Patient Safety Learning

Mental Health Awareness Week is an annual event which aims to raise awareness and promote open conversations about mental health.  In this Top picks, we’ve pulled together resources, blogs and reports from the hub that focus on improving patient safety across different aspects of mental health services and also supporting staff with their own mental health and wellbeing. 1 World mental health today: latest data (WHO, 2025) This World Health Organization (WHO) document draws on the latest information available to outline the state of mental health and mental health systems in the world. It shows that mental health conditions remain highly prevalent, with more than a billion people worldwide living with a mental disorder. This report provides essential data to guide national and global dialogue. It highlights where progress is being made – and where critical gaps persist. This report should serve as a vital tool for policy-makers, implementers and advocates alike. 2 Jay’s Personalised Safety Planning Toolkit: A guide to support meaningful safety planning for self-harm and suicide This toolkit is a co‑designed set of materials created with researchers, people with personal experience of suicide and self-harm, and healthcare professionals. Inspired by the family of Jaymie Mart, known as Jay, who died by suicide in 2012 at the age of 32, the toolkit—which was funded by the National Institute for Health and Care Research (NIHR)—offers clear, practical guidance to help adults create and review personalised safety plans. 3 Harry’s story: Acute Behavioural Disturbance In December 2022, Harry Vass died after experiencing Acute Behavioural Disturbance (ABD) and a complex disturbance in normal physiology. Harry’s death was found to be avoidable as carers were not fully aware of this condition associated with acute psychosis. In this blog, Harry’s mother Julie describes the barriers they faced in getting the right support and care for Harry before he died and highlights the need for healthcare staff to have a greater awareness of ABD and the associated risks of a medical emergency. You can also read a second blog by Julie, where she explains more about Acute Behavioural Disturbance and the changes she believes are needed to make sure patients like Harry are cared for appropriately. 4 Life Beyond the Cubicle: eLearning to support working well with families during mental health crises A set of eLearning modules designed to educate and update clinicians on the importance of involving families wherever possible during mental health crises to improve patient care, avoid harm and reduce deaths. They were developed as a partnership between Oxford Health NHS Foundation Trust and Making Families Count, with funding from NHS England South East Region (HEE legacy funds). The resources have been co-produced by people with lived experience as patients, family carers and clinicians, supported by an Advisory Group drawn from a wide range of expertise, tested in eleven NHS Trusts and independently evaluated. 5 Mental health crises: how to improve care In May 2024, National Institute for Health and Care Research (NIHR) Evidence held a webinar on care for adults in mental health crisis. The webinar shared research findings on what works in community crisis care, how acute day units compare to crisis resolution teams and whether peer-supported self-management can reduce acute readmissions. This Collection summarises the 3 research projects presented at the webinar. It includes video clips from the speakers and incorporates quotes from the day. The information will be useful for anyone involved in commissioning or delivering mental health crisis services. 6 Self-harm: assessment, management and preventing recurrence This new guideline from the National Institute for Health and Care Excellence (NICE) covers assessment, management and preventing recurrence for children, young people and adults who have self-harmed. It includes those with a mental health problem, neurodevelopmental disorder or learning disability and applies to all sectors that work with people who have self-harmed. The guideline sets out some important principles for care and treatment. For example, it states that self-harming patients treated in primary care must receive regular follow-up appointments, regular reviews of self-harm behaviour and a regular medicines review. 7 Hope Virgo: What needs to happen to stop people with eating disorders being failed by the healthcare system? In this blog, Hope Virgo, author and Secretariat for the All Party Parliamentary Group (APPG) on Eating Disorders, examines the crisis that continues in eating disorder services in the UK and the devastating impact this is having on patients and their families. She highlights how failures in services lead to avoidable deaths. Hope shares the key recommendations from a new report by the APPG and calls for adequate funding and attention to ensure people with eating disorders receive the help they need to recover. 8 Designing paediatric wards to support mental health Blog from the Health Services Safety Investigations Board (HSSIB) authored by Saskia Fursland, Senior Safety Investigator. She talks about her visit to a newly opened paediatric ward where its design has carefully considered children and young people with mental health needs. Saskia reflects on the learning which could support other paediatric wards to improve their environments. 9 Zero Suicide Alliance training The Zero Suicide Alliance is a collaboration of NHS trusts, charities, businesses and individuals who are committed to suicide prevention in the UK and beyond. Their website offers free online training courses to teach people the skills and confidence to have potentially life-saving conversations with someone they’re worried about. They offer short online modules covering general suicide awareness, social isolation and suicide in veterans and university students. 10 How can our team move past a traumatic event? After an extreme traumatic event there are things that you can do to help yourself, and your colleagues, to move on. Fiona Day, medical and public health leadership coach and chartered coaching psychologist, Stacey Killick, consultant paediatrician at Glan Clwyd Hospital, and Lucy Easthope, professor in practice at Durham University’s Institute of Hazard, Risk, and Resilience and adviser on disaster recovery give their tips in this BMJ article. 11 Trusted information collection: severe mental illness (Patient Information Forum) The Patient Information Forum (PIF) have launched a series of new collections to help people find trusted resources. Each collection only features resources that have the PIF TICK. That means they are easy-to-read, evidence-based and easy to understand. Topics include: schizophrenia, bipolar disorder and psychosis. 12 Vicarious trauma: The invisible epidemic In healthcare, an insidious epidemic lurks beneath the surface, affecting the very individuals tasked with providing care: vicarious trauma by empathy. Despite its profound impact, this phenomenon remains largely unrecognised and under-discussed within the sector. As leaders, it is imperative that we shed light on this invisible trauma and acknowledge it as one of the greatest challenges facing our industry, as Margarida Pacheco explains in this blog. 13 Beyond stereotypes: A lived experience guide to navigating support for disordered eating Disordered eating can affect anyone, but it can be confusing to understand and recognise it in our own personal experiences. This guide, published by East London NHS Foundation Trust, is a snapshot of how adults in East London have navigated those experiences of uncertainty while seeking support for disordered eating. For many of the contributors, preconceptions about what an eating disorder is (or isn’t) have previously acted as a barrier to seeking or receiving support. It also contains advice on how to seek support for disordered eating. 14 “The alarming rate of suicide among healthcare workers should be a wake-up call in the urgent need to support them” Frontline19 was established at the start of the Covid pandemic as an urgent response to support frontline workers who were under extreme pressure and experiencing significant mental health challenges. Psychotherapist Claire Goodwin-Fee is the founder and CEO of Frontline19. In this blog, Claire explains how systemic pressures and stigma around mental health are continuing to leave healthcare staff extremely vulnerable. 15 Blog: Why harmful gender stereotypes surrounding men’s approaches towards their feelings need challenging This blog explores why men are reluctant to seek support when they are struggling with their mental health and why the suicide rate is so high. It looks at initiatives that exist to encourage men to seek help and highlights what more could be done to support mens’ mental health. 16 Time for a rebalance: psychological and emotional well-being in the healthcare workforce as the foundation for patient safety In this editorial for BMJ Quality and Safety, Kate Kirk explains why staff well-being is the foundation to improving patient safety. 17 Top tips and key actions for successful collaborative partnership working across mental health services These top tips and key actions have been co-developed to support effective collaborative partnership working in the planning and delivery of community mental health services. They recognise that every heath and care system will experience challenges in relation to partnership working given the statutory and cultural differences of organisations working across the mental health pathways and that there will be different arrangements to frame local partnership working, including for example a Section 75 agreement. 18 Balancing care: The psychological impact of ensuring patient safety In this blog, Leah Bowden, a patient safety specialist, reflects on the impact her job has on her mental health and family life. She discusses why there needs to be specialised clinical supervision for staff involved in reviewing patient safety incidents and how organisations need to come together to identify ways we can support our patient safety teams. 19 NHS England: Staying safe from suicide: Best practice guidance for safety assessment, formulation and management This guidance supports the government’s work to reduce suicide and improve mental health services. It promotes a shift towards a more holistic, person-centred approach rather than relying on risk prediction, which is unreliable because suicidal thoughts can change quickly. Instead, it recommends using a method based on understanding each person’s situation and managing their safety. 20 The Motherhood Group: Black maternal mental health report UK The Motherhood Group has launched a landmark report on Black maternal mental health in the United Kingdom, shining a light on the urgent need for safe spaces, culturally competent peer support, digital access, and community-driven, anti-racist solutions. This report centres the lived experiences of Black mothers and highlights systemic barriers to quality, affordable mental healthcare. By leading this research, The Motherhood Group places Black mothers’ voices at the forefront of national conversations, providing policy-makers, health services, and communities with the insights needed to drive meaningful change. 21 Mental Maintenance at NEAS: a proactive approach to staff mental health The North East Ambulance Service NHS Foundation Trust (NEAS) provides emergency medical and patient transport services to a population of 2.7 million people in the North East region, employing over 3,400 staff members. Exposure to traumatic events, the demands of shift working and an uncertainty of what’s in store each day, can impact ambulance staff mental health. Read how North East Ambulance Service NHS Foundation Trust created a campaign to provide proactive staff mental health support. 22 Mind: The big mental health report 2025 Mind’s 2025 Big Mental Health Report explores the state of mental health, and mental health services and support across England and Wales. It builds on the insights from their 2024 report and gives a comprehensive picture of mental health to date, serving as a crucial guide that anyone can use. It explores the latest evidence on the nation’s mental health including how well services are supporting mental health in England and Wales. 23 Making sense after a suicide: living with blame, uncertainty, and the need for answers. You are not alone Each year, more than 700,000 people die by suicide worldwide. In the UK, it is around 7,000 – making it the biggest cause of death for people aged 20–34 and for men under 50. Making Families Count have created this resource to offer some comfort, recognition, and companionship in the aftermath of bereavement by suicide, whether it seems the person intended to take their own life, or their intention was unclear. The resource consists of a booklet and three short films of people’s stories of their bereavement by suicide. Written by Dr Rachel Gibbons, with contributions from a group of bereaved families, Dr Karen Lascelles, and comments and suggestions from other affected people and those who work with them. 24 National Audit of Eating Disorders Service Mapping Report 2025 The National Audit of Eating Disorders (NAED) is commissioned by the Healthcare Quality Improvement Partnership (HQIP) and funded by NHS England as part of the National Clinical Audit and Patient Outcomes Programme. In 2025 the NAED team conducted a comprehensive mapping of eating disorder service provision across England. This report provides an in-depth overview of NHS-funded and independent sector services for children, young people, and adults. 25 Mental health crisis care: legislative challenges in emergency departments (HSSIB) The Health Services Safety Investigations Body (HSSIB) published two reports intended for healthcare organisations, policymakers and the public to help improve patient safety in relation to safety issues identified for people experiencing a mental health crisis who come into contact with urgent and emergency care services. This first report focuses on the significant legal, policy and safety gap in the care of people in emergency departments (EDs) in mental health crisis. During consultation on this report, concerns were shared with HSSIB about the current challenges in relation to the resourcing and configuration of mental health services that exacerbate challenges faced in the ED. 26 Mental health: attempted suicide while under the care of community services (HSSIB) The second HSSIB investigation used the patient safety incident investigation (PSII) report template and Patient Safety Incident Review Framework (PSIRF) tools to investigate an attempted suicide in the community mental health setting. Findings and areas for improvement are listed for the organisations that were involved in this incident. However, the learning may be relevant to other organisations. Have your say Do you have any stories, insights or resources related to mental health? We would love to hear from you! Comment below (register for free here first) Get in touch with us directly to share your insights.

Clinical huddles, safety briefings and board rounds are now core tools for managing safety, flow and workforce pressures in real time. Done effectively they: give teams a shared picture of risk surface concerns from all staff improve visible leadership, communication and teamwork proactively improve patient safety in real time help prioritise work and escalation turn “soft intelligence” into concrete actions. Done badly, they have the potential to become tick-box rituals that waste time, shut down voices and do not result in improvement or change. This practical masterclass will focus on how to design and lead brief, focused and effective clinical huddles and safety briefings in busy NHS environments. It will explore different types of briefings (start-of-shift, safety huddles, flow huddles, theatre briefs, board rounds and debriefs), and how to make sure they genuinely improve safety, flow and team culture rather than becoming “just another meeting”. The event will also support you to redesign and improve your huddles and briefings for maximum impact. Through expert input, practical examples and focused exercises you will build the skills and confidence to lead briefings that: run to time are well attended involving the whole multidisciplinary team surface concerns from all staff improve patient safety in real time result in clear, trackable actions. Register hub members receive a 20% discount. Email [email protected] for discount code.

Training to support the development of core understanding and application of systems-based patient safety incident response throughout the healthcare system - in line with NHS guidance, based upon national and internationally recognised good practice. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: purpose of patient safety incident response framework introduction to complex systems, system thinking and human factors restorative just and learning culture duty of candour involving staff in incident response involving patients, families and carers in incident response improvement science and developing system improvement plans general response techniques interviewing and asking questions conducting observations, understanding work as done systems frameworks response types patient safety investigation planning, analysis and report writing commissioning and oversight of an internal investigation a high-level overview of system-based response tools. Who should attend? Lead investigators; Executives, commissioning, and service leads for investigations; Investigators supporting or overseeing patient safety incident investigations Register hub members receive a 20% discount. Email [email protected] for discount code.

This training will support the development of expert understanding and oversight of systems based patient safety incident response throughout the healthcare system - in line with NHS guidance, based upon national and internationally recognised good practice. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: PSIRF and associated documents (PSIRP, PSII standards) oversight framework effective oversight and supporting processes related to incident response maintaining an open, transparent, and improvement focused culture importance of communication and involvement of those affected (preventing further harm) commissioning and planning of patient safety incident investigations complex investigations spanning different organisational, care setting, and stakeholder boundaries. Who should attend? Executives, commissioning, & service managers supporting service lead investigator roles The following only after attending the 2-day systems approach to patient safety incident response: All Executive, Commissioner and Service Leads for investigation; All Lead investigators conducting patient safety incident investigations investigators conducting Register hub members receive a 20% discount. Email [email protected] for discount code.

Training to support the development of expertise involving patients, families, carers and staff when things go wrong, in line with NHS guidance, based upon national and internationally recognised good practice. To include the duty of candour and ‘being open’ principles. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: Duty of candour regulations. Being open and apologising when things go wrong. Challenges/complexities associated with cases where there is more than one investigation. Effective communication, including dealing with conflict and difficult conversations. Effective involvement of those affected by a patient safety incident throughout the incident response process to ensure a thorough and richer investigation. Sharing findings. Signposting and support: including loss, trauma and stress. Who should attend? Lead investigators conducting patient safety incident investigations. Executive and service lead for duty of candour. Executive and service lead for patient safety. Executive and service lead for the supporting response to patient safety incidents. Investigators supporting patient safety incident investigations. Register hub members receive a 20% discount. Email [email protected] for discount code.

This stakeholder kit supports the promotion of World Hand Hygiene Day, a WHO global initiative, on 5 May. World Hand Hygiene Day is a global initiative led by the World Health Organization (WHO) and is held on 5 May each year. You are encouraged to use these resources to raise awareness about how hand hygiene can help save lives by preventing the spread of infection. To support the WHO’s theme “Action saves lives”, the Commission’s overarching theme for World Hand Hygiene Day 2026 is: “Action saves lives – Safer care starts with clean hands”. By promoting World Hand Hygiene Day, you can help reinforce the importance of hand hygiene in preventing healthcare-associated infections.