Government announces investigation into care of mental health inpatients in England

The investigation has been prompted by a number of inpatient deaths at mental health facilities

11th July 2023 about a 3 minute read
“It is crucial that those impacted by poor care and those working on the front lines of the inpatient settings can share their experiences, reassured that HSSIB will use this information to improve care and not apportion blame or liability.” Rosie Benneyworth, chief investigator, Health Services Safety Investigations Body

A national investigation into mental health inpatient services in England will start in October, the government has announced.

The investigation, to be carried out by a new body called the Health Services Safety Investigations Body (HSSIB), will look at how trusts can learn from deaths in their care, how to improve the care of young people, how out-of-area placements are handled and how many staff are needed in inpatient services. Speaking in the House of Commons, Steve Barclay, the health and social care secretary, said the investigation body would “have teeth and work at speed.”

Rosie Benneyworth, the HSSIB chief investigator, said that any evidence would be kept anonymous: “It is crucial that those impacted by poor care and those working on the front lines of the inpatient settings can share their experiences, reassured that HSSIB will use this information to improve care and not apportion blame or liability.”

Mark Winstanley, chief executive of the charity Rethink Mental Illness, said there had been “appalling failures” in the standard of care delivered to patients.

He added that the investigation should have powers to issue alerts to improve patient safety but that the government should also address the staffing crisis in mental health services: “We believe that only if the government prioritises and urgently acts on these factors, can we prevent more avoidable tragedies and pave the way towards improved, safer care in mental-health inpatient units.”

The chief executive of Mind, Sarah Hughes, described the announcement as “a crucial step in tackling the serious concerns we have about the state of mental health inpatient care in England. It is testament to the families who have fought for change because of the suffering their loved ones have endured in mental-health hospitals.”

Improving the use of data and evidence

The announcement comes a time of concern over the deaths of patients in psychiatric settings. The government has just published the findings of an independent rapid review into mental health inpatient settings, which was set up to explore how government can improve the way data and evidence are used to identify risks to patient safety in mental health inpatient settings.

Evidence for the rapid review was taken from more than 300 experts in mental health inpatient pathways, including carers, nurses, psychiatrists, data experts, clinical directors and people with recent personal experience of using, or caring for someone who uses, mental health care services. Maria Caulfield, the minister for mental health said that the publication of the rapid review “recognises the importance of transparency and accountability as we continue to improve mental health services across the country.”

The review makes 13 recommendations in all. One is that NHS England should establish a programme of work with other health bodies to “agree how to make sure that providers, commissioners and national bodies are ‘measuring what matters’ for mental health inpatient services, and can access the information they need to provide safe, therapeutic care.”

Another recommendation is that every provider and commissioner of NHS-funded care “should have access to digital platforms that allow the collection of core patient information and associated data infrastructure to allow timely reporting of information to different decision makers.”

Caulfield said the recommendations “have identified ways in which the system can improve how data and evidence is used more effectively, which has the potential to bring us closer to understanding the risks to delivering safe and high-quality care and being able to intervene before things go tragically wrong.”

The government has said it will issue a response to the recommendations from the rapid review “in due course”.

FCC Insight

An investigation into the care provided at inpatient mental health units is well overdue. An enquiry is already looking into the deaths of nearly 2,000 mental health patients in Essex between 2000 and 2020, and it’s clear that what happened in Essex is not an isolated problem. The continued use of out-of-area placements for people in mental health crisis is a particular concern that needs to be addressed. We hope that the establishment of the Health Services Safety Investigations Body (HSSIB) signals a desire by government to take the problem seriously, and that the new body will have the power to make the changes necessary to ensure that patients are cared for safely.