Concern that NHS ‘not learning’ from mental health death reports

Safety investigations which occur after a person died during or shortly after care during a stay in a mental health facility are often seen as a “tick box exercise” and could be “compounding harm” for those affected, according to a new report.

The Health Services Safety Investigations Body (HSSIB) said there was evidence that the healthcare system “is not learning” from patient deaths.

A new report from the patient safety watchdog highlights how bereaved families have described having to “fight” to be involved in the investigation into the death of their loved one.

Families said they wanted safety investigations into the death of their loved one to “mean something”, but many described their involvement in the process as “tokenistic”.

Meanwhile, a family member described the investigation process as “worse than the actual death because they were reliving the death [of their family member] over and over again”.

The report also describes how some families believe a lack of person-centred care can leave patients “feeling hopeless, causing them unnecessary distress”.

“The investigation was told that there were key areas within mental healthcare where organisations did not feel they were learning from deaths,” the authors wrote.

This was particularly so in regards to person-centred care and people being treated in the right place.

The document features testimony from a mother who said her daughter had been “moved around the country like a parcel… it’s never about her, it’s never about her needs”.

And a bereaved family member said their loved one was in hospital for three years with “no progression, no hope, no exit plan, no therapy … there was no planned discharge or exit plan”.

The report suggests there is a culture of “blame”, whereby there is a perception among mental health staff that “someone needs to be held accountable” after patients die.

HSSIB warned that there is “limited” follow-up on recommendations from inquests and other patient safety investigations.

It said investigations into deaths are often variable in quality, and that different mental health providers report deaths and near misses in varied ways, meaning it is “hard” for risks to be identified.

HSSIB has called for a “systematic approach” to the way investigations are conducted.

Nichola Crust, HSSIB senior safety investigator, said: “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.”

Commenting on the report, Minesh Patel, from the charity Mind, said: “As families struggle to make sense of their loss, their grief is being compounded by a system that fails to listen and fully learn crucial lessons.

“At the same time, many overstretched staff working within the underfunded system feel terrified by a culture that can be more focused on blame than making genuine systemic change.

“We owe it to every person who has tragically lost their life in the mental health system to learn from their death and do better.”

Jeremy Bernhaut, from Rethink Mental Illness, added: “This  report is another sobering reminder of systemic failures in mental health services, with ineffective investigations and a failure to learn lessons following the tragic loss of life meaning many people remain at risk of serious harm.

“The government and NHS must act decisively to deliver the improvements so desperately needed.”

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.”

A Department of Health and Social Care spokesperson said: “We know that mental health patients have not been getting the care and treatment they deserve.

“We have already taken action to introduce significant reform to the Mental Health Act, to ensure that people with the most severe mental health conditions receive better, more personalised treatment, end the inappropriate detention of autistic people and those with a learning disability.”

“As part of our 10 Year Health Plan to reform the NHS, we will recruit 8,500 more mental health workers to reduce delays and provide faster treatment.