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  • Safe and wellbeing reviews: thematic review and lessons learned (NHS England, 21 February 2023)

    Patient Safety Learning
    • UK
    • Reports and articles
    • Pre-existing
    • Original author
    • No
    • NHS England
    • 21/02/23
    • Everyone


    This report details the findings of a thematic review of Safe and wellbeing reviews (SWRs) between October 2021 and May 2022. SWRs are undertaken for children, young people and adults that are autistic and/or have a learning disability who are being cared for in a mental health inpatient setting.

     SWRs are part of the NHS response to the safeguarding adults review concerning the tragic deaths of Joanna, Jon, and Ben at Cawston Park Hospital, who were each detained for a long period of time and did not receive appropriate care.


    The review found that while in many cases care and treatment were appropriate, there were a number of cases that raised specific patient safety concerns. Below is a summary of key themes from this report:

    Out of area placements

    An out of area placement occurs when a person with acute mental health needs who requires inpatient care is admitted to a unit that does not form part of the usual local network of services.

     This review found that there was significant variation for people who are autistic and/or have a learning disability in this regard. This was most striking in the South West of England and Midlands regions, where 73% and 68% of all placements, respectively, were out of area compared to the national average of 57%.

    The report notes this can have significant impacts on the person affected by this, making it more difficult for them to maintain links with family, local services, communities and clinical/social work professionals.

    Hospital rather than community care

    It found that a significant number of patients covered by SWRs did not need to be in a hospital setting to receive the right care and treatment. The national average was 41%, while in the South West of England 53% of individuals did not need to be in hospital settings. The report linked this figure to delays in discharge processes, with patients staying in hospital settings for longer than needed as a result.

    Concerns about the involvement of family members and carers

    Concerningly, the report notes that examples of poor communication with family members and carers ‘far outweighed’ examples of effective communication, including:

    • Being excluded from planning and decisions about their loved ones.
    • Not being provided with basic information such as how to contact family members and visiting times.
    • Not being listened to in relation to the care and treatment of their family member, or decisions about their care and wellbeing.

    There was regional variation in these figures, with one particularly striking case being an Integrated Care System stating that in 39% of their safe and wellbeing reviews, family representatives either could not be contacted for the purposes of the review, they did not want to be contacted or the individual did not want them to be contacted.


    Another area of concern cited was the availability and quality of advocacy for people in hospital, which the report describes as generally inconsistent. Concerns included:

    • Family members having to step into the role of advocates in place of professional advocacy, though they are generally not trained to do so, may not know all the options available and cannot be fully independent.
    • Some provides being resistance to creating a “culture of importance” around advocacy.
    • Poor advocacy awareness in places, which extended to limited attempts by providers to contact advocates and proactively involve them in processes and decisions relating to individuals.


    In the 3% of cases where safeguarding concerns were raised (50 out of 1,770), serious concerns noted by the report included:

    • Inconsistent and/or high levels of restraint, seclusion and segregation.
    • Patients not being assessed appropriately under the Mental Capacity Act or assessments not being completed in a timely way
    • Harms associated with weight gain during admission (increasing the likelihood of health problems and premature mortality) and long lengths of stay.
    • Issues associated with individuals being placed in inappropriate settings (for example, mixed-gender wards), the absence of CCTV in inpatient settings, issues with staff attitudes and relationships.
    • Low quality and inconsistent of incident reporting.
    • Inappropriate and inconsistent use of medication.

    The review also said that one region noted that safeguarding referrals were not always made appropriately, and plans were not always implemented to prevent the incidents from happening again.

    Physical health

    The report notes that it found multiple references to individuals with a high body mass index and significant weight gain following people being admitted to hospital, including instances where this led to people developing diabetes. This was a key area of concern also raised in the Cawston Park safeguarding adults review.

    Individual wellbeing and positive mental health

    The report noted that in many mental health inpatient settings there were not enough activities for people to do and not enough done to help maintain social connections. It noted that meaningful activities were not consistently available and, where they were, were not always age-appropriate, co-planned and person-centred.


    The report noted a number of workforce issues, including:

    •  Families and advocates raised concerns about whether wards were unsafe when there were significant staff shortages on them.
    • Staff burnout.
    • Heavy reliance on agency and/or temporary staff which can have negative impacts on patients being able to access regular activities and on patient-staff relationships.
    • Reports of staff not having the appropriate training or skillset to effectively meet the needs of individuals.

    Conclusions and next steps

    Throughout the report there are a number of sections detailing ‘key considerations’ for providers and Integrated Care Systems, though no specific actions. It notes towards the end of the report that following on from this, NHS England, on a national and regional footprint, working with people with lived experience, family carers, integrated care boards, providers and commissioners, will bring partners together to look at specific actions that will address the challenges and themes highlighted through this thematic review over the next 12 months.

    Safe and wellbeing reviews: thematic review and lessons learned (NHS England, 21 February 2023) https://www.england.nhs.uk/publication/safe-and-wellbeing-reviews-thematic-review-and-lessons-learned/
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