HSSIB investigation report. Mental health: physical health deterioration while under the care of a low secure unit (30 July 2026)

Summary

The Health Services Safety Investigations Body (HSSIB) engaged with a wide range of stakeholders, including clinicians and national leads, to learn more about the issues surrounding learning from patient safety events in mental health settings and to identify areas on which an investigation could focus to help improve patient safety.

People with a mental health condition often suffer from poor physical health, for a variety of reasons. This investigation set out to understand how deterioration of patients’ physical health is monitored in a mental health inpatient setting, and how staff respond if a patient’s physical health deteriorates. Evidence from stakeholders suggested that greater insight into the challenges faced at an organisational level would be helpful.

To support NHS organisations and local investigation staff, HSSIB identified an opportunity to model approaches to patient safety incident investigations (PSIIs) under the Patient Safety Incident Response Framework (PSIRF). Stakeholders told HSSIB this would help to increase local learning and provide examples of how PSIRF tools can be used to improve investigations. HSSIB has also used this opportunity to identify learning that may help improve how PSIRF can support staff in carrying out incident investigations.

This investigation has used the PSII report template and PSIRF tools to investigate the physical health deterioration of an inpatient in a low secure mental health setting. Findings and areas for improvement are listed for the organisations involved in the incident. However, the learning may be relevant to other organisations.

Content

The investigation identified five areas for improvement which the mental health trust could develop safety actions to address.

Area for improvement 1

• The opportunities available for people to make healthy lifestyle choices, including weight management, smoking cessation and exercise, while detained on the low secure unit.

Area for improvement 2

• Access to a suitable area within the low secure unit for staff to carry out physical health observations and assessments.

Area for improvement 3

• Clarify clinician roles, responsibilities, and processes, including those for prescribing, between mental health and physical health staff when caring for patients with acute agitation, to help effective assessment in the emergency department.

Area for improvement 4

• Trauma-informed organisational support for staff, and shared safety learning for patient safety events where care spans more than one healthcare provider.

Area for improvement 5

• The ability to identify and apply a personalised approach to care planning to encourage people detained in inpatient mental health settings to engage with specialist services.