not always meet the needs of individual patients or local populations.
• Inpatient ‘bed days’ are taken up by people who no longer need them, because people who are clinically fit for discharge are delayed in being transferred to their home or a suitable residence (appropriate placement).
• Reasons for delayed discharges include issues with housing support and establishing suitable accommodation. This means patients are not always in the right place of care.
• Barriers to discharge affect patient flow and may result in delays in admission for people with severe mental illness. This means they have to be cared for in a community setting while waiting for an inpatient bed.
• There is variation across the country in how drug and alcohol services are provided. The variation does not allow for fair and equitable treatment for all patients.
• Community services are vital to support people to stay as well as possible and to prevent hospital admissions. However, there is variation in community service provision across the country.

Staffing and resourcing

• Staffing and resource constraints in inpatient and community mental health settings impact their ability to provide safe and therapeutic care.
• In inpatient settings, constraints contribute to mental health wards aiming to staff for ‘safety’ but not always for ‘therapy’.
• Challenges for staff include the emotionally demanding nature of their work; this can lead to staff burnout and sickness, and further strain on services.
• There are gaps in mental health workforce planning, particularly in community services where there is no evidence based workforce planning tool to support a standardised staffing establishment setting model.

Digital support for safe and therapeutic care

• A lack of interoperability or integration between digital systems affects the provision of care across mental health, acute and community providers.
• Challenges in securing appropriate funding impacts on the ability of hospitals to integrate and update their digital services and infrastructure.
• Electronic patient record functionality is often not available or does not meet staff needs, and so it is not used. Examples include absent functions for food and fluid balance monitoring and risk assessment of venous thromboembolism (blood clots).
• Challenges in providing and maintaining patient-facing technology, for example televisions and payphones, impacts on the therapeutic environment and the ability of patients to maintain contact with families and loved ones.
• Where technology for monitoring patients had been introduced, implementation has required considerations to ensure it is used appropriately, is patient-centred, maintains therapeutic engagement, and supports patients to feel safe.

Suicide risk and safety assessment

• ‘Doing’ tasks, like ‘ticking’ checklists, overshadow meaningful, empathetic ‘being’ interactions with patients. Open, compassionate conversations that build trust and therapeutic relationships, enabling patients to own their risk while feeling supported, can help mitigate this.
• Investigation processes can contribute to a fear of blame, and subsequently contribute to defensive practices such as checklists and a ‘tick box’ culture. This inhibits open and honest conversations and the ability to put the patient, as their authentic self, at the heart of them.

Safety recommendations

1. HSSIB recommends that the Department of Health and Social Care continues to work with the ‘recommendations but no action working group’ and other relevant organisations, to ensure that recommendations made by national organisations specific to mental health inpatient settings are reviewed. This work should consider the mechanisms that supported or hindered the implementation of actions from these recommendations. This may help the Department of Health and Social Care understand what has worked when implementing actions from recommendations and enable learning about why some recommendations have not achieved their intention.
2. HSSIB recommends that the Secretary of State for Health and Social Care directs and oversees the identification and development of a patient safety responsibilities and accountabilities strategy related to health and social care integration. This is to support the management of patient safety risks and issues that span integrated care systems.

Safety observation

1. National bodies can improve patient safety in mental health inpatient settings in England by supporting provider investment in equipment, digital systems and physical environments to enable conditions within which staff are able to provide, and patients can receive, safe and therapeutic care.