Mental health services 'still not learning' from mental health inpatient deaths

Mental health services are not learning from inpatient deaths in England, a new report has found, citing a culture of fear and blame within the services.

The report from the Health Services Safety Investigations Body (HSSIB) revealed critical gaps in the safety and investigations process for patients who died both in the care of services and within 30 days of being discharged.

It found a "culture of blame" where individuals - including patients, families and organisations - fear the safety investigation process.

In turn, investigations were found to often not consider the emotional distress of all affected, which compounded harm, while legal processes may also "unintentionally shut down opportunities for learning", which fostered a culture of defensiveness.

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The report also revealed systemic issues in mental health facilities, including inconsistent discharge planning, limited access to crisis services and inadequate community therapy provision. These gaps contributed to poor patient outcomes.

Many families said they felt marginalised from the process that looked into why their loved ones had died, feeling like it was a "tick-box" exercise for the organisation.

Some family members described organisations as having "gaslighting, bullying" and "toxic environments", as they were forced to re-live the death of their family member over and over again.

"They [trust legal teams] don't come to the inquest wanting to learn, they come to the inquest wanting to defend," one coroner told the HSSIB.

The report comes after the government announced an investigation into mental health inpatient services across the country. It followed a series of investigations by Sky News highlighting failings within the system.

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In October 2022, an investigation into units run by The Huntercombe Group revealed repeated allegations of over-restraint and inadequate staffing, which left people at increased risk of self-harm.

And in May 2023, Sky News exposed safety risks within Wotton Lawn Mental Health Unit, an NHS service in Gloucester, where patients had got on the roof or absconded, and staff were photographed asleep on the job.

'Dead on a railway track'

The investigation heard from families who were prevented, or restricted, from visiting their loved ones.

One described visits as being in a "goldfish bowl" with no privacy. Another said they were only allowed to visit twice a week.

"She had been in hospital for three years with no progression, no hope, no exit plan, no therapy," one bereaved family member told researchers.

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"Her physical health needs were not met, she lost any independence and there was no planned discharge or exit plan."

One family member described how her daughter was "moved around the country like a parcel" because she did not fit within certain risk categories.

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The challenges of people presenting to emergency departments with mental health issues, and the subsequent long waits, were also described by staff as "significant".

"The combined elements for example of psychosis, struggling to communicate, lack of sleep, and being in ED [emergency department] for days can only make their mental health crisis worse," one staff member said.

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"We are left with the guilt of them absconding from ED and later finding out they have died on a railway track."

The report looked at inadequate provision of therapy, with one parent saying: "I've had experience with my daughter ringing crisis services saying that she's suicidal being sent away saying she's too distressed for them to speak to and that she should go away and calm down."

'The system is not learning from deaths'

It concluded by calling for a systemic approach to safety investigations that focused on collaboration, transparency and empathy.

Nichola Crust, HSSIB senior safety investigator, said: "In short: the system is still not learning effectively from deaths.

"The report contains many powerful excerpts from patients, families, carers and staff - it was hard to hear the pain, anger, guilt and distress they felt as they recounted their experiences. Emphasis on fairness, transparency and support for both families and staff is needed, and also their stories show the importance of learning and accountability, rather than blame."

She said the report painted a "sobering picture" but did examine where improvements could be made.

"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."