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Francine Gilmore, a patient with vestibular migraine, has written a report in a personal capacity* examining a patient safety gap where migraine prescribing overlaps with mental health risk. Drawing on Freedom of Information responses from 26 organisations and related evidence, the report identifies fragmented safeguards, unclear ownership and potential barriers to suitable treatment for clinically complex patients. In this blog, Francine shares her experience, the findings from her report and the actions she would like to see taken. The findings point to a clear need for change: migraine pathways must make mental health risk visible, owned in governance, recorded in clinical systems and reviewed for patient-safety learning. *The full report can be downloaded from the attachment at the end of the page. My (wobbly) journey I did not set out to write a patient safety report. I was trying to understand why so many medicines with potential contraindications had been offered to me. Quite literally a year to the date, since returning from the USA after my 30th birthday, I have been living with ongoing symptoms of what is now known to be vestibular migraine. The dizziness is relentless. When the dizziness starts, I am a safety risk. The headache pain can make life unbearable. So can photophobia, when ordinary light becomes too much to tolerate. Sunglasses are my new best friend. Somewhere along the way, I entered a state of medical hypervigilance. I was angry, frightened and exhausted. It felt as though, in trying to repair my physical health, I was once again being asked to risk my mental health. Every treatment decision felt like a game of medical Whac-a-Mole: solve the migraine problem, worry about mental health issues popping up later. Returning to full-time work has been a huge achievement. But doing so while still managing pain, dizziness and photophobia has also shown me how much invisible effort this condition demands. Yet migraine is only part of my picture. I also live with bipolar disorder and have a history of suspected serotonin syndrome (a serious condition caused by medications that build up high levels of serotonin in the body requiring hospitalisation). That means migraine treatment is not simply about whether a drug might help. It is also about whether it could destabilise my mental health, interact with other risks or cause another kind of harm. There. I have disclosed it publicly, likely where my professional networks will see it. But I am saying it because it matters and I know the risks. Managed mental illness should not be a nice to have consideration; it should make joined-up prescribing decisions more important. Before appointments, I print reports listing the medicines I am concerned about. I sit there trying to explain what I can and cannot take, aware that I may sound difficult, but also aware that I am the person who will live with the consequences if those risks are missed. I could probably deliver a TED Talk entitled 10 Things I Hate About Migraine Prophylaxis Options. The trouble is that there are considerably more than ten. The evidence The report is based on Freedom of Information responses and related information routes. The project file covers 26 organisations or evidence routes and more than 30 documents, so 1000+ pages of evidence. I used AI as a research and drafting tool, but every substantive finding was checked against the underlying evidence. Given the volume of material and the impact of disabling migraine, this was an accessibility tool as much as a drafting tool. The Migraine Trust states that migraine affects around one in seven people. My report also cites systematic review evidence showing increased odds of depression in people with migraine, increased odds of anxiety, and estimated bipolar disorder prevalence among people with migraine of 5.9% in population studies and 9% in clinic-based studies. The relationship is clinically relevant because migraine, mood disorders and some preventive medicines can overlap through neurological, psychiatric and medication-safety pathways. For patients already managing mental health medication, migraine prescribing is rarely a cleanly separate issue. There is also crossover in the medicines themselves. Amitriptyline, venlafaxine and nortriptyline are antidepressants and migraine preventives, while topiramate and valproate raise neuropsychiatric or psychiatric safety considerations. Greater occipital nerve blocks may also involve steroid exposure. Only last week I was offered lamotrigine and had to point out that this is also a centrally acting medicine with psychiatric relevance, particularly for someone with bipolar disorder. What I found in my research was a system that could point to safeguards in theory, but not clearly show who owned the risk in practice. NICE guidance, the British National Formulary, product warnings, local formularies, prescribing systems, referral routes and clinical judgement all matter. For patients like me, that gap affects which medicines feel safe to try, how much responsibility we are forced to carry and whether the whole picture is visible to the people making decisions. It also affects access. Some patients cannot safely use standard migraine preventives because of psychiatric history, psychotropic medication, previous adverse reactions or physical contraindications. If access to some specialist treatments depends on trying previous prophylaxis options, pathways need to show how contraindication, intolerance or clinical unsuitability are recorded and counted. Otherwise, patients can fall into a cruel gap: too complex for the standard route but not clearly signposted towards safer alternatives The report makes practical recommendations: clearer flagging of mental health and medication-safety risks defined ownership of the prescribing interface triggers for psychiatry or specialist pharmacy input better documentation and escalation processes recognition of contraindication, intolerance and clinical unsuitability when assessing access to specialist migraine treatments. Parliamentary questions asked On the eve of Patient Safety Learning publishing my report and blog, something unexpected happened. A number of parliamentary questions had already been tabled in the House of Commons about the issues the report raises. To me, the early answers seemed to confirm the gap the report had identified. On 15 June 2026, the Department of Health and Social Care (DHSC) said it had made no specific assessment of national arrangements for identifying, recording and acting on psychiatric history, psychotropic medication or previous psychiatric adverse drug reactions before someone starts a preventive migraine treatment. A second answer pointed to the Getting It Right First Time (GIRFT) programme as a way of reducing variation in migraine access. That sounded promising, until two follow up answers narrowed the position again. The DHSC then confirmed it had no plans to look any further than its 15 June position. Asked whether GIRFT covers governance for this prescribing interface, it confirmed on 1 July that it does not. GIRFT sets no formal governance requirements here. Those decisions are left to local providers and commissioners. Then came the House of Lords answer. On 6 July, the Government confirmed that the Medicines and Healthcare products Regulatory Agency (MHRA) now plans to review the evidence on mental health and related risks for licensed migraine prophylaxis medicines after receiving a report from a patient. It will consider whether product warnings need updating, and will look at suspected adverse drug reactions reported in the psychiatric disorders category. The answer records that this followed a report made to the MHRA. So the question is no longer just whether the risks are recognised. It is this: if the MHRA moves, how quickly will the rest of the system move with it?

At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That’s why we created the hub; providing a space for people to come together and share their experiences, resources and good practice examples. We have collated 15 resources relating to men's health, including information about male cancers, men's mental health, how to engage men earlier and insights around the impact of traditional ideas of masculinity on patient safety. *Trigger warning: some of the content below focuses on suicide. 1 Men's Health Strategy for England This document sets out the government’s 10-year strategy for men’s health in England. It details the government’s vision for men’s health over the next 10 years and actions they are taking now to improve the health and wellbeing of all men and boys in England. 2 Men’s Health: How to improve health outcomes, knowledge, and behaviours This report sets out the findings of new research conducted by Healthwatch England to inform the Government’s first-ever men’s health strategy for England. They commissioned a nationally representative poll of 3,575 men aged 18+ in June 2025 and also drew on local Healthwatch engagement, with men from diverse backgrounds, spanning a wide range of ages, ethnicities, occupations, and areas. 3 Men’s health: The lives of men in our communities Men in England are facing “a silent health crisis”, dying nearly four years earlier than women, while suffering disproportionately higher rates of cancers, heart disease and type 2 diabetes, according to a report by the Local Government Association. They are urging the Government to implement a men's health strategy similar to the women's health strategy of 2022. It wants men’s health to be recognised as “a national concern”. 4 Overcoming the barriers to engaging with prostate cancer Orchid is the UK’s leading charity for those affected by male cancer. In this interview, we speak to Ali Orhan, Chief Executive and Director of their Overcoming the Barriers to Engaging with Prostate Cancer project. Ali tells us how they are working alongside a network of volunteer community champions to improve awareness, support better outcomes and reduce health inequalities. 5 Prostate Cancer UK: risk checker Prostate cancer is the most common cancer in men, but most men with early prostate cancer don’t have symptoms. Use this risk checker to find out what you should do. 6 Samaritans Handbook: Engaging men earlier: a guide to service design This handbook from the Samaritans provides a set of principles upon which wellbeing initiatives for men should be based, drawn from what men have said is important to them. By following these principles, wellbeing initiatives are more likely to be effective for, and appeal to, men going through tough times before reaching crisis point. 7 Infopool prostate cancer patient resource This patient resource created by Prostate Cancer Research aims to equip patients and the public with information about prostate cancer. It contains information on testing and diagnosis, treatment choices, living with side effects, and clinical trials. 8 Men's Health - How can we take action? Here are our top 5 things to know and do Top tips for men on keeping healthy and advice on prostate and testicular cancer. 9 Prostate Cancer UK: Best practice pathway Developed to support healthcare professionals at the front line of prostate cancer diagnosis and care, Prostate Cancer UK's Best Practice Pathway uses easy to follow flowcharts to guide healthcare professionals deliver best practice diagnosis, treatment and support. 10 HSSIB report: Management of acute onset testicular pain This investigation reviewed the diagnostic and treatment pathway for testicular torsion. There was a predominant focus on delays and the human factors associated with the pathway. The investigation identified system-wide recommendations designed to prevent delays to the identification and treatment of testicular torsion happening in the future. 11 Prostate cancer: getting information and support This leaflet helps signpost people to support and information about prostate cancer, both nationally and regionally. 12 Why harmful gender stereotypes surrounding men’s approaches towards their feelings need challenging This blog explores men's mental health – how men are reluctant to seek support when they are struggling, why the suicide rate is so high, what initiatives exist to encourage men to seek help and what more could be done. 13 King's Fund blog: Inequalities in men’s health: why are they not being addressed? Almost half of England’s population is male, yet inequalities in men’s health seldom get specific attention. The women’s health strategy for England shone a light on the health care needs of girls and women through their life course, highlighting areas specific to their health – such as maternity and the menopause – and inequalities in health outcomes. But the wide, and widening, health inequalities experienced by men also require focus. 14 The incredibly obvious thing you should do about painful testicles Watch this short film about what to do if you experience pain in your testicle/s, by Cardiff Fertility Studies and the British Fertility Society, made in partnership with Orchid. 15 An Unfilled Prescription: Tapping Pharmacy's Potential to Boost Men's Health This report from the Men's Health Forum examines the role of community pharmacy in improving men’s health in the UK, the theme of Men’s Health Week 2026. The report sets out a five-point plan that pharmacies should adopt to become a male-friendly pharmacy, which encourages more men to engage. Share your insights and experiences Have you, or a loved one, experienced any of the issues raised in this blog? Would you like to share your insights to help improve outcomes in men's health? Perhaps you work in men's health and can share some of the barriers to safe care and what you believe needs to change to improve outcomes. You can share your thoughts in the comments below (sign up first for free) or email our team at [email protected].

Lucy Harding is a Patient Safety Partner at North London NHS Foundation Trust, where she has also been a patient and Peer Support Worker.   In this reflective piece, Lucy shares her insights around how design in healthcare can impact patient safety. She draws on her professional background and lived experience of inpatient mental health care as an autistic person, to highlight the critical relationship between design and emotional safety. *Content warning: references to suicidality and self-harm.  I have a particular interest in how the physical environment shapes emotional regulation, sensory experience, and feelings of safety. As an autistic person, I also value sensory design and service accessibility, and I’m passionate about creating therapeutic spaces that genuinely support recovery. Design is a core component of patient safety My interest comes from experiencing first-hand how profoundly the built environment can affect emotional state, distress levels, and the ability to feel safe and engage in treatment. Poorly designed wards can feel chaotic, overwhelming, and sometimes frightening. My experience of patient involvement in co‑production projects, from artwork to furniture selection, helped me realise that design isn’t superficial; it’s a core component of patient safety and experience. As an autistic person, sensory design is very important to me, and I’ve experienced how unmet sensory needs can escalate distress. These experiences have made me want to advocate for safer and more therapeutic environments. Seeing the transformative impact of thoughtful design for mental health —such as improved acoustics, better lighting, and more predictable, calming spaces— has shown me how design can actively support or hinder safety. How the environment can impact patient safety Environments that feel like containment: institutional or outdated spaces can make people feel unsafe, watched, or confined. People should have access to outdoor spaces and fresh air, but not every mental health ward provides immediate access (eg. many wards require leave from hospital to be agreed by a care team, as there are not gardens designed into the ward environment). Sensory overload: harsh lighting, echoing voices in corridors, and unpredictable multi‑use spaces can heighten distress, especially for autistic people and those with experiences of trauma. There were times I had no control over sensory input as a patient, and this felt extremely destabilising and made me unsafe. I disengaged with and resisted treatment, and I self-harmed. The National Autistic Society reports that the average length of stay for autistic people in mental health hospital is 4.6 years, which is a considerably long time.[1] The Assuring Transformation dataset can help ICBs to look at where inequalities are for autistic people without LD in comparison to the general population.[2] I am curious about how much building design contributes to this inequity (rather than the clinical care provided). Lack of temperature control: wards that become extremely hot or cold can make rooms unsafe both physically and emotionally. Hot rooms feel stuffy and uninviting to use, both for staff and patients. High temperatures can make me feel more irritable and less rational. Many psychiatric medications also impact body temperature regulation. As temperatures are rising globally, improving ventilation and prioritising resources for this is becoming more essential. Poor acoustic design: noise and echoing make communication difficult, increasing misunderstandings and conflict. Lack of safe respite spaces: without somewhere quiet to withdraw, people may seek unsafe alternatives. I hid on my windowsill often as a patient, escaping observations and noise – but being unseen for two hours was a risk, and I wasn’t always keeping myself safe. Old buildings and shared facilities: shared bathrooms and dormitory bedrooms, and a lack of purpose-use ward spaces can create conflict, distress, and act as a barrier to treatment being therapeutic. Designing ensuite bedrooms, creating dedicated rooms for therapy, group activities, and quiet/sensory rooms can make a difference to how safe a ward feels. When design supports safety An example of a positive design change I experienced was the installation of a sound‑absorbing panel at an inpatient mental health service. It made a noticeable difference- reducing echoing and softening the overall noise level, which helped communication feel calmer and more respectful. This kind of acoustic improvement reduces the intensity and unpredictability of sounds on a ward. Also, seeing our photographs on the wall made me, as a patient, feel safe, heard, and included. Connecting with others through art and design ultimately lifted me out of a state of intense suicidality and depression. That lens has led me to be very passionate about design being directly connected to patient safety. Challenges and barriers Key challenges and barriers to designing healthcare environments in ways that support patient safety: Budget constraints: sensory‑friendly or trauma‑informed design is often seen as optional rather than essential. Legacy buildings: older wards may be structurally unsuitable for modern design standards. Competing priorities: safety is often interpreted narrowly (eg ligature reduction, or a reduction in a particular category of reported incidents) rather than holistically, which can overshadow sensory and emotional safety. Lack of awareness: designers and decision‑makers may not fully understand sensory needs or lived experience perspectives. Operational pressures: busy wards can deprioritise environmental improvements or require more focus and time than ward staffing allows. Limited co‑production: without meaningful involvement from service users, important design needs can be overlooked. These barriers mean that environments sometimes prioritise containment over comfort, despite evidence that therapeutic design improves safety. Considerations for safer design Co‑production from the start: involve service users, carers, and staff in every stage of design—not just as a consultation step. Sensory‑informed design: consider lighting, acoustics, temperature, predictability, and access to quiet spaces. Flexibility and choice: offer different types of spaces for different needs—calming rooms, social areas, private space, and low‑stimulus zones. Accessibility as standard: such as acoustic design for autistic people, people with hearing impairments, and sensory processing differences. Trauma‑informed principles: prioritise dignity, autonomy, and emotional safety. Feedback loops: continue involving patients after the building opens to refine and improve the environment. Final reflections Feeling safe is not the same as being objectively safe, and both matter equally in mental health settings. Design should never be an afterthought: it is a therapeutic intervention in its own right. When we create environments that respect sensory needs, reduce distress, and promote autonomy, we support recovery and reduce risk. Co‑production with patients isn’t just good practice, it’s essential for designing spaces that truly work for the people who use them. References 1. National Autistic Society. Number of autistic people in mental health hospitals: latest data. June 2025. Accessed online 13/15/26. 2. NHS England. The Assuring Transformation dataset (Table 3, column F&G: average length of stay for autistic patients without a learning disability). March 2026. Accessed online 13/05/26.

This toolkit is a co‑designed set of materials created with researchers, people with personal experience of suicide and self-harm, and healthcare professionals. Inspired by the family of Jaymie Mart, known as Jay, who died by suicide in 2012 at the age of 32, the toolkit—which was funded by the National Institute for Health and Care Research (NIHR)—offers clear, practical guidance to help adults create and review personalised safety plans. Safety plans are structured tools that support people experiencing self‑harm or suicidal thoughts by helping them identify strategies to stay safe during a crisis. The resource is designed for families, friends, wider support networks, individuals themselves, and health and social care professionals. In this toolkit you will find: A guide through each step of the safety planning journey, from starting a plan to reviewing and updating it. Examples from people with experience of suicide and self-harm. Links to further resources and support information. You can use it to: Guide safety planning conversations. Support training. Encourage reflection and learning. This prototype toolkit is based on research evidence and was co-designed with people who have lived experience, alongside health and social care practitioners. It has been developed to support good-quality, personalised safety planning in practice. It follows national guidance, including recommendations from NICE and the NHS. This toolkit is dedicated to Jaymie, who sadly died by suicide. You can listen to Jaymie’s mother, Paula, share Jaymie’s story and explain why she believes personalised safety planning is important here.

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