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This 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.

Leapfrog content to raise awareness of the risks associated with waterborne pathogens. Waterborne diseases account for 118,000 hospitalisations each year in the United States and adds burdens to both patients and hospitals. Learn more about why creating a culture of prevention is important.

Matthew Zak Sheldrick (Matty) had struggled with their mental health throughout their adult life, but it wasn’t until 2019 that Matty was finally diagnosed with Autism. ADHD and Autistic Spectrum Disorder. However, they had never been sectioned under the Mental Health Act or had spent time as a voluntary patient in a mental health hospital.   Matty had moved to Brighton from Surrey in November 2021 having wanted to live independently. They were drawn to Brighton as they wished to be involved in the trans/non-binary community.   Matty’s mental health deteriorated during the summer of 2022 due to accommodation issues that they had been facing and issues with an online relationship. By 3rd September they were in crisis.  On 5 September 2022 Matty was admitted to A&E at the Royal County Hospital, Brighton. They remained within A&E, short stay ward, for 26 days awaiting a psychiatric bed. During this time no bed was found, and they were eventually discharged back home with support from the Crisis Home Treatment Team. Matty’s mental health had been affected by the unsuitability of the environment within A&E for someone awaiting an inpatient mental health bed.   Less than 5 weeks later Matty was again admitted to the A&E department at the Royal Sussex County Hospital on 3rd November 2022 in crisis. Their presentation fluctuated and this led to them being assessed under the Mental Health Act. However, they were not found to be detainable. They left the hospital shortly after the assessment and were sadly found hanging in the grounds of the hospital.  Matters of concern The lack of inpatient beds leading to the unacceptable wait time in A&E for those suffering with their mental health who are awaiting beds. In Matty’s case a bed was not found for them within a 26-day period. There being a shortage of beds for Autistic patients (both informal and detained) within the private sector that are being funded by the ICB. Evidence was heard that those providing beds within the public sector very often refused to accept autistic patients due to their additional risks. There being a shortage of beds for transgender patients who are in need of a mixed ward. In Matty’s case it appears there was a lack of appreciation by the ICB of his extensive length of stay in A&E. It appears that this information (and others who had lengthy stays) was not at that time being collected, monitored and acted on by the ICB. The unsuitability of the environment of A&E as a holding place for those in need of a mental health bed. The evidence was that the environment in A&E as a holding place is not conducive for those suffering with Autism and/or who are neurodiverse. The environment in A&E can exacerbate and cause further deterioration in their mental health. There is a gap in services for those who are not ill enough to be detained but who are too high risk to be sent home. There is a significant wait time for referral to the Assessment and Treatment Service. Therefore, any therapeutic input is delayed, and this results in repetitive attendances at A&E when in crisis. Current gaps in service around psychosocial support for transgender, non-binary and intersex adults have been provided by third party charitable organisations. It is understood that much of their funding has recently been withdrawn by the ICB. This is of particular concern as Brighton is recognised as having one of the largest trans communities in the Country.

Climate change is leading to a rise in heat-related illnesses, vector-borne diseases, and numerous negative impacts on patients’ physical and mental health outcomes. Concurrently, healthcare contributes about 4.6% of global greenhouse gas emissions. Low-value care, such as overtesting and overdiagnosis, contributes to unnecessary emissions. This review describes diagnostic excellence in the context of climate change and focus on two topics. First, climate change is affecting health, leading to the emergence of certain diseases, some of which are new, while others are increasing in prevalence and/or becoming more widespread. These conditions will require timely and accurate diagnosis by clinicians who may not be used to diagnosing them. Second, diagnostic quality issues, such as overtesting and overdiagnosis, contribute to climate change through unnecessary emissions and waste and should be targeted for interventions. The review also highlight implications for clinical practice, research, and policy. The findings call for efforts to engage healthcare professionals and policymakers in understanding the urgent implications for diagnosis in the context of climate change and reducing global greenhouse gas emissions to enhance both patient and planetary outcomes.

This investigation by the Healthcare Service Safety Investigation Body (HSSIB) is one of a series on the theme of patient safety in mental health inpatient settings. This investigation focused specifically on the conditions that contribute to safe and therapeutic care for adults who are staying in mental health wards or units. The demand on mental health inpatient services in England is high and has been increasing. It is reported that the quality of care received by patients admitted to these services varies, meaning patients may not receive the therapeutic care they need. Issues include limited shared decision making and a lack of consideration of recovery-focused goals. Patients may also be placed in situations that create safety risks associated with mental, physical or sexual harm. This investigation examines the impact of workforce challenges on the delivery of safe and therapeutic care to adult patients in acute mental health inpatient settings (settings for people who need urgent care and are experiencing a severe mental health problem). It also looks at the wider workplace conditions and the organisation of care to see how these factors affect care. The investigation’s scope included adults, older-adults and secure (adults who pose a risk to the public) inpatient settings. The investigation's findings and recommendations offer opportunities to make improvements to systems, practices and future plans to support the delivery of therapeutic care, and therefore safety, in mental health inpatient settings. Findings Mental health inpatient workforce Patients in mental health inpatient settings did not always feel safe and staff were not always able to develop therapeutic relationships with patients in support of their care and safety. Best practice standards for care were not embedded across inpatient settings. Some inpatient models of safety continued to focus on restrictive approaches, rather than relational approaches. Approaches were influenced by the ability of the workforce to form therapeutic relationships with patients. Workforce challenges across the multidisciplinary workforce had negatively influenced the ability of staff to develop therapeutic relationships with patients and therefore patient safety had been affected. Workforce challenges included difficulties recruiting staff and retaining experienced staff, and concerns around the knowledge and skills available to support therapeutic relationship formation and trauma-informed care. The mental and physical health care needs of patients cared for in acute inpatient settings may have changed and acuity may now be greater than in the past. Staff were not always equipped with the required knowledge and skills to understand and meet the mental and physical needs of patients. Wards were not always staffed to ensure patients could access the knowledge and skills of a multidisciplinary team. Some patients had no or limited access to professionals such as dietitians or speech and language therapists. Workforce challenges varied across regions. Barriers to region-wide coordinated workforce planning included unclear national expectations, difficulties predicting workforce needs, limited provider engagement, and a lack of available staff. The goals of the NHS Long Term Workforce Plan may be unattainable if barriers to implementation are not recognised and addressed. Barriers found included education capacity to build the workforce and poor working conditions affecting retention. There were conflicting views about how best to educate pre-registration nursing (mental health) students and where responsibility should lie to support their development of mental and physical health care skills. Registered nurses (mental health) may be being promoted to supervisory roles with limited experience. Inexperience influenced the supervision and development of new staff, and leaders may be reluctant to challenge attitudes that undermine the quality of care. Built mental health inpatient environments The built environments (estates and physical environments) of inpatient settings varied. Some environments were not therapeutic, did not contribute to formation of therapeutic relationships, and had created situations where patients and staff could and had been harmed. The short-, medium- and long-term investment requirements for safe and therapeutic built environments across mental health inpatient settings were not always known at regional and national levels. Capital funding for the NHS to maintain, improve and create new built environments was finite and unable to meet the needs of mental health inpatient settings. Hazards in built environments could not always be removed or mitigated, and environments could not be improved to be therapeutic. There were concerns about the long-term ability of some high-secure built environments to maintain patient, staff and public safety. There was no specific process for high-secure services to access the capital funds they required for long-term estate planning. There was limited evidence around how best to design therapeutic built environments to meet potential changes in patients’ needs and acuity. Providers wanted clarity on design standards and on the role of technology to support the safety of patients experiencing mental health problems. Social and organisational factors influencing mental health inpatient care The development of psychologically safe and therapeutic social environments was not always possible because of demands on services, workforce constraints, workforce knowledge and skill development, and cultural influences. Providers of mental health inpatient care were not always able to accommodate patients in single-sex spaces. Best practice standards in relation to ensuring sexual safety were not always embedded. Approaches to accommodating patients who were transgender and non-binary varied in mental health inpatient settings. Staff wanted to meet the needs and preferences of all patients but this was not always possible. Digital systems had contributed to incidents where patients had been harmed. Clinical information was not always easily accessible in electronic patient records or had not been shared across different care providers’ systems. Availability and access to physical healthcare services for mental health inpatients varied. Access was influenced by how providers designed and set up their services, the knowledge and skills of staff, and collaboration between acute and mental health care providers. In some locations, care pathways between different care providers were limited. This reduced continuity of care and made it more difficult to access physical health services, which increased the need for patients to be transferred to acute physical health hospitals. Inequalities continued to exist in the care of patients experiencing mental health problems. Availability and access to services for different patient groups further influenced the ability of inpatient providers to deliver safe and therapeutic care. Some organisational cultures and individual beliefs surrounding people experiencing mental health problems continued to negatively influence attitudes towards their care, including access to physical healthcare. Safety recommendations HSSIB makes the following safety recommendations Mental health inpatient workforce HSSIB recommends that The Shelford Group reviews and updates the Mental Health Optimal Staffing Tool on a regular basis following collection of recent data from mental health inpatient settings. This is to ensure the tool remains valid for potential changes in patients’ needs and the level of care they require, and to support providers to make decisions about workforce requirements that support therapeutic and therefore safe care. HSSIB recommends that NHS England works collaboratively with relevant national bodies and stakeholders including professional regulators, the Department of Health and Social Care, and relevant royal colleges to: Identify and clarify the goals of acute mental health inpatient care and the roles, required skills and ongoing professional development needs of the multidisciplinary workforce team. Review and update the NHS Long Term Workforce Plan with consideration of the concerns around changes in patients’ needs and the need for a multidisciplinary approach to ensure therapeutic care is provided. Develop a strategic implementation plan to address workforce issues in mental health inpatient settings that identifies the social and technical barriers to implementation and sets out actions to address them. This is to develop, enable, support and retain a future multidisciplinary mental health inpatient workforce that is able to deliver therapeutic and safe care to patients. Built mental health inpatient environments HSSIB recommends that the Department of Health and Social Care, with input from stakeholders including NHS England, identifies the short-, medium- and long-term requirements of NHS mental health built environments to ensure they enable delivery of safe and therapeutic care to patients, and create a supportive working environment for staff. This is to support the development of a strategic and long-term approach to capital investment and prioritisation for NHS built environments. HSSIB recommends that the Department of Health and Social Care undertakes assessment of the capital requirements of the built environments across high-secure services in England and develops plans to ensure the long-term safety of patients, staff and the public. Social and organisational factors influencing mental health inpatient care HSSIB recommends that NHS England, working with relevant stakeholders, develops guiding principles for providers of mental health inpatient care to support local decision making when accommodating patients, including patients who are transgender and non-binary. This is to ensure a provider’s equality and human rights obligations are considered, and all patients are cared for in environments where they feel safe and that are therapeutic. Safety observations HSSIB makes the following safety observations Providers of mental health inpatient care can improve patient safety by ensuring that where professional judgement is used to help make workforce decisions, this accounts for ward physical environments, changes in patient acuity, and the individual mental and physical health care needs of patients that require support from a multidisciplinary workforce. Those involved in the provision of undergraduate and pre-registration education (educational institutions and placement providers) and preceptorship/induction programmes can improve patient safety by collaboratively ensuring that staff entering mental health related professions are developing the required knowledge and skills, including in trauma-informed care, to care for patients with mental and physical health care needs. Those involved in healthcare research can improve patient safety by seeking to understand the design principles for mental health inpatient settings that underpin safe and therapeutic care. Research should include consideration of sensory environments, the role of technology, and the changing needs of patients. Those involved in the design of new and upgraded built environments for mental health inpatient settings can improve patient safety and the delivery of therapeutic care by involving relevant stakeholders in design processes. Stakeholders include people with lived experience (patients and staff) and experts in human factors and ergonomics. Any design should also consider the changing needs of patients. Providers of mental health inpatient care can support patient safety by evaluating and addressing local barriers to the effective use of technology to support patient care, including through gaining insights from people with lived experience (patients and staff) and ensuring the digital infrastructure is available, usable and reliable. Safety responses HSSIB proposes the following safety responses for integrated care boards HSSIB suggests that integrated care boards work collaboratively with the NHS and independent sector to review their system-level workforce plans to ensure they recognise and mitigate the safety challenges in mental health inpatient settings and agree how variation across a geographical area can be mitigated. HSSIB suggests that integrated care boards: 1) ensure system-level infrastructure strategies clearly reflect the risks across their mental health inpatient built environments, and 2) ensure prioritisation of capital funding is equitable across different healthcare settings in a geographical area. HSSIB suggests that integrated care boards: 1) work with mental health inpatient providers to identify patient needs that require input from other providers and agencies, and 2) facilitate cross-provider working arrangements between mental health, acute and primary care providers to minimise the need for transfers of care unless clinically necessary.

Theatres are a high risk area. This poster from the Association for Perioperative Practice and BD illustrates how to plan and practise to manage a surgical fire. Download a pdf of the poster from the attachment below.

Tony Clarke suffered from a chronic inflammatory skin disease, hidradenitis suppurativa. In September 2020, Tony underwent surgery to remove infected tissue on one side of his body. When he entered the operating theatre, Tony’s surgical team first covered part of his body with an alcohol-based solution, to keep the area clean. Then, when the operation began, the surgeons began cutting off the infected tissue using a diathermy pen, a device that targets electrically-induced heat to stop wounds from bleeding. However, shortly into the surgery, disaster struck: heat from the surgical pen had ignited the alcohol on Tony’s body. “But because alcohol burns so hot, no fire was seen,” says Tony, recalling an explanation he later received from the hospital.  “The surgeons were concentrating on the right side of my body. The left side was left burning for about 20 minutes.” For the next four months, Tony travelled back to the hospital every three days, to get his injuries checked and bandages changed. During that time, Tony describes himself as ‘totally disabled.’ In September this year, Tony, as a patient ambassador for prevention of surgical fires, spoke at a conference held in York by the Association for Perioperative Practice (AFPP). There, perioperative practitioners from across the country gathered to listen to Tony’s experience. “I was speaking to lots and lots of different professionals in the medical service and they'd never heard of it [being set on fire during surgery]. It was a rarity for them,” Tony says. Tony’s now working with different health agencies, with the aim of stopping preventable surgical burns entirely.

This study in the American Journal of Surgery aimed to understand the impact of operating room temperature and humidity on surgical site infection (SSI). The authors found that large deviations in operating theatre temperature and humidity do not increase the risk of SSI.

The climate and ecological crises are both driven by human activities. They each have catastrophic implications for human health and their strong interconnection creates a vicious circle where each is reinforced by the other. A stable natural environment is critical for limiting global warming and achieving the UN’s Sustainable Development Goals (SDGs). Conversely, the loss of biodiversity is a major threat to human, animal, and environmental health. In order to mitigate harm and maximise the co-benefits of action, it is important that policies tackle both climate change and biodiversity loss together. This policy report by the UK Health Alliance on Climate Change, describes the impacts of biodiversity loss on land and oceans for human health and puts forward recommendations to reduce biodiversity loss, restore nature, and achieve climate goals for the benefit of health.

PLACE assessments will provide motivation for improvement by providing a clear message, directly from patients, about how the environment or services might be enhanced. The 2023 programme is planned for launch in early September 2023. Good environments matter. Every NHS patient should be cared for with compassion and dignity in a clean, safe environment. Where standards fall short, they should be able to draw it to the attention of managers and hold the service to account. PLACE assessments will provide motivation for improvement by providing a clear message, directly from patients, about how the environment or services might be enhanced. The assessments involve local people (known as patient assessors) going into hospitals as part of teams to assess how the environment supports the provision of clinical care, assessing such things as privacy and dignity, food, cleanliness and general building maintenance and, more recently, the extent to which the environment is able to support the care of those with dementia or with a disability. Recruitment and training of patient assessors is the responsibility of those organisations undertaking assessments. The assessments take place every year, and results are published to help drive improvements in the care environment. The results show how hospitals are performing both nationally and in relation to other hospitals providing similar services.

Poster presentation from Dr Felicity Brokke and Ken Spearpoint at the recent GOSH Patient Safety and Human Factors Conference.

Because hospitals exist for a long time and are expensive to build and to operate, it is crucial to use the abundant, available empirical evidence to guide design. “Evidence-based design” has documented how to make hospitals safer and less stressful. This article, published in The Conversation, looks at the challenges involved.