The HSSIB report says there is a need for a systemic approach to safety investigations and learning for improvement 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.

Nichola Crust, senior safety investigator at the HSSIB, said: ‘Our report provides insight into the complexity and ambiguity that surrounds learning from inpatient deaths. It highlighted the limitations of what healthcare systems are currently able to achieve. It was clear from our investigation that they're aiming to implement meaningful learning and actions to prevent future deaths in a landscape that is fraught with grief and blame, and also are dealing with significant systemic issues, gaps and poor cultures that serve to undermine patient safety in mental health care. In short: the system is still not learning effectively from deaths.'

The investigation found ‘a culture of blame' where individuals, including patients and families, and organisations fear safety investigation processes.

Many families said they felt marginalised and excluded from the investigation process, experiencing them as a ‘tick box' exercise and without a culture of transparency, learning and accountability.

Crust added: ‘This report has been published at a crucial time for reform in the NHS and we would expect the findings of this report to contribute to the Government's long-term plans in relation to mental health settings. Whilst the report does paint a sobering picture, it also does pinpoint the opportunities for improvement, through our findings and safety recommendations. We emphasise areas that should be prioritised to remove the barriers and limitations to learning – only then will the system see an improvement in patient safety, a reduction in compounded harm and ultimately a reduction in deaths in inpatient care.'

An NHS England spokesperson said: ‘Every patient, family and member of staff should experience a culture of care in our mental health hospitals. This report highlights the national standards NHS England has developed to improve care for mental health patients, and our national improvement programme is working to provide specific support for every provider of NHS-commissioned inpatient services.'