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In June 2023 the Secretary of State for Health and Social Care announced that HSSIB would undertake a series of investigations focused on mental health inpatient settings. This overarching report brings together and explores cross-cutting patient safety risks across five individual investigations. The aim of this report is to examine patient safety risks identified across the following HSSIB investigations: Creating conditions for learning from deaths and near misses in inpatient and community mental health services: Assessment of suicide risk and safety planning (12 September 2024) Creating conditions for the delivery of safe and therapeutic care to adults in mental health inpatient settings (24 October 2024) Mental health inpatient settings: out of area placements (21 November 2024) Mental health inpatient settings: Supporting safe care during transition from inpatient children and young people’s mental health services to adult mental health services (12 December 2024) Mental health inpatient settings: Creating conditions for learning from deaths in mental health inpatient services and when patients die within 30 days of discharge (30 January 2025) Findings Safety, investigation, and learning culture There remains a fear of blame in mental health settings when safety events happen. This contributes to a more defensive culture despite staff actively wanting to learn. Many recommendations to support learning for improvements in mental health care do not lead to implemented actions. Reasons for this include a lack of impact assessment resulting in unintended consequences, no clear recipient involved in the development of recommendations, and duplicated recommendations across organisations. System integration and accountability The integration of health and social care within an integrated care system currently relies on relationships, with an expectation and hope that they will work well. However, where this is not the case, a lack of clear accountability can result in poor outcomes for people with mental illness and severe mental illness. The delivery of care for people with mental illness and severe mental illness is challenging because health and social care services are not always integrated and their goals are not always aligned. Physical health of patients in mental health inpatient settings There are gaps in the provision of physical health care for people with severe mental illness, including inconsistent health checks, poor emergency responses, and misattribution of physical symptoms to mental illness. The misattribution of physical symptoms to patients’ mental health was observed and had the potential to contribute to worsened patient outcomes. National reports, strategies and research have made recommendations to improve the physical health of people with severe mental illness. However, there is evidence that recommendations are delayed in implementation and people continue to die prematurely. Integrated care boards lack the required data and the necessary analytical capability to assess disparities in access, experience and outcomes related to the physical health needs of people with severe mental illness. There is variation in how the physical health checks are carried out on mental health inpatient wards, with limitations in processes for following up on patients’ physical health needs. There is variation in the knowledge, skills and experience of staff who undertake physical health checks and in the environments in which these checks take place. Patients may not always be supported in terms of health education about their physical health risks and modifiable risk factors, for example smoking, dietary advice and physical activity. Caring for people in the community Integrated care boards cannot consistently draw reliable insights from data at national, system or local level, to optimise and improve services, patient care, and outcomes across mental health pathways of care. This results in variability in service provision which does not always meet the needs of individual patients or local populations. Inpatient ‘bed days’ are taken up by people who no longer need them, because people who are clinically fit for discharge are delayed in being transferred to their home or a suitable residence (appropriate placement). Reasons for delayed discharges include issues with housing support and establishing suitable accommodation. This means patients are not always in the right place of care. Barriers to discharge affect patient flow and may result in delays in admission for people with severe mental illness. This means they have to be cared for in a community setting while waiting for an inpatient bed. There is variation across the country in how drug and alcohol services are provided. The variation does not allow for fair and equitable treatment for all patients. Community services are vital to support people to stay as well as possible and to prevent hospital admissions. However, there is variation in community service provision across the country. Staffing and resourcing Staffing and resource constraints in inpatient and community mental health settings impact their ability to provide safe and therapeutic care. In inpatient settings, constraints contribute to mental health wards aiming to staff for ‘safety’ but not always for ‘therapy’. Challenges for staff include the emotionally demanding nature of their work; this can lead to staff burnout and sickness, and further strain on services. There are gaps in mental health workforce planning, particularly in community services where there is no evidence based workforce planning tool to support a standardised staffing establishment setting model. Digital support for safe and therapeutic care A lack of interoperability or integration between digital systems affects the provision of care across mental health, acute and community providers. Challenges in securing appropriate funding impacts on the ability of hospitals to integrate and update their digital services and infrastructure. Electronic patient record functionality is often not available or does not meet staff needs, and so it is not used. Examples include absent functions for food and fluid balance monitoring and risk assessment of venous thromboembolism (blood clots). Challenges in providing and maintaining patient-facing technology, for example televisions and payphones, impacts on the therapeutic environment and the ability of patients to maintain contact with families and loved ones. Where technology for monitoring patients had been introduced, implementation has required considerations to ensure it is used appropriately, is patient-centred, maintains therapeutic engagement, and supports patients to feel safe. Suicide risk and safety assessment ‘Doing’ tasks, like ‘ticking’ checklists, overshadow meaningful, empathetic ‘being’ interactions with patients. Open, compassionate conversations that build trust and therapeutic relationships, enabling patients to own their risk while feeling supported, can help mitigate this. Investigation processes can contribute to a fear of blame, and subsequently contribute to defensive practices such as checklists and a ‘tick box’ culture. This inhibits open and honest conversations and the ability to put the patient, as their authentic self, at the heart of them. Safety recommendations HSSIB recommends that the Department of Health and Social Care continues to work with the ‘recommendations but no action working group’ and other relevant organisations, to ensure that recommendations made by national organisations specific to mental health inpatient settings are reviewed. This work should consider the mechanisms that supported or hindered the implementation of actions from these recommendations. This may help the Department of Health and Social Care understand what has worked when implementing actions from recommendations and enable learning about why some recommendations have not achieved their intention. HSSIB recommends that the Secretary of State for Health and Social Care directs and oversees the identification and development of a patient safety responsibilities and accountabilities strategy related to health and social care integration. This is to support the management of patient safety risks and issues that span integrated care systems. Safety observation National bodies can improve patient safety in mental health inpatient settings in England by supporting provider investment in equipment, digital systems and physical environments to enable conditions within which staff are able to provide, and patients can receive, safe and therapeutic care.

This report sets out the Care Quality Commission (CQC) activity and findings during 2023/24 from their engagement with people who are subject to the Mental Health Act 1983 (MHA) as well as a review of services registered to assess, treat and care for people detained using the MHA. The MHA is the legal framework that provides authority for hospitals to detain and treat people who have a mental illness and need protection for their own health or safety, or the safety of other people. What the report found: Systems We remain concerned that the high demand for mental health services, without the capacity to meet it, means people cannot always get the right care at the right time. Not being able to access care in a timely way can lead to people’s mental health deteriorating while they wait for support. Through our monitoring activity, we have seen how system pressures mean people are detained far from home or in environments that do not meet their needs. Many services told us that patients seem to be more unwell on admission than in the past. Services need to balance the increase in demand for inpatient beds with ensuring existing patients are not discharged too soon. Workforce In 2023/24 there were continuing problems with workforce retention and staffing shortages, as well as concerns around training and support for staff. Although the mental health workforce has grown by nearly 35% since 2019, shortages in both medical and support roles continue to have a negative impact on patient care. Shortages of doctors also continue to affect the delivery of our second opinion appointed doctor (SOAD) service. We remain concerned about the long-term sustainability of the service, with proposals in the Mental Health Bill due to increase the numbers of second opinions required while reducing the timeframes for delivery of some second opinions. Inequalities We are concerned that some of the key issues we raise in this report, including access to mental health support, are particularly challenging for certain groups of people, such as people from ethnic minority groups and those living in areas of deprivation. We identified several issues around people not understanding their rights, despite services having a legal duty to provide this information. There was variation in how well services met people’s needs. While many provided access to spiritual leaders, we remain concerned about gaps in the knowledge of staff around caring for autistic people. Children and young people Children and young people continue to face challenges in accessing mental health care. Increasing demand is leading to long waits for beds, and increases the risk of being placed in inappropriate environments and/or being sent to a hospital miles away from home. Once in hospital, we are concerned that access to specialist staff is being affected by low staffing levels, leading to patients’ needs not being met. In addition, the quality of physical environments for children and young people varies; access to food and drink, and food preparation facilities were key issues for many children and young people. Challenges in transitions of care between children and young people’s mental health services and adult mental health services remain, with many young people still falling through the gaps and not getting the care and support they need. Environment Through our MHA monitoring visits, we found that the quality of inpatient environments continues to vary. We are concerned about the impact of poor-quality environments on patients and have seen examples of how ageing and poorly-designed facilities affect people’s care. Being able to go outside brings therapeutic benefits for patients, but access to outdoor facilities varied across services. Gardens were usually well maintained, and in some services, patients were encouraged to grow plants and vegetables. However, we also found examples of unwelcoming gardens and at some services, patients’ access to outdoor spaces was limited. This issue was also raised by members of our Service User Reference Panel.

The use of surveillance technologies including CCTV, body-worn cameras and wearable sensors is becoming increasingly common in inpatient mental health settings. Surveillance of this kind is commonly justified as an effort to improve safety and cost-effectiveness. However, the use of surveillance technologies has been questioned in light of limited research conducted and the sensitivities, ethical concerns and potential harms of surveillance. This systematic review aimed to: map how surveillance technologies have been used in inpatient mental health settings. explore how they are experienced by patients, staff and carers. examine evidence regarding their impact.

This is one of a series of Health Services Safety Investigations Body (HSSIB) investigations on the theme of patient safety in mental health inpatient settings. The investigation examined how providers conduct timely and effective investigations into deaths of patients receiving care in inpatient units or within 30 days of discharge. This included a review of local, regional and national oversight frameworks, as well as data collection mechanisms. The aim of the investigation was to understand how providers learn from deaths, and how they use that learning to improve. The investigation sought to understand the impact on individuals involved in the care of patients who died while in mental health inpatient care or shortly after discharge. It reflects the experiences of families, carers and staff. The investigation recognises the complex nature of mental health inpatient care and discharge. The findings present opportunities to improve systems and practices in mental health services, with potential relevance to other healthcare settings in England. The investigation identified significant challenges in maintaining safety, conducting effective investigations, managing data on deaths and ensuring system-wide learning. These findings reiterate findings from other reports on inconsistencies in data reporting, lack of consistent terminology and difficulty in cross-provider comparisons. The investigation found gaps in discharge planning, crisis service accessibility and access to community therapy that were potentially contributing to poor patient outcomes, including deaths. The investigation highlighted system-level issues in service commissioning, patient flow, integrated working and accountability, compounded by a lack of system-level learning and application. The investigation found there is a culture of blame in which individuals and organisations are afraid about safety investigation processes. The report emphasises the need for a systemic approach to safety investigations and learning with a focus on collaboration, transparency and oversight, with a shift from procedural practices to a culture rooted in empathy, person-centred care and active involvement of families. Findings Understanding how providers ensure timely and effective investigations Investigations into patient safety incidents in mental health do not always take a system-wide perspective, limiting the ability to capture the full complexity of care. The current national framework for incident response faces implementation barriers in mental health settings, due to the differences in care requirements compared to acute physical health settings. Training for the implementation of the Patient Safety Incident Response Framework includes developing knowledge of systems thinking and system-based approaches to learning from patient safety incidents. However, some organisations described their training focused on acute physical health contexts and does not sufficiently account for the mental health care context. There is no national system to track and ensure the implementation of investigation recommendations, resulting in limited strategic oversight of patient safety investigations and a lack of structured learning for improvement. Many families feel marginalised and excluded from the investigation process, experiencing investigation processes as a ‘tick box’ exercise and without a culture of transparency, learning, and accountability. Processes for learning from deaths are feared by families, staff and organisations because of a reported focus on blame which does not align with the stated goals of an effective safety culture that is orientated around learning to support systemic change. Families often feel excluded from care processes, with their concerns about safety planning and risk mitigation often overlooked, which complicates their ability to help keep their family member safe. Legal processes within organisations may unintentionally shut down opportunities for learning, fostering a culture of defensiveness rather than reflection. Staff lack the time, permission and safe spaces to support open, reflective conversations about patient safety incidents, which are essential for learning and improvement. Patient safety incident investigations, and other associated investigation processes if a death occurs, often do not consider the emotional distress experienced by all affected. This results in compounded harm. The investigation also became aware of areas of mental health inpatient care where investigations had not effectively addressed ongoing concerns about inpatient mental health care: Gaps were identified in discharge planning, crisis service accessibility and community therapy provision, and staff skilled in mental health, resulting in people being left in unsafe situations where they may self-harm. There is significant variability in therapeutic engagement and a lack of personalised care which has left some patients feeling hopeless and disconnected. The term ‘therapeutic engagement’ may be interpreted differently across mental health services. This has resulted in some approaches becoming clinically focused rather than person focused. Providers told the investigation that incidents of people using items of clothing to ligature resulting in catastrophic self-harm was increasing. However, the investigation did not identify specific guidance on how to reduce and respond to non-anchored ligature risks, or on managing access to known ligature risk items. Staff face ongoing challenges in balancing ‘least restrictive approach’ policies and the therapeutic benefit of decisions about care, with the need to ensure patient safety, often creating tension in care delivery. Examining national, regional, and local oversight and accountability frameworks for deaths in mental health inpatient services Many previous national recommendations to improve the care of patients with mental health needs have not been taken forward to date, leaving no clear plan for implementing the recommendations. Some integrated care boards do not have full oversight of patient safety risks across all the services they oversee. Instead of having a clear, formal structure for accountability in patient safety investigations, they often rely on informal relationships or collaborations between providers. This lack of complete oversight can make it difficult to ensure that patient safety investigations are thorough and standardised across different organisations, leading to potential inconsistencies in addressing safety issues. Some integrated care boards and regional teams struggle with gathering and analysing data on patient safety due to resource and reporting limitations. This means they do not always have a complete picture of the risks at a system-wide level. Data gaps limit the ability of integrated care boards to identify co-morbidities (when patients have multiple health conditions) and understand health inequalities, especially among people with serious mental illness. This creates challenges for integrated care boards to address broader health trends and inequities within their regions effectively. The involvement of patient safety partners and people with lived experience in safety meetings is variable, limiting their ability to contribute. Some non-executive directors with responsibility for safety and quality struggle to scrutinise and interpret complex data sets on patient safety and deaths due to the volume and lack of triangulation of information presented. This limits meaningful oversight and learning. Examining the mechanisms that capture data on deaths (and near misses) across the mental health provider landscape, including up to 30 days after discharge There is inconsistency in data reporting. Mental health providers report deaths and near misses in varied ways, using different definitions and methods. This inconsistency makes it difficult to compare data across providers and understand overall trends in patient safety. There is not a standardised national system requiring providers to report deaths in the same way. This means that each provider’s reports may look different, which reduces the reliability of data for understanding patient safety across the board. There is not a single, comprehensive database that includes all deaths and near misses within mental health services, including those occurring within 30 days after a patient’s discharge. This makes it hard to see the full picture of patient safety outcomes and identify patterns or risks. There is not a centralised organisation or process effectively overseeing and co-ordinating data on deaths. This lack of oversight limits the ability to identify systemic issues, reduce duplicated efforts, and drive consistent improvements across mental health services. There is currently limited co-ordinated effort among organisations that produce data relating to deaths, and individual providers may be collecting and analysing similar data on their own. This leads to duplicated work, wasting time and resources that could be better used if there was improved collaboration. It also results in considerable variation in the data being presented. Recommendations and observations HSSIB makes the following safety recommendations: Safety recommendation R/2025/052: HSSIB recommends that the Department of Health and Social Care works with NHS England and other relevant stakeholders, to clarify national expectations for meaningful and restorative learning from patient safety events and deaths in mental health services. This is to ensure effective learning is supported through processes that provide high-quality and transparent investigations within a culture of compassion. Safety recommendation R/2025/053: HSSIB recommends that NHS England works with other stakeholders to define the term ‘therapeutic relationship’. This is to support building trust and compassionate relationships between staff and patients from admission to inpatient settings through to discharge, to improve patient outcomes. Safety recommendation R/2025/054: HSSIB recommends that NHS England, working with other relevant national bodies, develops guidance on how to reduce and respond to non-anchored ligature risks. This will help staff to support people who attempt to hurt themselves with non-anchored ligatures and improve patient safety whilst maintaining a therapeutic environment. Safety recommendation R/2025/055: HSSIB recommends that the Department of Health and Social Care creates a national oversight mechanism that supports co-ordination, prioritisation and oversight of safety recommendations to implementation across the system. This is to ensure that recommendations from public inquiries, independent patient safety investigations and other patient safety investigation reports, as well as prevention of future death reports from inquests, are analysed and monitored and reviewed until their implementation using a continuous quality improvement approach to learning. Safety recommendation R/2025/056: HSSIB recommends that the Department of Health and Social Care working with NHS England, and other relevant stakeholders, develop a comprehensive, unified data set with agreed definitions for recording and reporting deaths in mental health services to include deaths that occur within a specific time period after discharge. This will support any revisions required to the current NHS England Learning from Deaths Framework. The creation of a comprehensive, unified data set would enhance system-wide visibility, co-ordination and collaboration, reduce duplication of effort, and maximise the impact of improvement work through strategic oversight. HSSIB makes the following safety observations: Safety observation O/2025/057: Integrated care boards and organisations that provide mental health care can improve patient safety by working together to support the facilitation of cross-organisational investigations and learning. This should be achieved in a way that enables people involved in an investigation to come together to share perspectives and build relationships to enable learning. This may provide opportunities for effective and meaningful organisational learning and facilitate reparation and trust-building for everyone involved. Safety observation O/2025/058: Organisations that provide mental health care can improve patient safety by adopting a comprehensive person-centred care approach that prioritises the individual needs, preferences and rights of each patient. This approach should ensure consistent access to meaningful therapeutic activities, actively involve families in care planning and decision making, and create supportive environments tailored to the sensory and emotional needs of neurodivergent individuals. Safety observation O/2025/059: NHS boards can improve patient safety by supporting their non-executive directors (NEDs) with responsibility for quality and safety to attend NED-specific training on quality of care and patient safety. This may include modules on compassionate leadership, the importance of psychological safety, safety science in investigations and techniques for supportive challenge. By fostering these skills, NEDs can better understand the complexities of healthcare delivery, engage meaningfully with staff, and ensure that patient safety and quality care remain at the forefront of their governance role. Safety observation O/2025/060: Integrated care boards and organisations that provide mental health care can improve safety by involving people with lived experience and family carers in coaching for executive leaders. This could include creating learning networks within provider collaboratives. By embedding these roles, executive teams and non-executive directors would receive direct insights from those with personal experience of mental health services, helping them to co-produce learning from deaths and drive improvements in care. Related HSSIB reports Learning from inpatient mental health deaths and near misses: assessment of suicide risk and safety planning (September 2024) Mental health inpatient settings: creating conditions for the delivery of safe and therapeutic care to adults (October 2024) Harm caused by mental health out of area placements (November 2024) Mental health inpatient settings: Supporting safe care during transition from inpatient children and young people’s mental health services to adult mental health services (December 2024)

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.