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Over 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

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

More than 1 in 6 physicians have thought about or attempted suicide. 38% of them knew of at least one fellow doctor who had suicide ideation. A Medscape survey asked physicians what factors they saw behind the suicide issues, the role their job stress plays and where doctors in a crisis can turn for effective professional help.

This annual report from the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) provides information relating to people aged 10 and above who died by suicide between 2012 and 2022 across the UK and Jersey. It also presents findings on the number of people under mental health care who have been convicted of homicide, and those in the general population in the UK. Key findings Patient suicide numbers and rates Over 2012-2022, there were 18,670 suicides by patients in the UK and Jersey, an average of 1,697 deaths per year, 26% of all general population suicides. The number of patient suicides increased in 2018 following a change in the standard of proof for suicide at inquest. In England and Wales, an increase in suicides registered in 2023, suggesting a possible rise in suicides occurring in 2022, has been reported by the Office for National Statistics. It is too early to say if this rise will be evident in our 2022 patient suicide figures. Social and clinical characteristics A high proportion of patients who died by suicide showed evidence of isolation and social adversity; nearly half (47%) lived alone, and a sixth (17%) had recently experienced serious financial problems (see details on page 12). Suicide-related internet use was reported in 8% of patients. A history of alcohol (47%) or drug (38%) misuse was common. Over half (55%) had a comorbid mental health diagnosis. The majority (62%) of patients who died had a history of self-harm. The proportion who had recently (<3 months) self-harmed (31%) has increased over the report period. Clinical care There were 4,718 (27%) patients who died by suicide in acute care settings, including in-patients (5%), and post-discharge care (13%) or crisis resolution/home treatment (13%) (with overlap between these latter two groups), an average of 429 deaths per year. There were an estimated 72 suicides by mental health in-patients in 2022, around 4% of all patient suicides in that year. Of all in-patients, 40% died on the ward, 50% were off the ward on agreed leave, and 10% had left the ward without staff agreement or left with agreement but failed to return. The proportion of inpatients who died on the ward has increased by 31% between 2012-2015 and 2019-2022. There were an estimated 198 deaths by suicide in the 3 months after discharge from mental health in-patient care in 2022, 11% of all patient suicides. The number and rate of post-discharge suicide has risen since 2017. Of all patients who died in the first week after discharge, the highest number occurred on day 3 (63 patients, 20%) post-discharge (taking day 1 as the day of discharge). However, in 2019-2022 the highest number occurred on day 6 (20 patients, 22%). Real-time surveillance study NCISH is establishing an additional method of patient suicide data collection through real-time surveillance (RTS) in England and asking all trusts to notify it of suspected suicides by inpatients or those recently discharged, without waiting for inquest. To date we have been notified of 67 suspected suicide deaths, the majority (44, 67%) by in-patients. Early themes include high proportions of in-patients being detained under the Mental Health Act (55%) and being admitted to wards outside of the patient’s local area (35%). Suicide and bipolar disorder In 2012-2022, there were 1,491 suicides by patients with bipolar disorder, 8% of all patient suicides, an average of 136 deaths per year. The average number in 2019-2022 increased by 19% compared to the average number in 2015-2018. Patients with bipolar disorder were more often female (47%), living alone (52%) and older, with more aged 45-64 (50%), than other patients who died by suicide. Overall, a minority (39%) were receiving lithium treatment and only 12% were receiving psychological treatment. More patients with bipolar disorder were non-adherent with medication (15%) and had experienced drug side effects (12%). Suicide and missed contact and/or non-adherence with medication In 2012-2022, there were 3,817 suicides by patients who missed their last contact with mental health services, 22% of all patient suicides, an average of 347 deaths per year. There were 1,998 suicides by patients who were nonadherent with drug treatment, 12% of all patient suicides, an average of 182 deaths per year. Our estimates for 2022 show an increase in the proportion of patients with missed contact but a fall in those non-adherent with medication. Missed contact was often accompanied by clinical morbidity (for example, additional psychiatric diagnoses, self-harm, alcohol and/or drug misuse), and socioeconomic adversity (for example, unemployment, financial problems, living alone). Services had made contact with the patient’s family in 28% of those who had missed their last appointment. The majority (63%) of non-adherent patients had severe mental illness. Half (47%) were prescribed oral antipsychotics. Reasons for non-adherence were reported to be the patient’s impaired insight into their illness (31%), side effects (15%) and lack of effectiveness (13%). Suicide and recent bereavement In 2012-2022, there were 1,312 suicides by patients who had been recently (<3 months) bereaved, 8% of all patient suicides, an average of 119 deaths per year. The number increased over two-fold in 2016-2022 compared to in 2012-2015, presumably due to better recognition by clinicians. Patients bereaved were more often female (40%) than other patients who had not recently been bereaved and they were more likely to be older, widowed (20%) and living alone (54%). A third (34%) had a primary diagnosis of depression. More died on or near the date of a family member or friend’s death anniversary compared to other patients (7% v. 1%). In 2020-2022, half (51% v. 35%) had reported suffering from insomnia and a third (35% v. 30%) had recently misused alcohol.

Mr Thomas Henry Robin Kingston was a 45 year old man who was visiting his parents in Kemble Gloucestershire for the weekend. He had recently been experiencing anxiety, but had not expressed any suicidal ideation. On Sunday 25 February 2024 after lunch he began to unload his car, and prepared to return to London. Between approximately 1700-1800 hours he removed a shotgun from his vehicle which he had recently borrowed from his father for a shoot. He then accessed an annex attached to his parent’s property. Within a locked bathroom he self inflicted a gun shot to the head, and sustained injuries incompatible with life. He was subsequently found by his father. He was pronounced deceased at 1854 hours by attending police, who confirmed there were no suspicious circumstances surrounding his death. Intent remains unclear as the deceased was suffering from adverse effects of medications he had recently been prescribed. The medical cause of death was 1A Traumatic wound to head.                  Matters of Concern Whether there is adequate communication of the risks of suicide associated with the selective serotonin reuptake inhibitor (SSRI) medications, and Whether the current guidance to persist with SSRI medication or switch to an alternative SSRI medication is appropriate when no benefit has been achieved and/ or especially when any adverse side effects are being experienced.

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

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

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.

This is one of a series of Health Services Safety Investigations Body (HSSIB) reports on the theme of patient safety in mental health inpatient settings. This investigation explored the issue of care of people experiencing mental health problems and includes discussion about suicide, death and sexual safety.  The aim of the investigation was to examine the impacts of transition from inpatient children and young people’s mental health services to adult mental health services on people who have experienced it, their families and carers, and on staff involved. The investigation also considered wider system implications regarding the integration of childhood to adulthood transitional services across health, social care and education. Key findings Young people may be discharged from inpatient children and young people’s mental health services because they have reached ‘transition age’ and not because their mental health care needs have changed. Adult mental health services criteria for ongoing care as an ‘adult’ inpatient may mean young people are discharged from inpatient children and young people’s mental health services to an alternative setting which is not suitable to meet their ongoing needs, for example bed and breakfast hostels, with community services providing more limited mental health care and support. Young people, families and carers are not reliably informed of, or prepared for, the differences in care approach between inpatient children and young people’s mental health services and inpatient adult mental health services. Health, social care, local authorities and education do not always work together in a consistent and integrated way to support positive outcomes for young people who are transitioning from inpatient children and young people’s mental health services to adult mental health services. There is currently no alignment, equity of access, or clear responsibility and accountability for children and young people’s health, education and social support that spans their transition from childhood to adulthood. In many children and young people’s mental health services, ‘blanket’ safeguarding measures are implemented overnight for people reaching 18. These measures are not based on a change in individual behaviours or risks. Perceived safeguarding challenges are a driver for rigid aged-based transitions. Young people, their families, and carers described that communication and information sharing changed when the young person reached 18. This meant safety risks were not always discussed and families and carers were not involved in safety planning or risk mitigation. NHS England service specifications and commissioning guidance for inpatient children and young people’s mental health services do not support needs-based flexible transitions. More flexible, developmentally appropriate needs-led transitions were seen to have more positive patient outcomes. Definitions of ‘children’, ‘young people’ and ‘adults’ vary across legal and professional guidance. This contributes to challenges in defining these groups across services. In comparison with young people in mainstream education, the education needs of young people transitioning from inpatient children and young people’s mental health services due to reaching 18 are not always being met. A robust training needs analysis and competency assessment of the inpatient mental health workforce is required if changes to the specifications and delivery of inpatient mental health services are made. Report recommendations HSSIB recommends that NHS England reviews and updates its inpatient children and young people’s mental health services specifications and commissioning guidance to ensure they support developmentally appropriate, needs-based transitions. Any changes to service delivery will require a review of funding lines to enable successful implementation. HSSIB recommends that NHS England reviews and revises its guidance and policies to ensure consistency regarding the language used for age ranges (for example children, young people, young adults and adults). This is to support a consistent approach to healthcare delivery that aligns services and mitigates gaps. HSSIB recommends that the Care Quality Commission work with the Department of Health and Social Care to understand prioritisation for assessing transitions in mental health care within Integrated Care System assessments. Any subsequent work should include the development of a methodology to identify the challenges described in the investigation report relating to transition from inpatient children and young people’s mental health services, to adult mental health services. This is to improve the safety, quality and consistency of transitions across England. HSSIB recommends that the Department of Health and Social Care works across government to identify opportunities to support closer cooperation between local government, education and health systems for the safe and effective transition of young people into adulthood. This is to ensure alignment, equity of access, and clear responsibility and accountability for their health, education and social support that spans the ages of 16 to 25. Cross governmental work would be supported by the adoption of consistent language for age ranges of children, young people, and adults. HSSIB recommends that NHS England provides guidance regarding communication of essential safety and risk mitigation information when patients transition from inpatient children and young people’s mental health services due to reaching transition age. This is to safeguard vulnerable people and may include how to share information with families and carers, health and social care providers, and third sector organisations.