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Content ArticleInpatient mental health services in the UK are under intense scrutiny and increasing pressure. Staff shortages, patient safety concerns, and outdated environments are just some of the issues drawing media and political attention. There’s widespread agreement that improvements are needed, but the question is: where do we begin? This HSJ article highlights five shifts that are needed to help inpatient mental health services better support the people they serve.
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EventWe know acute mental health wards are not safe for patients or staff. Efforts to reduce coercion and restrictive practice are often complex and are poorly implemented. Services continue failure to understand incidents and the dynamic milieu of wards in real-time. The staffing and skill mix of services are under constant pressure. Recent research, #WardSonar, has successfully focused on enabling patients to highlight when the pressure on wards is building and can predict when incidents might occur. The challenge remains enabling staff to listen to and respond to real-time data. Register
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News Article
Hospital and manager guilty over patient death
Patient Safety Learning posted a news article in News
A hospital trust and a staff member have been found guilty of health and safety failings over the death of a young woman in a mental health unit. Alice Figueiredo, 22, was being treated at Goodmayes Hospital, east London, when she took her own life in July 2015, having previously made many similar attempts. Following a seven-month trial at the Old Bailey, a jury found that not enough was done by the North East London Foundation NHS Trust (NELFT) or ward manager Benjamin Aninakwa to prevent Alice from killing herself. The trust was cleared of the more serious charge of corporate manslaughter, while Aninakwa, 53, of Grays in Essex, was cleared of gross negligence manslaughter. The jury deliberated for 24 days to reach all the verdicts, setting a joint record in the history of British justice, according to the Crown Prosecution Service (CPS). Both the trust and Aninakwa were convicted under the Health and Safety at Work Act. It was only the second time an NHS trust has faced a corporate manslaughter charge. During the trial, prosecutors said that not only was Alice repeatedly able to self-harm while she was in hospital, but that these incidents were not properly recorded or assessed. The court also heard there were concerns about Benjamin Aninakwa's communication, efficiency, clinical and leadership skills. The trust had previously placed him on a performance improvement plan for three years, which ended in December 2014. In addition, there was a high turnover of agency staff on the ward, the court heard. Mrs Figueiredo says she raised concerns about her daughter's care verbally and in writing on a number of occasions to the hospital and to Mr Aninakwa. After Alice died, she said the family found it very difficult to get answers about what happened. For nearly a decade they gathered evidence and pressed both the police and the CPS to take action. Read full story Source: BBC News, 9 June 2025 -
Content ArticleOver the past two decades, suicide prevention efforts have expanded significantly, yet deeply held assumptions continue to shape policy in ways that may limit effectiveness. This paper critically examines key assumptions in suicide prevention, including the predictability of suicide, the role of suicidal ideation, and the conflation of self-harm and suicide. It challenges the view that mental illness is the primary cause of suicide and questions whether psychiatric hospital admission ensures safety. The paper also argues that overemphasis on prediction fosters fear-driven responses and explores how shifting the focus beyond risk reduction could foster more nuanced, compassionate and sustainable approaches to care. Further reading on the hub: Understanding the true impact of suicide in inpatient mental health settings: reflections from a psychiatrist
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Content Article
Trigger warning: This blog contains themes that may be triggering for some people. Hope Virgo is an author, a multi award winning mental health campaigner, and secretariat for the All-Party Parliamentary Group (APPG) for eating disorders. In this blog, she explores the patient safety issues affecting children with eating disorders and their families. Hope highlights how lack of investment and understanding is leading to avoidable harm and shares five key actions for change. This blog is part of our World Patient Safety Day 2025 series - Safe care for every newborn and every child. My campaigning work was born out of wanting to fight the injustices that so many people affected by eating disorders go through. Having lived with anorexia from the age of 12-17 before being admitted to a mental health hospital where I began my journey to recovery, I know first-hand just how awful eating disorders are. I have spent huge amounts of life feeling frustrated by how many people get turned away from services for not having that “particular stereotypical look” and with how much neglect is taking place in treatment across the UK. Patient safety concerns Often people still think someone with an eating disorder will be underweight or have been labelled with anorexia. Eating disorders are so much more than that. During my campaign work and the APPG evidence sessions, I’ve met hundreds of people who have been denied treatment for not looking that way. We have spoken to parents who have children with avoidant restrictive food intake disorder (ARFID), who have not been able to access treatment and support. The reality is, there is a postcode lottery and a lot of children and their families aren’t being given the best chance of life. Many carers also tell me how often their concerns are dismissed as silly worries. This cultural dismissiveness across eating disorder services and the lack of training and funding, is leading to huge issues for patient safety. It is causing people to die. It can feel so hard to speak up when support is so limited, but as a parent or carer, learning to push for support is crucial. I’d also recommend looking at the amazing resources for carers produced by the organisation FEAST. Stigma, misunderstanding and dangerous narratives Eating disorders are an illness that is massively stigmatised and misunderstood. Contrary to many assumptions, people with an eating disorder: are not making a lifestyle choice are not being difficult are not all white females. Eating disorders can impact people of any age, size, gender or race. Stigma and misunderstanding leads to so many people being denied treatment for an eating disorder. Marked as ‘untreatable’ One narrative that we have seen in the last two years is an increasing amount of people with eating disorders being marked as untreatable, too complex and in some cases as terminal and moved to palliative care. This dangerous narrative is causing many people to be discharged from services too soon and given inadequate care. If they are discharged prematurely and still have a malnourished brain they are not being given the chance for it to fully rewire - leading them at high risk of relapse. Time for change For too long eating disorders have been stigmatised and underfunded, with very little specific staff training. For children’s services, whilst there has been some investment, it has been very limited. Five key changes to support patient safety The APPG published a report in January 2025 calling on the government for five key things: Develop a national strategy for eating disorders. Provide additional funding for eating disorder services. This funding should address the demand for both adult and children’s services. Launch a confidential inquiry into all eating disorder deaths. Increase research funding for eating disorders: The aim is to enhance treatment outcomes and ultimately discover a cure for eating disorders. Ensure non-executive director oversight for adult and children's eating disorder services. This oversight and accountability should be implemented in all NHS Trusts and Health Boards in the UK. Recovery When you have an eating disorder, it completely consumes you. It takes over every area of your life. And it consumes your family life too. The research shows that people can and do recover at any age, severity of illness or length of illness. So why are we allowing so many to remain stuck living with an eating disorder and denying them the care they need? Over the last few years. we have seen pockets of good practice in services from the development of integrated enhanced cognitive behavioural (I-CBTE) therapy, to areas where GPs have quickly referred patients or supported families to recover. With the right support and treatment in place for people with eating disorders we will not only save lives but also money. Through early intervention we can prevent hospital admissions and prevent begin becoming more malnourished thus leading to quicker recovery times. Final thoughts Eating disorders are a serious mental health issue. They have the highest mortality rate of any other psychiatric illness yet are often hidden in plain sight. It doesn’t have to be this way. People with eating disorders can and do make full recoveries, we just need to do better to enable this to happen. This growing epidemic can only be reversed by investing into prevention, early intervention, and timely, high-quality treatment. Access to services needs to be free from discriminating criteria and bias. The current inpatient treatment approach results in poor outcomes and 40-50 percent relapse rates. Without a cultural shift and a complete reformation of services nothing is going to change. Campaigners, clinicians and others need to work together to make this change happen. March with us On 21 June, 2025, we’ll be taking to the streets of London for the third consecutive year to march for those we love, for those we have lost, and for the future generations affected by eating disorders. This march is not just a walk — it’s a statement to demand better services and put an end to the neglect faced by those struggling with eating disorders across the UK. Find out how you can join. -
Content Article
NHS England: Urgent and emergency care plan 2025/26
Patient Safety Learning posted an article in NHS England
This report sets out how the NHS will resuscitate urgent and emergency care, with a focus on getting patients out of corridors, keeping more ambulances on the road, and enable those ready to leave hospital to do so as soon as possible. Summary of actions and impact for patients and carers Focus as a whole system on achieving improvements that will have the biggest impact on urgent and emergency care services this winter By the year-end, with improvement over winter, we expect to: Reduce ambulance wait times for Category 2 patients – such as those with a stroke, heart attack, sepsis or major trauma – by over 14% (from 35 to 30 minutes). Eradicate last winter’s lengthy ambulance handover delays by meeting the maximum 45-minute ambulance handover time standard, helping get 550,000 more ambulances back on the road for patients. Ensure a minimum of 78% of patients who attend A&E (up from the current 75%) are admitted, transferred or discharged within 4 hours, meaning over 800,000 people a year will receive more timely care. Reduce the number of patients waiting over 12 hours for admission or discharge from an emergency department compared to 2024/25, so this occurs less than 10% of the time. This will improve patient safety for the 1.7 million attendances a year that currently exceed this timeframe. Tackle the delays in patients waiting to be discharged – starting with the nearly 30,000 patients a year staying 21 days over their discharge-ready-date, saving up to half a million bed days annually. Increase the number of children seen within 4 hours, resulting in thousands of children every month receiving more timely care than in 2024/25. Develop and test winter plans, making sure they achieve a significant increase in urgent care services provided outside hospital compared to last winter Improve vaccination rates for frontline staff towards the pre-pandemic uptake level of 2018/19. This means that in 2025/26, we aim to improve uptake by at least 5 percentage points. Increase the number of patients receiving urgent care in primary, community and mental health settings, including the number of people seen by Urgent Community Response teams and cared for in virtual wards. Meet the maximum 45-minute ambulance handover time standard. Improve flow through hospitals, with a particular focus on reducing patients waiting over 12 hours, and making progress on eliminating corridor care. Set local performance targets by pathway to improve patient discharge times, and eliminate internal discharge delays of more than 48 hours in all settings. Reduce length of stay for patients who need an overnight emergency admission. This is currently nearly a day longer than in 2019 (0.9 days) and needs to be reduced by at least 0.4 days . Reduce the number of patients who remain in an emergency department for over 24 hours while awaiting a mental health admission. This will provide faster care for thousands of people in crisis every month. National improvement resource and additional capital investment is simplified and aligned to supporting systems where it can make the biggest difference Allocating over £370 million of capital investment to support: Around 40 new same day emergency care centres and urgent treatment centres. Mental health crisis assessment centres and additional mental health inpatient capacity to reduce the number of mental health patients having to seek treatment in emergency departments. Expansion of the Connected Care Records for ambulance services, giving paramedics access to the patient summary (including recent treatment history) from different NHS services, enabling better patient care and avoiding unnecessary admissions. -
Content ArticleThis guidance supports trusts and community providers in enabling frontline staff to fulfil their legal requirements under the Mental Capacity Act (MCA) 2005, specifically when supporting people with a learning disability. A Health Services Safety Investigations Body Report in 2023, on the care of acute hospital inpatients with a learning disability in England, found variation in staff understanding and application of the MCA in the care of people with a learning disability. Leadership within Trusts have been asked to ensure they understand the guidance, take the actions indicated and make these resources available to all frontline staff.
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News Article"We've got two," explains Emer Szczygiel, emergency department head of nursing at King George Hospital, as she walks inside a pastel coloured room. On one wall, there's floral wallpaper. It is scored through with a graffiti scrawl. The words must have been scratched out with fingernails. There are no other implements in here. Patients being held in this secure room would have been searched to make sure they are not carrying anything they can use to harm themselves - or others. "So this is one of two rooms that when we were undergoing our works, we recognised, about three years ago, mental health was causing us more of an issue, so we've had two rooms purpose built," Emer says. "They're as compliant as we can get them with a mental health room - they're ligature light, as opposed to ligature free. They're under 24-hour CCTV surveillance." There are two doors, both heavily reinforced. One can be used by staff to make an emergency escape if they are under any threat. What is unusual about these rooms is that they are built right inside a busy accident and emergency department. The doors are just feet away from a nurse's station, where medical staff are trying to deal with acute ED (emergency department) attendances. On a fairly quiet Wednesday morning, the ED team is already managing five mental health patients. One, a diminutive South Asian woman, is screaming hysterically. She is clearly very agitated and becoming more distressed by the minute. Despite her size, she is surrounded by at least five security guards. She has been here for 12 hours and wants to leave, but can't as she's being held under the Mental Capacity Act. Her frustration boils over as she pushes against the chests of the security guards who encircle her. "We see about 150 to 200 patients a day through this emergency department, but we're getting on average about 15 to 20 mental health presentations to the department," Emer explains. "Some of these patients can be really difficult to manage and really complex." "If a patient's in crisis and wants to harm themselves, there's lots of things in this area that you can harm yourself with," the nurse adds. "It's trying to balance that risk and make sure every emergency department in the country is deemed a place of safety. But there is a lot of risk that comes with emergency departments, because they're not purposeful for mental health patients." Read full story Source: Sky News, 4 June 2025
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News Article
‘Urgent’ safety issues in mental health hospitals, review concludes
Mark Hughes posted a news article in News
Mental health patients and nursing staff are being failed by a system “buckling under the weight of demand and decades of underinvestment”, nursing leaders have warned. Their comments came in response to the publication of the Health Services Safety Investigations Body (HSSIB)'s final report in its series of investigations focusing on mental health inpatient services in England. The report warned that staffing and resource constraints in inpatient and community mental health settings were impacting the ability to provide safe and therapeutic care to patients. Read full article Source: Nursing Times, 29 May 2025 -
News Article
Mental health A&E centres to open across England
Patient Safety Learning posted a news article in News
Specialist mental health crisis centres will be opened across England over the next decade in an attempt to reduce crowding in accident and emergency (A&E) departments, the NHS has confirmed. Ten hospital trusts have been piloting new assessment centres to deal with people experiencing a mental health crisis. The aim is to get these patients into appropriate care in a calm environment, avoiding long waits in A&E. NHS England said the new units would reduce overcrowding in hospitals and relieve pressure on emergency services, including the police. But Andy Bell, the CEO of the Centre for Mental Health, an independent charity, said any new provision needed to be properly funded. The scheme is expected to be expanded nationally to "dozens of locations", the government said, as part of its 10-year NHS plan. These clinics will be open to walk-in patients as well as those referred by GPs and police, with specialist staff present to treat people in acute mental distress. Speaking to the Times newspaper, NHS England chief Sir Jim Mackey hailed the "pioneering new model of care", external, where people can "get the right support in the right setting". "As well as relieving pressure on our busy A&Es, mental health crisis assessment centres can speed up access to appropriate care, offering people the help they need much sooner so they can stay out of hospital." Read full story Source: BBC News, 24 May 2025 -
News ArticlePlans for NHS staff to restrain and detain people experiencing a mental health crisis, instead of the police doing so, are “dangerous”, doctors, nurses and psychiatrists have warned. The former prime minister Theresa May has proposed legislation in England and Wales that would change the long-established practice for dealing with people who may pose a risk to themselves or others because their mental health has deteriorated sharply. But a coalition of eight medical groups, ambulance bosses and social work leaders said the switch would put mental health staff at risk and damage their relationship with vulnerable patients. The row has echoes of the controversy stirred by the Metropolitan police’s decision in 2023 to stop responding to 999 calls involving mental ill health unless they involved a threat to life. The force said the change meant officers were attending crimes such as robberies faster, but mental health groups said they feared it could result in deaths. May and two ex-health ministers, Syed Kamall and Frederick Curzon, have tabled amendments to the mental health bill going through parliament which, if passed, would lead to mental health nurses, psychiatrists or other doctors being called out to restrain and detain someone under the Mental Health Act. Those professionals would each become an “authorised person” who is allowed to detain someone under the act. But in a joint statement on Monday the eight groups said the risks posed by someone in a mental health crisis meant police officers must continue to always attend. The groups include the Royal College of Psychiatrists, the Royal College of Nursing and the British Medical Association. The groups said: “Removing police involvement entirely has hugely dangerous implications, as entering someone’s home without permission is fraught with huge risks and is only currently done with the assistance of police intelligence. Without this, professionals may be entering homes without police help and therefore lacking crucial intelligence that could ensure their safety.” Read full story Source: The Guardian, 26 May 2025
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News ArticleTwo men with paranoid schizophrenia stabbed members of the public in separate attacks weeks before Valdo Calocane's killings in Nottingham – and all were under the care of the same NHS trust, the BBC has found. Josef Easom-Cooper and Junior Dietlin injured six men in the stabbings in Nottinghamshire in 2023. Within weeks, Calocane - who also has paranoid schizophrenia - stabbed to death Barnaby Webber, Grace O'Malley-Kumar and Ian Coates on 13 June 2023. Nottinghamshire Healthcare NHS Trust has been criticised over its care of Calocane, and in response to the BBC's findings, apologised to those "affected for any aspects of our care that were not of the high standard our patients deserve". On 9 April 2023, Easom-Cooper stabbed a worshipper who was leaving an Easter Sunday service at St Stephen's Church in Sneinton. Easom-Cooper's mother, Shelly Easom, said that as a teenager, her son was under the care of child and adolescent mental health services (CAMHS) in Nottingham. She said the stabbing could have been prevented if her son's paranoid schizophrenia had been taken more seriously. "It's disgusting that it takes someone to either lose their life or be stabbed before somebody thinks 'oh, hang on a minute, maybe we need to do something here'. "The mental health services in Nottingham have routinely and systematically let him down and also the victim," she added. Read full story Source: BBC News, 23 May 2025
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News Article
Cutting mental health waiting times ‘could save UK £1bn a year’
Patient Safety Learning posted a news article in News
Ministers have been told cutting waiting times for thousands of people in Britain’s mental health crisis could help employment and save the government £1bn a year. According to research by Lancaster University, providing access to faster treatment across England through the NHS would help to improve the health of hundreds of thousands of people while bringing economic benefits for the nation at large. In a new study to be published in the latest edition of the respected Review of Economics and Statistics academic journal, Prof Roger Prudon found that a one-month delay in the start of mental health treatment resulted in 2% of patients losing their jobs. Drawing on data for waiting times from the Netherlands between 2012 and 2019, Prudon said a one-month reduction could help as many as 80,000 people get access to treatment annually, which would save more than €300m (£253m) in unemployment-related costs every year. He said the same calculation could be applied to the UK, given a comparable prevalence in mental health problems, as well as similar treatment times and cost to the economy and public finances from unemployment. Read full story Source: The Guardian, 21 May 2025 -
Content ArticleThis blog for Health Services Safety Investigations Board (HSSIB), is 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.
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Event
Deprivation of Liberty: Moving forward
Patient Safety Learning posted an event in Community Calendar
It has been widely recognised that there are number of challenges associated with the current system, both in DoLS and in the court, and we have to deal with these challenges with the tools that we have for now. Attention needs to turn to getting deprivation of liberty in the community cases to court more effectively, as well as cases involving children and young people. It is also vital that providers understand the Mental Capacity Act and use it effectively. By attending this conference you will hear from leading professionals on next steps for Deprivation of Liberty Safeguards as well as it’s interaction with the Mental Health Act. You will also hear what the implications are for the NHS, keeping people at the heart of decisions about them, as well as lessons from getting Deprivation of Liberty wrong in practice. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/liberty-protection-safeguards-mca or email [email protected] Follow the conference on Twitter @HCUK_Clare #LPS2025 hub members receive a 20% discount. Email [email protected] for discount code. -
News Article
‘My son is falling through the cracks of the child mental health system’
Patient Safety Learning posted a news article in News
A six-year wait for ADHD treatment on the NHS highlights a growing crisis. One mother tells of her frustrations: I wasn’t surprised by the children’s commissioner report out today, calling for urgent action to tackle waiting lists in mental health care for children. Ten years ago, I received a call from my son's reception teacher. They asked me to come in and said he was showing some developmental delays, and autistic traits. Within six months my son, who is now 15, was diagnosed with autism and ADD (attention deficit disorder) and medicated. Fast forward to his younger brother, and he has been languishing on a waiting list for six years. The school referred him to CAMHS (child and adolescent mental health services) to be assessed for ADHD in November 2021. The school could see how much I was struggling and sent CAMHS an email each week asking where he was on the waiting list. Despite this, it took until October 2024 for him to be diagnosed with ADHD. By then he was in secondary school. Something Rachel de Souza, the children’s commissioner for England, said really stuck out to me. She said: “The numbers in this report are staggering — but these are not numbers, these are real children.” Read full story (paywalled) Source: The Times, 19 May 2025 -
Content ArticleThis report describes children’s access to mental health services in England during the 2023-24 financial year, based on new analysis of NHS England data. Demand continues to grow for Children and Young People’s Mental Health Services (CYPMHS, commonly known as CAMHS) , with the number of children with active referrals increasing by nearly 10,000 since last year to 958,200. Compared to last year, there have been some areas of progress: fewer children’s referrals are being closed before treatment, and investment in CYPMHS has increased in real terms and when adjusted for inflation. However, figures continue to highlight some concerning trends: Many children were still experiencing long waits to access mental health services, and the number of children with active referrals who were still waiting for treatment to begin at the end of the year has increased by almost 50,000 children from 270,300 in 2022-23 to 320,000 in 2023- 24. Almost half of those referred for being ‘in crisis’ have their referrals closed or were still waiting for their second contact at the end of the year. There has been an uptick in children being referred for suspected and diagnosed neurodevelopmental conditions; these conditions are associated with some of the longest waits. The accessibility of mental health services in England continues to vary widely from one ICB area to another, leading to a postcode lottery in children’s access to suitable support for their mental health conditions.
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News Article
CEO: TV show sparked ‘overwhelming’ regulator scrutiny
Patient Safety Learning posted a news article in News
An “overwhelming” number of regulators were involved with a trust after an undercover documentary exposed care failings, its chief executive has said. Channel 4 aired hidden camera footage from Essex Partnership University Foundation Trust mental health inpatient wards in 2022. This revealed staff sleeping on duty and concerns over use of restraints. Trust CEO Paul Scott said on Thursday: “Understandably, those with regulatory responsibilities were very interested in the Dispatches programme and our response to it. But the sheer volume of people who wanted some assurance that we were taking seriously and making improvements [was] overwhelming.” He estimated he had attended around 19 boards or equivalent structures to provide assurance from different angles. “Nineteen regulators over one organisation felt overwhelming.” Mr Scott made the comments during his evidence to the Lampard Inquiry, which is looking into thousands of mental health patient deaths in Essex between 2000 and 2023. The probe is expected to report its findings before the end of 2027. In his written submission, Mr Scott had mentioned the “complexity of the nature and oversight of regulation” facing trusts from multiple parties within health and social care. Read full story (paywalled) Source: HSJ, 16 May 2025 -
Content Article
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 Restraint Reduction Network: Supporting people with lived experience As all forms of restrictive practice can result in harm, it is important that people are able to identify restrictive practices and challenge their inappropriate use. The Restraint Reduction Network have a range of resources that people with lived experience, parents and carers may find helpful. The resources are designed to support people to understand what restrictive practices are, when and why they might be used, people’s rights, and how to identify and challenge unacceptable and unethical practices. 2 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. 3 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. 4 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. 5 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. 6 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. 7 Rethinking doctors’ mental health and the impact on patient safety: A blog by Ehi Iden This blog by Ehi Iden, hub topic lead for Occupational Health and Safety, reflects on the increasing workload and pressure healthcare professionals face, the impact this has on patient safety and why we need to start 're-humanising' the workplace. He highlights that, “It takes a safe healthcare worker to deliver safe healthcare to patients.” 8 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. 9 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. 10 Blog: Shifting the dial on mental health support for young black men In this blog for NHS Confederation, Kadra Abdinasir talks about how mental health services have failed to engage with young black men, and describes how services need to change to overcome the issue. She argues that delivering effective mental health support for young black men requires a move away from a crisis-driven response, to investment in system-driven, community-based projects. Kadra looks at learning from Shifting the Dial, a three-year programme recently piloted in Birmingham as a response to the growing and unmet needs of young black men aged 16 to 25. A recent report on the project found that most young men involved in Shifting the Dial reported good outcomes related to their wellbeing, confidence, sense of belonging and understanding of mental health. 11 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. 12 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. 13 “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. 14 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. 15 Learning how to protect the health system by protecting the caregivers This commentary in JAMA Network Open looks at the increasingly recognised problem of burnout among US healthcare professionals. General Social Survey data suggest that almost one-half of US health care workers experienced symptoms of burnout often or very often in 2022, up from less than one-third in 2018. The article explores research that demonstrates the extent of the issue and highlights studies looking at ways to reduce burnout. The authors conclude that systemic change will be required to tackle the issue. 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. 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. -
News ArticlePeople who have both substance misuse problems and mental health disorders are being overlooked by the NHS, leading to avoidable harm and even suicides, say experts. Better coordination between services, monitoring of outcomes, and training for clinicians on how to treat the conditions simultaneously are needed to tackle this problem, said the authors of a report1 on co-occurring substance misuse and mental health (CoSUM) disorders. The report from the Royal College of Psychiatrists says people with CoSUM disorders experience poorer health, worse engagement with work, and higher mortality and rates of suicide than people who have either a mental illness or a substance misuse disorder. Read full story (paywalled) Source: BMJ, 13 May 2025
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News ArticleThe Royal College of Psychiatrists (RCPsych) is calling on MPs to consider serious concerns about the Terminally Ill Adults (End of Life) Bill for England and Wales, ahead of the pivotal Commons Report stage debate and Third Reading. With too many unanswered questions about the safeguarding of people with mental illness, the College has concluded that it cannot support the Bill in its current form. RCPsych is once again sharing its expert clinical insight to support MPs in making informed decisions ahead of the debate in Westminster on Friday 16 May 2025. During the Committee stage of the parliamentary process, the College raised questions about the assessments of the coordinating doctor and independent doctor, and is now raising further questions about the multidisciplinary panel (which would include a psychiatrist) being proposed by the Bill. Dr Lade Smith CBE, President of the Royal College of Psychiatrists, said: "After extensive engagement with our members, and with the expertise of our assisted dying/assisted suicide working group, the RCPsych has reached the conclusion that we are not confident in the Terminally Ill Adults Bill in its current form, and we therefore cannot support the Bill as it stands. "It’s integral to a psychiatrist’s role to consider how people’s unmet needs affect their desire to live. The Bill, as proposed, does not honour this role, or require other clinicians involved in the process to consider whether someone’s decision to die might change with better support. "We are urging MPs to look again at our concerns for this once-in-a-generation Bill and prevent inadequate assisted dying/assisted suicide proposals from becoming law." Read press release Source: RCPsych, 13 May 2025
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News Article
Charity boss slams 'reprehensible' health trusts
Patient Safety Learning posted a news article in News
Health trusts have repeatedly tried to prevent coroners from issuing Prevention of Future Death reports in order to protect their reputations, an inquiry has heard. Deborah Coles, director of the charity Inquest, told the BBC the "reprehensible" behaviour was a pattern "played out across the country" but was "exemplified" in Essex. She gave evidence at the Lampard Inquiry, which is looking into the deaths of more than 2,000 people being treated by NHS mental health services in Essex between 2000 and 2023. In her evidence to the inquiry, Ms Coles said the "lack of candour" on the part of mental health trusts in Essex was the reason a statutory public inquiry needed to be held. "It's difficult to say how traumatising that is for families when they sit in at an inquest… and then see legal representatives try and effectively stop a coroner from making a Prevention of Future Deaths report, external, which is ultimately about trying to safeguard lives in the future - and I find that reprehensible," she said. "We are talking here about trying to protect lives and also remember those who've died where those deaths were preventable." Read full story Source: BBC News, 13 May 2025 -
News ArticleThousands of people in a mental health crisis are enduring waits of up to three days in A&E before they get a bed, with conditions “close to torture” for those in such a distressed state. At one hospital, some patients have become so upset at the delays in being admitted that they have left and tried to kill themselves nearby, leading nurses and the fire brigade to follow in an attempt to stop them. A&E staff are so busy dealing with patients seeking help with physical health emergencies that security guards rather than nurses sometimes end up looking after mental health patients. The findings are included in research by the Royal College of Nursing. Its leader, Prof Nicola Ranger, called the long waits facing those in serious mental ill health, and the difficulties faced by A&E staff seeking to care for them, “a scandal in plain sight”. The RCN’s research into “prolonged and degrading” long stays in A&E also disclosed that: Some trusts that previously had no long waits for mental health patients now have hundreds. The number of people seeking help at A&E for mental health emergencies is rising steadily and reached 216,182 last year. The recruitment of mental health nurses has lagged far behind the rise in demand. The number of beds in mental health units has fallen by 3,699 since 2014. Rachelle McCarthy, a senior charge nurse at Nottingham university hospitals NHS trust, said: “It is not uncommon for patients with severe mental ill health to wait three days. Many become distressed and I totally understand why. I think if I was sat in an A&E department for three days waiting for a bed I would be distressed too.” Read full story Source: The Guardian, 13 May 2025
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News ArticleA former health ombudsman has condemned mental health services for their handling of two vulnerable young men who died in their care. Sir Rob Behrens, who was parliamentary and health service ombudsman (PHSO) from 2017 to 2024, spoke at the Lampard Inquiry, which is examining the deaths of more than 2,000 people under mental health services in Essex over a 24-year period. Sir Rob said it was "a disgrace" how Essex Partnership University NHS Foundation Trust (EPUT) had failed in its care of 20-year-old Matthew Leahy, who died in 2012, and a 20-year-old man referred to as Mr R, who died in 2008. "This was the National Health Service at its worst and needed calling out," Sir Rob said. Sir Rob referred in his inquiry appearance to several reports made during his tenure, including "Missed Opportunities", which looked into the circumstances surrounding the deaths of Mr Leahy and Mr R. Mr Leahy was found unresponsive at the Linden Centre in Chelmsford. He reported being raped there just days before he died. Sir Rob told the inquiry the PHSO identified "19 instances of maladministration" in Mr Leahy's case by North Essex Partnership University NHS Foundation Trust - a predecessor to EPUT - including that his care plan was falsified. The former ombudsman said there had been "a near-complete failure of the leadership of this trust, certainly before it was merged" with South Essex Partnership Trust to become EPUT. "This was an indictment of the health service," he added. Read full story Source: BBC News, 6 May 2025
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Content ArticleIn 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.
