Summary
This is the second of two investigation reports into crisis care in emergency departments (EDs). An interim report was published in April 2026 following early identification of a significant legal, policy and safety gap in the care of people in mental health crisis in EDs.
This report is part of the Health Services Safety Investigations Body (HSSIB)’s wider work on safety issues for people experiencing a mental health crisis who come into contact with urgent and emergency care services. A related investigation is examining the 999 and 111 response to mental health crisis and will report its findings in spring 2027.
The two investigations consider different points in the same pathway. Wider health and care system issues are included where they directly affect ED care, and further themes may be brought together in a separate, final report drawing on evidence from both investigations.
Around 3% of ED attendances are mental health-related. However, people experiencing mental health problems are twice as likely as other patients to remain in the ED for more than 12 hours.
Content
Findings
People’s experience in the emergency departments
Prolonged waits, crowding, overstimulation, lack of privacy, limited observation and unmet basic needs could increase distress, deterioration and risk to people in crisis, other people using EDs, visitors and staff.
Safety risks were not experienced equally. Protected characteristics, communication and sensory needs, neurodevelopmental needs, trauma, previous experiences and wider circumstances could affect how people experienced the ED environment, how their distress and needs were understood, and how able they were to participate in care and decision making.
Children and young people could experience prolonged waits in EDs or paediatric settings while assessments continued, when responsibility for care was unresolved, or while suitable onward provision was sought.
EDs were often not designed or resourced to provide prolonged therapeutic mental health crisis care. Dedicated mental health spaces varied in availability, design and suitability, and there were no nationally defined service standards or built environment standards. Some mental health assessment rooms did not meet Royal College of Psychiatrists’ Psychiatric Liaison Accreditation Network standards.
People with complex social circumstances, housing instability or co-occurring substance use could fall between services, leaving EDs managing needs beyond their intended role.
Variation in the capacity, accessibility, integration and responsiveness of mental health crisis services meant that they could not always provide a timely or suitable alternative to ED attendance for patients in mental health crisis.
Workforce – knowledge, skills and resources
Workforce skills, confidence and capacity were not always matched to the needs of people coming to an ED in mental health crisis.
Staff described gaps in specialist skills, legal knowledge, trauma-informed care, therapeutic engagement, de-escalation and clinical supervision.
Workforce pressures also affected staff wellbeing, contributing to burnout, compassion fatigue, moral distress and potential moral injury.
Enhanced therapeutic observation and care was variable, with some services relying on agency or security staff for one-to-one supervision.
Liaison psychiatry provision was variable, with differences in staffing resources, commissioning and delivery of Core 24 standards limiting timely mental health input in EDs.
Limited availability of approved mental health professionals (AMHPs) and Section 12 doctors, particularly out of hours, delayed Mental Health Act assessments and exposed gaps in national oversight of statutory workforce capacity and resilience.
Oversight and decision making
Families and carers were not consistently involved in a person’s assessment, safety planning or discharge decisions in EDs, and information shared by family members was not always used to support safety.
Many people already known to mental health services did not appear to have co-produced crisis or relapse prevention plans.
Arrangements in the ED for urgent mental health admission for patients in mental health crisis, under Section 140 of the Mental Health Act, were not always clear or effective.
Wider healthcare pressures increased pressure on EDs, including limited mental health inpatient beds, delayed Mental Health Act assessments due to limited access to AMHPs and Section 12 approved doctors, variable liaison psychiatry provision and limited alternatives to ED attendance.
Governance, accountability and escalation of safety concerns was variable, with evidence of staff feeling tension and fear. Escalation meetings were often experienced as shifting responsibility and risk between services.
Delayed admission to mental health inpatient care, prolonged stays in the ED, the exclusion of families from information and decisions about their family member, and a lack of support for the person once discharged from the ED were not consistently recognised, captured or used to monitor safety incidents or to inform safer care.
Information sharing and systems
Poor interoperability and information sharing between IT systems meant that ED and liaison psychiatry staff could not consistently access or share risk history, crisis plans, safeguarding information, recent assessments and family-held information to support safe patient care.
Interagency working
Delays or gaps in appropriate health provision can transfer risks between organisations responsible for providing care under Section 136 pathways.
Interfaces between services including police, ambulance, drug and alcohol, social care, voluntary sector and other services were inconsistent, increasing operational risk and leaving EDs managing needs beyond their intended role.
Section 136 pathways were not always supported by clear ownership across police, health and local authority services, timely access to health-based alternatives, shared risk management, effective transfer of care or sustained multi-agency learning. This is reported to have become more challenging following Right Care, Right Person implementation.
Safety recommendations
HSSIB recommends that the Department of Health and Social Care/NHS England works with relevant national stakeholders, to set out and support national minimum operational service standards and built design expectations for emergency departments. This will help reduce unwarranted variation and meet the therapeutic needs of individuals who attend emergency departments in a mental health crisis.
HSSIB recommends that the Department of Health and Social Care/NHS England works with relevant national stakeholders, to ensure people in mental health crisis in emergency departments are kept safe by addressing the findings of this report. This programme of work should provide further support and/or guidance to address:
clear expectations for roles, responsibilities and accountability for clinically appropriate, co-ordinated Mental Health Act assessment pathways;
effective shared care, governance and escalation arrangements and processes to identify, escalate and review delays related to assessment, bed availability and onward care;
arrangements to assess, plan for and assure the capacity, capability and resilience of the workforce, including access to relevant specialist and statutory professionals;
agreed measures and reporting arrangements to monitor workforce and pathway pressures, evaluate improvement actions, identify variation in access, waiting, experience, use of restrictive interventions, and address inequalities between population groups.
Safety observations
Organisations with responsibilities for regulation, oversight and assurance of urgent and emergency mental health crisis care can improve patient safety by using the findings of this report to review how they monitor the safety and effectiveness of care for people in mental health crisis who attend emergency departments.
Organisations with responsibilities for regulation, oversight and assurance of mental health crisis care can improve patient safety by reviewing the extent to which patients, families and carers are involved in care and decision making for people in mental health crisis who attend emergency departments. Understanding why family and carer involvement is not consistently achieved will help organisations identify opportunities to improve assessment, safety planning and discharge processes, to help keep people safe.
Safety learning for integrated care boards
HSSIB suggests that integrated care boards can improve patient safety by ensuring that people with lived experience, families and carers are involved in the design, delivery and governance of urgent and emergency mental health crisis care. This involvement can help to inform decisions, improve services and identify safety risks that may not be visible through operational data alone.
HSSIB suggests that integrated care boards can improve patient safety by supporting sustained relationships and effective joint governance arrangements between acute and mental health providers, and other organisations involved in urgent and emergency mental health crisis care. These relationships can help partners develop a shared understanding of local demand, pathway gaps, escalation routes and the impact of delays on people in crisis, families and staff.
Recommended Comments
Create an account or sign in to comment