Patient safety incidents within adult community-based mental health services in England: A mixed-methods examination of reported incidents, contributory factors, and proposed solutions (4 February 2025)

Summary

Relatively little is known about mental healthcare-related harm, with patient safety incidents (PSIs) in community-based services particularly poorly understood. This study aimed to characterise PSIs, contributory factors, and reporter-identified solutions within community-based mental health services for working-age adults.

Content

Data was obtained on PSIs reported within English services from the National Reporting and Learning System. Of retrieved reports, the authors sampled all incidents reportedly involving ‘Death’, ‘Severe harm’, or ‘Moderate harm’, and random samples of a proportion of ‘Low harm’ or ‘No harm’ incidents.

Of 1825 sampled reports, 1443 were eligible and classified into nine categories. Harmful outcomes, wherein service influence was unclear, were widely observed, with self-harm the modal concern amongst ‘No harm’ (15.0%), ‘Low harm’ (62.8%), and ‘Moderate harm’ (37.6%) categories. Attempted suicides (51.7%) and suicides (52.1%) were the most frequently reported events under ‘Severe harm’ or ‘Death’ outcomes, respectively. Incidents common to most healthcare settings were identified (e.g. medication errors), alongside specialty-specific incidents (e.g. Mental Health Act administration errors). Contributory factors were wide-ranging, with situational failures (e.g. team function failures) and local working conditions (e.g. unmanageable workload) widely reported. Solution categories included service user-directed actions and policy introduction or reinforcement.