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Found 257 results
  1. Content Article
    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
  2. Content Article
    Mental Health Awareness Week is an annual event which aims to raise awareness and promote open conversations about mental health.  In this Top picks, we’ve pulled together resources, blogs and reports from the hub that focus on improving patient safety across different aspects of mental health services and also supporting staff with their own mental health and wellbeing. 1 Restraint Reduction Network: Supporting people with lived experience As all forms of restrictive practice can result in harm, it is important that people are able to identify restrictive practices and challenge their inappropriate use. The Restraint Reduction Network have a range of resources that people with lived experience, parents and carers may find helpful. The resources are designed to support people to understand what restrictive practices are, when and why they might be used, people’s rights, and how to identify and challenge unacceptable and unethical practices. 2 Harry’s story: Acute Behavioural Disturbance In December 2022, Harry Vass died after experiencing Acute Behavioural Disturbance (ABD) and a complex disturbance in normal physiology. Harry’s death was found to be avoidable as carers were not fully aware of this condition associated with acute psychosis. In this blog, Harry’s mother Julie describes the barriers they faced in getting the right support and care for Harry before he died and highlights the need for healthcare staff to have a greater awareness of ABD and the associated risks of a medical emergency. You can also read a second blog by Julie, where she explains more about Acute Behavioural Disturbance and the changes she believes are needed to make sure patients like Harry are cared for appropriately. 3 Life Beyond the Cubicle: eLearning to support working well with families during mental health crises A set of eLearning modules designed to educate and update clinicians on the importance of involving families wherever possible during mental health crises to improve patient care, avoid harm and reduce deaths. They were developed as a partnership between Oxford Health NHS Foundation Trust and Making Families Count, with funding from NHS England South East Region (HEE legacy funds). The resources have been co-produced by people with lived experience as patients, family carers and clinicians, supported by an Advisory Group drawn from a wide range of expertise, tested in eleven NHS Trusts and independently evaluated. 4 Mental health crises: how to improve care In May 2024, National Institute for Health and Care Research (NIHR) Evidence held a webinar on care for adults in mental health crisis. The webinar shared research findings on what works in community crisis care, how acute day units compare to crisis resolution teams and whether peer-supported self-management can reduce acute readmissions. This Collection summarises the 3 research projects presented at the webinar. It includes video clips from the speakers and incorporates quotes from the day. The information will be useful for anyone involved in commissioning or delivering mental health crisis services. 5 Self-harm: assessment, management and preventing recurrence This new guideline from the National Institute for Health and Care Excellence (NICE) covers assessment, management and preventing recurrence for children, young people and adults who have self-harmed. It includes those with a mental health problem, neurodevelopmental disorder or learning disability and applies to all sectors that work with people who have self-harmed. The guideline sets out some important principles for care and treatment. For example, it states that self-harming patients treated in primary care must receive regular follow-up appointments, regular reviews of self-harm behaviour and a regular medicines review. 6 Hope Virgo: What needs to happen to stop people with eating disorders being failed by the healthcare system? In this blog, Hope Virgo, author and Secretariat for the All Party Parliamentary Group (APPG) on Eating Disorders, examines the crisis that continues in eating disorder services in the UK and the devastating impact this is having on patients and their families. She highlights how failures in services lead to avoidable deaths. Hope shares the key recommendations from a new report by the APPG and calls for adequate funding and attention to ensure people with eating disorders receive the help they need to recover. 7 Rethinking doctors’ mental health and the impact on patient safety: A blog by Ehi Iden This blog by Ehi Iden, hub topic lead for Occupational Health and Safety, reflects on the increasing workload and pressure healthcare professionals face, the impact this has on patient safety and why we need to start 're-humanising' the workplace. He highlights that, “It takes a safe healthcare worker to deliver safe healthcare to patients.” 8 Zero Suicide Alliance training The Zero Suicide Alliance is a collaboration of NHS trusts, charities, businesses and individuals who are committed to suicide prevention in the UK and beyond. Their website offers free online training courses to teach people the skills and confidence to have potentially life-saving conversations with someone they’re worried about. They offer short online modules covering general suicide awareness, social isolation and suicide in veterans and university students. 9 How can our team move past a traumatic event? After an extreme traumatic event there are things that you can do to help yourself, and your colleagues, to move on. Fiona Day, medical and public health leadership coach and chartered coaching psychologist, Stacey Killick, consultant paediatrician at Glan Clwyd Hospital, and Lucy Easthope, professor in practice at Durham University’s Institute of Hazard, Risk, and Resilience and adviser on disaster recovery give their tips in this BMJ article. 10 Blog: Shifting the dial on mental health support for young black men In this blog for NHS Confederation, Kadra Abdinasir talks about how mental health services have failed to engage with young black men, and describes how services need to change to overcome the issue. She argues that delivering effective mental health support for young black men requires a move away from a crisis-driven response, to investment in system-driven, community-based projects. Kadra looks at learning from Shifting the Dial, a three-year programme recently piloted in Birmingham as a response to the growing and unmet needs of young black men aged 16 to 25. A recent report on the project found that most young men involved in Shifting the Dial reported good outcomes related to their wellbeing, confidence, sense of belonging and understanding of mental health. 11 Vicarious trauma: The invisible epidemic In healthcare, an insidious epidemic lurks beneath the surface, affecting the very individuals tasked with providing care: vicarious trauma by empathy. Despite its profound impact, this phenomenon remains largely unrecognised and under-discussed within the sector. As leaders, it is imperative that we shed light on this invisible trauma and acknowledge it as one of the greatest challenges facing our industry, as Margarida Pacheco explains in this blog. 12 Beyond stereotypes: A lived experience guide to navigating support for disordered eating Disordered eating can affect anyone, but it can be confusing to understand and recognise it in our own personal experiences. This guide, published by East London NHS Foundation Trust, is a snapshot of how adults in East London have navigated those experiences of uncertainty while seeking support for disordered eating. For many of the contributors, preconceptions about what an eating disorder is (or isn’t) have previously acted as a barrier to seeking or receiving support. It also contains advice on how to seek support for disordered eating. 13 “The alarming rate of suicide among healthcare workers should be a wake-up call in the urgent need to support them” Frontline19 was established at the start of the Covid pandemic as an urgent response to support frontline workers who were under extreme pressure and experiencing significant mental health challenges. Psychotherapist Claire Goodwin-Fee is the founder and CEO of Frontline19. In this blog, Claire explains how systemic pressures and stigma around mental health are continuing to leave healthcare staff extremely vulnerable. 14 Blog: Why harmful gender stereotypes surrounding men’s approaches towards their feelings need challenging This blog explores why men are reluctant to seek support when they are struggling with their mental health and why the suicide rate is so high. It looks at initiatives that exist to encourage men to seek help and highlights what more could be done to support mens’ mental health. 15 Learning how to protect the health system by protecting the caregivers This commentary in JAMA Network Open looks at the increasingly recognised problem of burnout among US healthcare professionals. General Social Survey data suggest that almost one-half of US health care workers experienced symptoms of burnout often or very often in 2022, up from less than one-third in 2018. The article explores research that demonstrates the extent of the issue and highlights studies looking at ways to reduce burnout. The authors conclude that systemic change will be required to tackle the issue. 16 Time for a rebalance: psychological and emotional well-being in the healthcare workforce as the foundation for patient safety In this editorial for BMJ Quality and Safety, Kate Kirk explains why staff well-being is the foundation to improving patient safety. 17 Top tips and key actions for successful collaborative partnership working across mental health services These top tips and key actions have been co-developed to support effective collaborative partnership working in the planning and delivery of community mental health services. They recognise that every heath and care system will experience challenges in relation to partnership working given the statutory and cultural differences of organisations working across the mental health pathways and that there will be different arrangements to frame local partnership working, including for example a Section 75 agreement. 18 Balancing care: The psychological impact of ensuring patient safety In this blog, Leah Bowden, a patient safety specialist, reflects on the impact her job has on her mental health and family life. She discusses why there needs to be specialised clinical supervision for staff involved in reviewing patient safety incidents and how organisations need to come together to identify ways we can support our patient safety teams. Have your say Do you have any stories, insights or resources related to mental health? We would love to hear from you! Comment below (register for free here first) Get in touch with us directly to share your insights.
  3. News Article
    People who have both substance misuse problems and mental health disorders are being overlooked by the NHS, leading to avoidable harm and even suicides, say experts. Better coordination between services, monitoring of outcomes, and training for clinicians on how to treat the conditions simultaneously are needed to tackle this problem, said the authors of a report1 on co-occurring substance misuse and mental health (CoSUM) disorders. The report from the Royal College of Psychiatrists says people with CoSUM disorders experience poorer health, worse engagement with work, and higher mortality and rates of suicide than people who have either a mental illness or a substance misuse disorder. Read full story (paywalled) Source: BMJ, 13 May 2025
  4. News Article
    A former health ombudsman has condemned mental health services for their handling of two vulnerable young men who died in their care. Sir Rob Behrens, who was parliamentary and health service ombudsman (PHSO) from 2017 to 2024, spoke at the Lampard Inquiry, which is examining the deaths of more than 2,000 people under mental health services in Essex over a 24-year period. Sir Rob said it was "a disgrace" how Essex Partnership University NHS Foundation Trust (EPUT) had failed in its care of 20-year-old Matthew Leahy, who died in 2012, and a 20-year-old man referred to as Mr R, who died in 2008. "This was the National Health Service at its worst and needed calling out," Sir Rob said. Sir Rob referred in his inquiry appearance to several reports made during his tenure, including "Missed Opportunities", which looked into the circumstances surrounding the deaths of Mr Leahy and Mr R. Mr Leahy was found unresponsive at the Linden Centre in Chelmsford. He reported being raped there just days before he died. Sir Rob told the inquiry the PHSO identified "19 instances of maladministration" in Mr Leahy's case by North Essex Partnership University NHS Foundation Trust - a predecessor to EPUT - including that his care plan was falsified. The former ombudsman said there had been "a near-complete failure of the leadership of this trust, certainly before it was merged" with South Essex Partnership Trust to become EPUT. "This was an indictment of the health service," he added. Read full story Source: BBC News, 6 May 2025
  5. Content Article
    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.
  6. News Article
    A trust is being investigated for manslaughter in relation to the death of three patients, HSJ has learned. HSJ understands the three patients died by suicide while inpatients at Leicestershire Partnership Trust’s Bradgate Unit, in Glenfield Hospital, between September 2020 and July 2021. Leicestershire Police confirmed it was investigating “offences relating to corporate manslaughter and gross negligence manslaughter” in relation to the deaths. A police spokesperson told HSJ: “The investigation remains ongoing. No charges have been brought at this time.” The trust said: “Leicestershire Partnership Trust is fully cooperating with the police. We are unable to comment any further while the investigation is ongoing.” It comes as an employment tribunal brought by Mariam Benaris, previously a consultant at the unit, who is alleging wrongful dismissal, has heard concerns about safety on the unit during the peaks of the pandemic. Dr Benaris told the tribunal she and other staff raised concerns with trust leaders and a healthcare regulator about unsafe practices at the Beaumont Ward of the Bradgate Unit at that time. The ward was being used for all new admissions as part of infection control procedures. Read full story (paywalled) Source: HSJ, 2 May 2025
  7. News Article
    Chris Nichols was one of 2,000 mental health inpatients who died in Essex between 2000 and 2023. The Lampard Inquiry is tasked with finding out why In one of his final conversations with his mother, Chris Nichols was upbeat and hopeful despite a period of turbulence and poor mental health. He had phoned Linda Lindsay from Colchester Hospital, in Essex, where he had sought help after the latest in a series of suicide attempts. Despite complaining of voices in his head and acknowledging he had hurt himself, there was a note of optimism as he told her things were going to change. “He told me ‘it’s all right, Mum, you don’t need to worry. I’m going to get help’,” says Lindsay, 70, recounting the phone call in May 2022. “If only that happened.” Shortly afterwards, in the early hours of May 30, Nichols was discharged and took a cab home, his right wrist bandaged from the self-inflicted wounds. On June 3 he took his own life at his home in Clacton-on-Sea, aged 44. Nichols’s mother and stepfather Iain Lindsay, 72, believe his suicide was preventable. He had a long history of mental health issues and alcohol dependency, and had been at A&E on May 24 after overdosing on the anxiety drug Clonazepam. His relatives cannot understand why, given his risk factors, he was released so quickly, discharged to his GP and advised to self-refer to alcohol related services. They say he was not given a clear care plan or proper support. Read full story (paywalled) Source: The Times, 25 April 2025 Related reading on the hub: What is the Lampard Inquiry and what could it change?
  8. Content Article
    *Trigger warning: content related to suicide Rachel Gibbons is the Vice Chair of the Psychotherapy Faculty at the Royal College of Psychiatrists. In this opinion piece she draws on personal and professional experience to explore the complex relationship between patient safety and inpatient suicide. Rachel argues that fantasy-driven ideas of control and simplistic blame narratives do profound harm—both to clinicians and those bereaved. I'm a consultant psychiatrist whose professional trajectory was profoundly shaped by a harrowing experience early in my career. In 2009, during my first 18 months as a consultant, four of my patients died by suicide. The intense aftermath—serious incident inquiries, coroner's court appearances, and the emotional fallout—fundamentally changed who I was, both personally and professionally. Before this, I was someone different; afterward, thoughts about suicide dominated my consciousness. Since then, I've dedicated my professional life to deeply understanding suicide, it’s devastating impact on those bereaved, and the complex interactions involved in patient safety. Central to my work is the question of truth in patient safety—how to engage honestly and realistically with this complex subject. Too often, safety is driven by fantasies of control rather than by realistic expectations and honest acknowledgment of uncertainty. When our expectations are unrealistic, it harms clinicians and bereaved families alike. The profound trauma of inpatient suicide When suicide occurs within inpatient settings, its impact can be especially devastating. These tragedies unfold in two distinct scenarios: deaths occurring off the ward, and those taking place directly on the ward itself. Deaths on the ward can be especially traumatic—sometimes violent and occurring in the immediate presence of staff and other patients. I have personally been involved in such cases, witnessing first-hand the traumatic ripple effect across an entire organisation. The sudden, shocking nature of an inpatient death reverberates, intensifying every response, from the serious incident inquiry to appearances at the coroner’s court. Unfortunately, we don’t often give sufficient attention to the profound trauma staff and patients experience when exposed to inpatient suicide. If not effectively addressed, this trauma can linger unresolved for years, manifesting repeatedly in patterns of care—a phenomenon Freud described as "repetition compulsion". Unprocessed trauma can harm staff and affect the safety and wellbeing of future patients. The double-edged sword of patient safety investigations It’s essential that every inpatient death prompts a thorough patient safety investigation. However, the issue isn’t the investigation itself; it’s how easily the concept of patient safety can become distorted following a traumatic death. When a suicide occurs, intense emotions and destructive forces are unleashed within an organisation. This often results in attempts to create a simplistic causal narrative for the tragedy—a narrative that can never truly capture the complexity of suicide. In the aftermath of suicide, people’s ability to mentalise—to think clearly and compassionately—is severely compromised. The intense emotional turmoil often triggers a search for blame. As the deceased patient’s agency is often discounted, blame shifts rapidly towards clinicians. I've seen distressing examples where clinicians become scapegoats, absorbing an organisation’s collective anxiety and guilt. Organisations can behave almost like sentient beings, attempting self-preservation by shifting blame onto individual staff, often with devastating personal and professional consequences. Improving support for bereaved families The anxiety surrounding inpatient suicides can make it challenging for organisations to engage compassionately and openly with bereaved relatives. Defensive postures, though understandable given potential repercussions, ultimately harm those grieving. One proven way to mitigate confrontation and provide genuine support is appointing Family Liaison Officers. These dedicated individuals advocate for bereaved families, offering emotional support, clarity, and careful communication, thus alleviating confrontational dynamics. Supporting staff in caring for the bereaved Staff must not be left unsupported in their interactions with grieving families. Effective engagement with bereaved relatives requires thoughtful, organisational leadership and strategic planning. I've witnessed harmful situations where clinicians, driven by guilt, rush prematurely to communicate with bereaved families. Such impulsive actions, however well-intentioned, can cause unintended harm. Again, Family Liaison Officers are instrumental in mediating this delicate and emotionally charged communication, providing guidance and helping staff navigate difficult interactions more safely. Creating reflective spaces for staff Mental health work, particularly in inpatient environments, is intensely emotional and psychologically demanding. In the aftermath of a patient suicide, it becomes vital for organisations to provide reflective spaces—dedicated times and places where clinicians can safely process traumatic experiences. Without such spaces, unprocessed trauma can manifest as "acting out," leading to harmful patterns in care delivery and clinician burnout. Embedding regular reflective practice is essential, enabling staff to maintain their psychological wellbeing and enhancing patient safety through thoughtful, compassionate care. Final thoughts: seeking truth and compassion in patient safety Throughout my career, my core interest remains the truthful engagement with suicide and patient safety. We need honest, realistic frameworks that acknowledge limitations, complexity, and uncertainty. Fantasy-driven ideas of control and simplistic blame narratives do profound harm—both to clinicians and those bereaved. True safety comes from authentic, reflective practice, compassionate communication, and careful systemic support. Further reading on the hub: Rethinking suicide prevention: from prediction to understanding
  9. Content Article
    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 12 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: call for evidence This call for evidence will inform the development of a Men’s Health Strategy for England. It seeks the views of the public, as well as health and social care professionals, academics, employers and stakeholder organisations. It's particularly interested in the lived experience of all those directly affected by men’s health issues. 2 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”. 3 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. 4 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. 5 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. 6 Shifting the dial on mental health support for young black men In this blog, Kadra Abdinasir talks about how mental health services have failed to engage with young black men, and describes how services need to change to overcome the issue. She argues that delivering effective mental health support for young black men requires a move away from a crisis-driven response, to investment in system-driven, community-based projects. Kadra looks at learning from Shifting the Dial, a three-year programme recently piloted in Birmingham as a response to the growing and unmet needs of young black men aged 16 to 25. 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. 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].
  10. News Article
    Failing to properly diagnose and treat people with bipolar disorder, external is wasting billions of pounds a year in the UK, according to new data shared exclusively with the BBC. Experts say many of the estimated million people living with this condition are "ghosts in the system", whose lives are being torn apart by poorly managed extreme suicidal lows or manic, erratic highs. Emma was diagnosed with bipolar disorder in her early 30s, after experiencing a mental health crisis. When she was 32 weeks pregnant, her grandmother died unexpectedly, sending her into a "deep low". "I felt awful, but the perinatal team wouldn't take me on," she says. "They said my symptoms weren't that serious." When Emma gave birth, the extreme lows of her pregnancy were replaced by an unexpected high. She felt amazing in the days after her baby was born - but she didn't sleep and her behaviour became increasingly erratic. A few weeks later, her mood flipped again. When her baby was three weeks old, Emma took an overdose. It took a week in hospital for her liver function to return. But even after that, she was in and out of hospital for a year before finally being diagnosed with bipolar disorder, and medicated correctly. "If I had the correct care, and been listened to during my pregnancy or even earlier, I could have avoided taking that overdose - 100%," she says. Experts have told the BBC how most people living with bipolar disorder in the UK are "undertreated, undiagnosed and left to try and survive in a system that has failed them". The majority who, like Emma, are eventually diagnosed with bipolar disorder, are incorrectly prescribed antidepressants initially, which makes their symptoms worse rather than better. Experts also say there is a lack of continuity of care from GPs through to psychiatrists. According to the Royal College of Psychiatrists (RCPsych), bipolar disorder is a manageable condition. Dr Trudi Seneviratne, registrar at the RCPsych and a commissioner on the Bipolar Commission, says it is "completely treatable" with a combination of medication, talking therapies and lifestyle factors. "But there are many, many people who are suffering in silence with lower levels of symptoms because there isn't a good clinical care pathway for them in the UK." Read full story Source; BBC News, 1 April 2025
  11. Content Article
    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.
  12. News Article
    Jagdip Sidhu was the platonic ideal of an NHS doctor. He took very little private work, despite it being common for consultants. His only exception was for those who needed urgent care that couldn’t get treated on the NHS. It was a point of ethics. “He said: I’m only going to do it for people who clinically cannot wait,” explains Amandip, Jagdip's brother. “I’m not going to sit and profit off people’s adverse health and misery.” But the hospital was impossible to get away from. On days and nights off, he would get urgent messages from the managers at his NHS trust asking him to clear more beds on the ward or hit new performance targets. Gradually, he had less time for anything outside of work. He’d developed “tunnel vision”, as Amandip describes it. By 2017, something had broken in him. “He had just suddenly aged,” recalls his brother, pausing for a moment before continuing. “It’s very hard to explain. But for someone who had a lot of vitality in life and charisma about him, it started to drain away.” His hair began to turn grey. He was constantly tired, surviving on just three or four hours of sleep each night and often working more than 14 hours a day. “He’d come and see mum and literally just pass out on the sofa,” recalls Amandip. He spoke less and less. Jagdip was also losing faith in the medical system whose values he once embodied, and confided to his brother that he thought the struggling NHS was “finished”. One day, Amandip got a call from his brother. “I saw his number flash up, and I knew something was wrong,” he recalls. Jagdip explained that he had been signed off work on medical leave after nurses he worked with noticed he was struggling to function. He was petrified. “He said: ‘I can’t ever go back to that hospital. They’ll crucify me. They’ll say ‘you made mistakes’, and I’ll be struck off’,” recalls Amandip. “Because he was signed off sick, he felt that he couldn’t be a doctor anymore. That was his identity as an adult human being forcibly stopped, outside of his control.” One afternoon, Amandip received an email from Jagdip. It was a confusing list of instructions, including how to access his financial accounts, life insurance policies, when to get the car MOT’d. There was no explanation. It ended with a short sign-off — he had gone to Beachy Head, a beauty spot atop the cliffs of the South Coast, with the car. As call after call went straight to voicemail, the panic started to set in. Jagdip called Jagdip’s wife — there was no sign of him at home. He had left without taking his wallet and house keys. Amandip raced across London to his brother’s house. When he arrived, it was already crawling with police. They had found the car by Beachy Head, but there was no sign of Jagdip. An agonising two hours later, he heard the crackle of the officers’ radio as they walked into the room and started to speak. “I remember them saying ‘This is the part of the job I really hate’,” Amandip recalls. They had found his brother’s body, identified by the car keys that were still in his pocket. Jagdip was 47 years old. There were a lot of questions in the blur of weeks and months afterwards. But above all, one thought haunts Amandip: did his brother’s job in the NHS play a role in his death? Read full story Source: The Londoner, 15 March 2025
  13. News Article
    The rate of patients dying by suicide shortly after discharge from mental health units has increased in recent years, with researchers calling for better post-discharge support. According to the National Confidential Inquiry into Suicide and Safety in Mental Health annual report – an audit published by the Health Quality Improvement Partnership – the number and rate of deaths after discharge from a ward have been gradually increasing since 2017, after falling from 2013-17. The rate in 2022, the most recent figures reported, was 14.1 per 10,000 discharges. Isabelle Hunt, senior research fellow at the Manchester University and report co-author, told HSJ the most recent figures should be “treated with caution”, but added that the rise in post-discharge suicides could be attributed to the case mix of patients. A “reduction in inpatient beds” could mean “a higher-risk group of patients are being managed by services” and being discharged when more unwell. Dr Hunt said the increases could also be associated with changes in the circumstances patients are being discharged to. “Around a quarter of patients who died by suicide within three months of discharge were known to have been discharged to housing, financial or employment problems and a fifth were discharged to poor social support,” Dr Hunt said. “Awareness of the stressors patients may face after leaving hospital is a key element when judging the appropriateness of discharge, and greater involvement of families and carers is likely to provide a clearer picture of the circumstances a patient is returning to.” Read full story (paywalled) Source: HSJ, 12 March 2025
  14. News Article
    A TikTok star who died after consuming a poisonous substance she bought online told an NHS support worker about the purchase a month before her death, an inquest has heard. Imogen Nunn took a poisonous substance and died in Brighton, East Sussex, on New Year’s Day 2023. The 25-year-old, who was deaf, raised awareness of hearing and mental health issues on her social media accounts, which gained more than 780,000 followers. On Monday, an inquest into her death in Horsham heard that Nunn was “failed” by services that were meant to help her, according to a statement by her mother, Louise Sutherland. The inquest was told that Nunn, who was called “Immy” by loved ones, had contacted her support worker at the deaf adult community team (DACT) at South West London and St George’s NHS trust on 23 November 2022, and told them she had “bought something online that she planned to take to end her life”. She also made reference to a “pro-choice suicide forum”, the court heard. In the statement read to the inquest, Thomas Beamont, representing Sutherland and Nunn’s father, Ray, said: “Ray and I believe that Immy felt hopeless and let down by the time of her death, and that she was failed. “Immy didn’t want to die, but she was exhausted from fighting desperately for the help she needed.” Read full story Source: The Guardian, 17 March 2025
  15. Content Article
    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.
  16. Content Article
    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. Frontline workers, particularly in healthcare, are often overlooked when it comes to mental health support. These individuals are regularly exposed to traumatic incidents and are frequently required to function under highly stressful conditions. Despite this, there has historically been little provision for their mental health. Frontline19 is working to address this gap, both by providing direct support and by tackling the stigma that prevents many healthcare workers from seeking help. When I set up Frontline 19, I initially thought I’d be able to help around 50 people, but on the first day, 750 people came forward and we had to adapt - fast. Now in 2025, we have supported over a million individuals through one-to-one counselling, psychological support, and group interventions. A broad spectrum of challenges We receive requests for support from individuals facing a broad spectrum of challenges. These include post-traumatic stress disorder (PTSD) - often triggered or exacerbated by their work during the pandemic - as well as suicidal ideation, which remains alarmingly prevalent among healthcare workers. Other common issues include anxiety, stress, and depression. Recently, there’s been a noticeable shift in the nature of calls. While the acute trauma of the pandemic has subsided, the ongoing effects of working during this time as well as the current pressures of working within a severely depleted healthcare system with over 100,000 vacancies are taking their toll. Staff frequently report feeling demoralised, burnt out, and physically and emotionally exhausted. The unrelenting demands of their roles have led to a chronic state of distress for many, highlighting the need for sustained support even beyond crisis periods. 1 in 4 have suicidal thoughts One of my primary concerns is the alarming rate of suicide among healthcare workers; we know that 1 in 4 have experienced these thoughts. The combination of unmanageable workloads, exposure to trauma, and inadequate support creates a perfect storm for acute mental ill health. Additionally, the year-round pressures - such as seasonal surges in patient numbers and the cumulative effects of staff shortages - are creating long-term damage to individuals and the wider system. Systemic pressures and the normalisation of burnout The mental health challenges staff face are deeply intertwined with systemic issues. These include chronic understaffing, lack of resources, and the erosion of social care services, which leave healthcare workers trying to fill impossible gaps. Many also face moral injury - the psychological distress that occurs when they are unable to provide the level of care they know their patients need. The constant exposure to such situations takes a significant toll, leading to feelings of guilt, shame, and helplessness. I’m deeply concerned about the normalisation of burnout. Many staff no longer see chronic stress as an anomaly but rather as an inescapable reality of their jobs. This level of despair and resignation is worrying, as it suggests systemic failures that need urgent attention. Unsafe conditions for staff and patients Many healthcare workers face unsafe conditions daily, where systemic resource shortages create high-risk environments for both patients and staff. When adverse outcomes occur, the consequences can be devastating for patients and deeply distressing for the staff involved. In these situations, professionals often find themselves under intense scrutiny, facing potential repercussions despite having done everything possible within the constraints they are working under. These circumstances place their professional safety in jeopardy, and the level of support they receive afterward varies greatly, leaving many to navigate the aftermath alone. Addressing the root causes We believe in addressing the root causes, not just the symptoms. This means embedding meaningful, mandatory, and regular mental health training for all healthcare staff, from students to senior professionals. Although staff frequently face very difficult situations, the additional pressures of working in a system on its knees means that sadly mental ill health has almost become an occupational hazard - and one that requires the proper understanding and support to address it. The current reliance on “resilience training” is counterproductive. It places the burden on individuals to adapt to broken systems rather than the NHS addressing the systemic issues itself. Instead, we need structural changes, such as improved working conditions, better staffing levels, and access to basic amenities like free parking, 24/7 meal options, rest areas, and designated on-call rooms. Supporting staff wellbeing would have a direct positive impact on patients. When healthcare workers feel valued, supported, and equipped to do their jobs, they are better able to provide high-quality care. This, in turn, enhances patient safety and outcomes. The alarming rate of suicide among healthcare workers should be a wake-up call in the urgent need to support them. Contact Frontline 19 Individuals can visit our website frontline19.com to complete a secure form or email us at [email protected]. From there, they will be triaged and connected with appropriate support. Our services are entirely free for individuals and completely confidential. We are not an immediate crisis response service. If you are experiencing a mental health crisis and you feel at immediate risk of harm, please call 999. Samaritans can be contacted on 116 123 or email [email protected] Share your experience Do you work in healthcare? What did you think about the issues raised in Claire's blog? How could staff wellbeing being better supported? What impact would improvements have on patient safety? Please comment below (sign up first for free) or contact us at [email protected]. Related reading Balancing care: The psychological impact of ensuring patient safety Top picks for staff psychological safety Understanding moral injury: a short film (HEE and NHSE&I) Hidden wounds Why I ‘walk on by’
  17. News Article
    The parents of Thomas Kingston have warned about the side effects of antidepressants after he took his own life. Mr Kingston died from a head injury in February last year at his parents' home in the Cotswolds. A gun was found near his body. The 45-year-old had stopped taking his medication, which had been prescribed by a GP at the Royal Mews Surgery in the days leading up to his death. His parents, Martin and Jill Kingston, are now calling for a change in how patients are prescribed selective serotonin reuptake inhibitors (SSRI) - a widely used type of antidepressant. Martin Kingston told BBC Radio 4's Today programme he believes both the patient and the people close to them should be told more explicitly about the potential side effects of the medication, including what can happen if they stop taking it. The couple want patients to sign a document confirming they've been told about the difficulties of going on and coming off the medication. This could include the patient being told that "it's an extreme case, but it could lead to suicide", Mrs Kingston says. "We'd really like to see that a person, a spouse, a partner, a parent, a close friend, somebody, was going to walk with them through it. Maybe they should be at that signing time." Recording a narrative conclusion at an inquest into his death in December, Katy Skerrett, senior coroner for Gloucestershire, said Thomas Kingston had taken his own life. "The evidence of his wife, family and business partner all supports his lack of suicidal intent," she said at the inquest. "He was suffering adverse effects of medication he had recently been prescribed." In a prevention of future deaths report, made in January, Ms Skerrett said action must be taken over the risk to patients prescribed SSRIs. She questioned whether there was adequate communication of the risks associated with such medication. Read full story Source: BBC News, 4 January 2025 Related reading on the hub: The question that will save lives: Interview with Katinka Blackford Newman, founder of Antidepressant Risks Long-lasting sexual dysfunction after taking antidepressants: Lack of recognition harmful to patients Post-SSRI Sexual Dysfunction: After 30 years, why is the health system still failing to recognise this life-limiting adverse effect?
  18. Content Article
    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.
  19. Content Article
    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.
  20. News Article
    A new report from the Health Services Safety Investigations Body (HSSIB) has shed light on significant systemic issues within mental health services, highlighting a persistent culture of fear and blame, and a lack of patient and family involvement, which obstruct effective learning from inpatient deaths. The HSSIB report scrutinises how mental health providers learn from deaths occurring in inpatient units and within 30 days post-discharge. The investigation reveals multiple processes involved in learning from deaths, including the Learning from Deaths Framework, coroner's inquests, and investigations following patient safety events. The report indicates that there are substantial challenges in maintaining safety, conducting effective investigations, and ensuring system-wide learning. It identifies that investigations and patient safety event analyses, although intended to promote transparency and learning, often suffer from variable quality. Local investigations frequently lack comprehensive information and fail to observe clinical work practices in real-time, hindering a complete understanding of care delivery. A critical revelation of the investigation is the prevalent culture of blame within mental health services. Patients, families, and organisations often fear safety investigation processes, which are perceived as punitive rather than educational. The report underscores that patient safety investigations rarely account for the emotional distress experienced by those involved, leading to compounded harm. Read full story Source: National Health Executive, 30 January 2025
  21. Content Article
    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)
  22. News Article
    Disjointed, delayed, and substandard care for people with both mental illness and additional needs are highlighted throughout reports sent to integrated care boards on the deaths of 24 people, HSJ has found. A lack of inpatient beds, poor communication, staff shortages, and care fragmentation were common concerns raised with 18 ICBs in relation to 24 deaths linked to mental health care since the boards’ creation in July 2022, HSJ analysis reveals. Of a total of 53 “prevention of future death reports” addressed to ICBs, 24 focused primarily on mental health – the most common theme of the reports. Many of those who died were young, and many had additional needs, such as autism, ADHD or learning disabilities. They often endured long delays because of poorly-connected physical and mental health services. Some were refused multiple referrals because of the complexity of their needs. Twenty-two of the 24 deaths were from suicide or self-harm. Read full story (paywalled) Source: HSJ, 28 January 2025
  23. Content Article
    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.
  24. News Article
    As The Times reports on how the failure to act on coroners’ recommendations costs lives, Lottie Hayton says many are not issuing Prevention of Future Deaths reports in the first place. Lottie's mum, Carrie, was sectioned on September 16, 2022. When Carrie took her own life two months later, the inquest into her death criticised the care she received and her “rapid discharge”. But, owing to significant flaws in the inquest system in England and Wales, lessons from her care and death will not be learnt. Four days after Carrie’s admission, on September 20, when the duty doctor came back from bank holiday leave, he “introduced” himself. The brief introductory meeting amounted, according to the medical notes, to an assessment of mum’s mental state. Thirteen minutes after he recorded the introduction, mum was discharged. The discharge notes read: “Mrs Hayton utilised her leave well and did not present with any suicidal thoughts. It was felt the inpatient environment would be detrimental to her grieving process and her risks could be managed with home treatment and community team support.” That the risks were not able to be managed with home treatment is obvious by the fatal outcome. The review recommends a clear solution: “Acute Inpatient Operational Policy must take place to ensure clear provision for what should happen when a rapid discharge occurs.” In Carrie’s case, there was no evidence of a policy or process being followed. At the conclusion of an inquest a coroner can issue a Regulation 28 Prevention of Future Deaths report, or PFD, to an organisation or individual, outlining actions which could be taken by them to prevent future similar deaths. An average of 500 PFD reports are issued every year but it is ultimately up to an individual coroner to decide whether they issue one. The facts of Carrie’s case and the serious incident investigator’s submission, would, you might assume, lead to the coroner thinking that a PFD should and could be issued with simple recommendations. But the coroner overseeing the inquest in Dorset, chose not to issue a PFD. Read full story (paywalled) Source: The Times, 15 January 2025
  25. Content Article
    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.
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