Learning from patient safety incidents

A recent investigation and report by the Health Services Safety Investigations Body has explored how to learn from deaths in mental health inpatient units or when patients die within 30 days of discharge. It found gaps in discharge planning, crisis service accessibility, and access to community therapy that may have contributed to poor outcomes for patients, including deaths.

The investigation looked at how mental health inpatient service providers conducted investigations following the deaths of patients and looked at national, regional and local oversight frameworks to examine how providers learn from these deaths. They found significant challenges in maintaining safety, conducting effective investigations, managing data on deaths, and ensuring system-wide learning.

The authors of the investigation report also pointed to a culture of blame where individuals and organisations were 'afraid about safety investigation processes'. It emphasised a need for a systemic approach to safety investigations and learning focusing on collaboration, transparency and oversight, and encouraging a culture of empathy, person-centred care and the active involvement of families.

This investigation forms part of a series by the HSSIB – its other work has included investigations of deaths of mental health inpatients and near misses, creating conditions for the delivery of safe, therapeutic care in inpatient settings, and harm caused by mental health out-of-area placements. 

These investigations came about after an announcement by the Secretary of State for Health and Social Care in June 2023 and this current report comes at a time when the government is responding to the findings of the Independent investigation of the NHS in England by Lord Darzi who said the NHS was in 'serious trouble' and highlighted increased waiting lists for mental health services.

BPS President Dr Roman Raczka said the HSSIB report highlighted the urgent need for joined-up care for those using mental health inpatient services as well as those who had been recently discharged. 'Over 6m referrals are made to NHS Talking Therapies and other mental health services every year in England alone. Service users deserve high quality care in safe and compassionate environments whilst accessing inpatient services, and in the community upon discharge.

'There must be an opportunity to effectively learn from patient safety incidents, however, a long-term lack of investment in services is preventing this from happening. The government must properly fund mental health services and grow the workforce, while embedding a greater focus on prevention. Only then will mental health patients, and their families, get the expert support they need.'

Read the full report.