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This Patient Safety Supplement aims to raise staff awareness of the risk of self‑harm with people using plastic bags as ligatures in Health Service Executive (HSE) and HSE‑funded services, including emergency care, in the Republic of Ireland. A ligature is an item used for tying or binding something tightly. To help prevent the risk of self-harm from bin bags or liners, this supplement shares alternative product options, including for sanitary bins. These options are based on learning from a number of our mental health services across the country.

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.   The resources can be downloaded by NHS Trust Learning and Development teams to support a Trust-wide approach to essential learning and training.   Through short film and audio scenarios and case studies, Life Beyond the Cubicle shows why it is so important to involve family and friends, helps clinicians reflect on why they don’t do so routinely, and how they can overcome these barriers. The resources are engaging and interactive. The modules are: Introduction (includes guidance on how to use this resource) Module 1: Why do families and friends matter? Module 2: Assumptions and expertise Module 3: Feelings and fears Module 4: Confidentiality and Information Sharing Module 5: Safety planning Resources for family and friends They are free to the health and social care workforce. Further reading on the hub: Safer outcomes for people with psychosis Patient Safety Spotlight interview with Rosi Reed, Development and Training Coordinator at Making Families Count The future has been around for too long—when will the NHS learn from their mistakes?

Despite the prevalence of diabetes amongst individuals with Serious Mental Illness (SMI), diabetes care is not currently audited within mental health inpatient settings as it audited in physical health settings. This project piloted an audit to assess the diabetes care within London NHS Mental Health Trusts. The Health Innovation Network in partnership with South London and Maudsley NHS Foundation Trust (SLaM) developed and piloted a diabetes audit. Following the SLaM pilot, the audit was completed by all nine London Mental Health Trusts. A diverse approach was taken to spread and adoption. This included piloting the audit within one MH Trust, refining, and then rolling out the audit to eight London Mental Health Trusts. Outcomes The audit evidenced a need to improve: Access to diabetes specialists; no Mental Health Trust had access to consultant diabetologists. Seven out of nine Trusts had no access to Diabetes Specialist Nurses. Staff and patient education; Mental Health Trusts offered no or irregular education. Policy communication e.g. 76% of mental health wards stated they did not have or did not know of their Trust’s diabetes self-management policy. Patients rated diabetes care as 3.63 out of 5. Since sharing the findings Mental Health Trusts have made improvements, these include: recruiting Diabetes Specialist Nurses and Physicians Associates. sharing self-management policies. offering educational training. creating physical health forums. The team used networking opportunities with key stakeholders such as London Diabetes Clinical Network and Diabetes Inpatient Network and the London Physical Health Leads Network and the Cavendish Square Group (Medical Directors and CEOs of all London MH Trusts) to ensure more than 7,000 stakeholders were aware of the project findings. The Health Innovation Network also produced a report and was successful in gaining both a poster and presentation at the 2023 Diabetes UK Conference which has a national and international audience. The audit revealed that improving diabetes care in mental health settings remains a priority for London Mental Health Trusts and the London Diabetes Clinical Network.

In this video, Chris tells his story of how he dealt with a traumatic childhood and subsequent diagnosis of schizophrenia. He talks about the medication and therapy that have helped him. Warning: The film does contain references to distressing themes.

This is the transcript of an oral statement to the House of Commons by Steve Barclay MP, Secretary of State for Health and Social Care, on improving safety in mental health in-patient services across England. In this statement the Secretary of State: Provided an update on the independent inquiry into mental health in-patient care across NHS trusts in Essex between 2000 and 2020. He announced that in response to concerns raised by the inquiry’s Chair, Dr Geraldine Strathdee, about the extremely low engagement from staff at Essex Partnership University NHS Foundation Trust, the Government had made the decision to give the inquiry statutory powers. He also noted that Dr Strathdee would be standing down from the inquiry and a new Chair would be appointed in due course. Advised that the findings and recommendations of a rapid review of how data is used in in-patient mental health settings in England has now been published, noting that the Government will consider this report and respond in due course. Stated that the Department of Health and Social Care would be working alongside the new Health Services Safety Investigations Body to undertake a series of investigations focused on mental health inpatient settings on the following themes: how providers learn from deaths in their care and use that learning to improve services, including post-discharge services; how young people are cared for in mental health in-patient services and how that care can be improved; how out-of-area placements are handled; and how to develop a safe staffing model for all mental health in-patient services. The statement was followed by questions and comments from members of the House of Commons.

On the 23 January 2023 the Minister for Mental Health and Women’s Health Strategy, Maria Caulfield MP, announced the commencement of a rapid review into patient safety in mental health inpatient settings in England. The review Chair, Dr Geraldine Strathdee, was asked to consider how improvements could be made to the way that data and information is used in relation to patient safety in mental health inpatient care settings and pathways, including for people with a learning disability and autistic people. This report contains the findings of this review and an associated set of recommendations. Below is a brief summary of the main recommendations set out in this report. The findings and recommendations in full can be read here. Recommendation 1 NHS England should establish a programme of work, co-produced with experts by experience and key national, regional and local leaders, including Care Quality Commission (CQC), Integrated Care Systems (ICSs), provider collaboratives, independent safeguarding bodies, professional bodies, provider representatives and third sector organisations, among others, to agree how to make sure that providers, commissioners and national bodies are ‘measuring what matters’ for mental health inpatient services, and can access the information they need to provide safe, therapeutic care. Recommendation 2 Digital platforms that allow the collection of core patient information and associated data infrastructure must allow submissions into relevant national data sets, directly or through other interoperable platforms, and facilitate data flows between systems of different local provider organisations to support joined-up understanding of care pathways. These systems should allow the data collected to be made available to different decision makers, including CQC, at the appropriate level of aggregation and without requiring duplicative submissions, and allow benchmarking across trusts and independent sector providers. NHS England’s Transformation Directorate should scope out options for how this ambition could be delivered, including cost implications and a value for money assessment to help providers meet this aim specifically for mental health, including specific ways in which mental health electronic patient record improvement and data sharing can be prioritised and interdependencies with other systems and programmes of work. Recommendation 3 ICSs and provider collaboratives should bring together trusts and independent sector providers, along with other relevant stakeholders such as independent safeguarding bodies, across all healthcare sectors to facilitate the cross-sector sharing of good practice in data collection, reporting and use. Recommendation 4 The Department of Health and Social Care, in partnership with NHS England and CQC and supported by key experts from across governmental and non-governmental organisations, should convene all the relevant organisations who collect and analyse mortality data to determine what further action is needed to improve the timeliness, quality and availability of that data. Recommendation 5 Provider boards should take the following actions to improve their capacity to identify, prevent and respond to risks to patient safety: Every provider board should urgently review its membership and skillset and ensure that the board has an expert by experience and carer representative. Every provider board should ensure that its membership has the skills to understand and interpret data about mental health inpatient pathways and ensure that a responsive quality improvement methodology is embedded across their organisations. CQC should assess and report on whether the membership of the boards of providers of mental health inpatient services includes experts by experience (including carer) representatives and whether boards are maintaining an appropriately high level of data literacy and quality improvement expertise on mental health inpatient pathways among their membership as part of their assessments. Every provider board should urgently review its approach to board reports and board assessment frameworks to ensure that they highlight the key risks in all of their mental health inpatient wards, as set out in the safety issues framework, and that they support the board to take action to mitigate risks and improve care, including both quantitative data and qualitative ‘soft intelligence’ such as feedback from patients, staff and carers. NHS England should review and update the guidance on board assessment frameworks. Recommendation 6 Trust and provider leaders, including board members, should prioritise spending time on wards regularly, including regular unannounced and ‘out-of-hours’ visits, to be available to and gather informal intelligence from staff and patients. Recommendation 7 All providers of NHS-funded care should review the information they provide about their inpatient services to patients and carers annually and make sure that comprehensive information about staffing, ward environment, therapeutic activity and other relevant information about life on the wards is available. CQC should assess the quality, availability and accessibility of this information as part of their assessment of services. Recommendation 8 ICSs and provider collaboratives should map out the pathway for all their mental health service lines to establish which parties need access to relevant data at all points on the pathway and take steps to ensure that data is available to those who need it. Recommendation 9 ICSs will develop system-wide infrastructure strategies by December 2023 and the mental health estate needs to be fully incorporated and represented in these strategies and in subsequent local action plans. This recommendation is for local ICSs to review the mental health estate to inform these and future strategies, recognising there are evidence-based therapeutic design features that can contribute to reducing risk and improving safety. Recommendation 10 Providers should review their processes for allowing ward visitors access to mental health inpatient wards with a view to increasing the amount of time families, carers, friends and advocates can spend on wards. The Department of Health and Social Care should consider what more can be done to strengthen the expectation for all health and care providers in England to allow visiting. Recommendation 11 All providers of NHS-funded care should meet the relevant core carer standards set by the National Institute for Health and Care Excellence (NICE) and Triangle of Care, England. Regulators, including CQC and professional regulators, should consider how to monitor the implementation of these carer standards, especially where there is greater risk of unsafe closed cultures developing. ICSs should consider how to routinely seek carer feedback. Inpatient staff training programmes should identify how they can benefit from carer trainers. For patients detained under the Mental Health Act, families and carers should be part of all detention reviews. Recommendation 12 Professional bodies, such as the Royal Colleges, should come together across healthcare sectors to form an alliance for compassionate professional care. This multi-professional alliance should: work together and learn from each other to identify ways to drive improvement in the quality of compassionate care and safety across all sectors, including mental health services, and how they can support staff to provide it along with their specialist data units, where they exist, contribute to the work set out in recommendation. Recommendation 13 Except where specified, these recommendations should be implemented by all parties within 12 months of the publication of this report. Government ministers, through the Department of Health and Social Care, should review progress against these recommendations after 12 months.

Patients in seclusion in mental health services require regular physical health assessments to identify, prevent and manage clinical deterioration. Sometimes it may be unsafe or counter-therapeutic for clinical staff to enter the seclusion room, making it challenging to meet local seclusion standards for physical assessments. Alternatives to standard clinical assessment models are required in such circumstances to assure high quality and safe care. The primary aim of this study was to improve the quality of physical health monitoring by making accurate vital sign measurements more frequently available. It also aimed to explore the clinical experience of integrating a technological innovation with routine clinical care. The results showed that the non-contact monitoring device enabled a 12 fold increase overall in the monitoring of physical health observations when compared to a real-world baseline rate of checks. Enhancement to standard clinical care varied according to patient movement levels. Patients, carers and staff expressed positive views towards the integration of the technological intervention.

Preventing patients from self-harming is an ongoing challenge in acute inpatient mental health settings. New technologies that do not require continuous human visual monitoring and that maintain patient privacy may support staff in managing patient safety and intervening proactively to prevent self-harm incidents. This study in the Journal of Mental Health aimed to assess the effect of implementing a contact-free vision-based patient monitoring and management (VBPMM) system on the rate of bedroom self-harm incidents. The results showed a 44% reduction in bedroom self-harm incidents and a 48% reduction in bedroom ligatures incidents, suggesting that that the VBPMM system helped staff to reduce self-harm incidents, including ligatures, in bedrooms.

Autistic patients trapped in mental health units tell their stories, revealing a system of poor treatment, abuse and long stretches inside with their symptoms only getting worse.