The report said critical recommendations to improve mental health inpatient services are too often not implemented, which leads to missed opportunities to learn, improve and prevent harm to patients and NHS staff.
Craig Hadley, senior safety investigator at HSSIB, said: ‘Too often, we see well-intentioned recommendations fall through the cracks—not because people don't care, but because systems don't always support change in a meaningful or sustained way.'
HSSIB also found a fear of blame in mental health settings when safety events happen contributing to a more defensive culture despite staff actively wanting to learn.
The report identified fragmentation between health and social care services hindered delivery of services. HSSIB has made a direct recommendation to the secretary of state for health and social care to clearly define patient safety responsibilities and accountabilities in the context of integrated care.
The report also explores suicide risk assessment, noting language often used in these settings can minimise patient experiences and create fear.
Other findings include: gaps in the provision of physical health care for people with severe mental illness; ICBs being unable to 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; staffing and resource constraints; and a lack of interoperability or integration between digital systems.
Hadley added: ‘Our findings call for a more joined-up, approach to improvement to ensure that mental health services are safe, effective and patient-centred.'
Reaction
Rebecca Gray, mental health director at the NHS Confederation, said: ‘The mental health sector – like the rest of the NHS – has long been starved of capital investment. That is why we are calling for the Government to use the upcoming Spending Review to increase capital investment and open up much needed new routes for mutual investment from the private sector.
‘One of the main aims of the Mental Health Bill – currently passing through Parliament – is to provide more therapeutic care, with the "Culture of Care" and inpatient quality improvement programmes already beginning to address these issues. We look forward to working with the Government and our members to implement the reforms more widely.'
A Department of Health and Social Care spokesperson said: ‘Patient safety is paramount, and we know that mental health patients have not been getting the high-quality care and treatment they deserve.
‘That's why this Government is investing an extra £680m in mental healthcare this year, hiring more support workers, delivering more talking therapies and opening new mental health crisis centres around the country.
‘We are also modernising the Mental Health Act to ensure patients receive better, more compassionate treatment, appropriate to their needs.'
