On 30 January 2025, the Health Services Safety Investigations Body (HSSIB) published its fourth investigation report, revealing significant shortcomings in how England's mental health services learn from inpatient deaths and those occurring within 30 days post-discharge.
Key findings include:
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Inadequate learning from deaths: Many mental health trusts lack systematic processes to learn from inpatient deaths or those occurring shortly after discharge.
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Limited patient and family involvement: Families often feel excluded from care decisions, with their concerns overlooked.
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Unsafe care environments: Staff shortages and poor physical conditions hinder the delivery of therapeutic care.
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Disjointed care systems: Insufficient collaboration between NHS trusts, social care, and local authorities leads to fragmented care and missed opportunities for systemic learning.
To address these issues, HSSIB recommends:
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Adopting person-centred care approaches.
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Enhancing family involvement in care planning.
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Improving safety training for healthcare leaders.
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Involving individuals with lived experience in leadership coaching.
This report serves as a critical call to action for policymakers and healthcare leaders to implement meaningful reforms that prioritise patient safety and effective learning from past incidents.
Source: HSSIB
