HSSIB publishes second mental health PSIRF exemplar investigation

The report uses the patient safety incident investigation (PSII) report template and PSIRF tools to examine the deterioration of a person’s physical health while receiving inpatient mental health care. It is the second of three HSSIB exemplar PSIRF reports focused on mental health care and has been developed in response to stakeholder feedback requesting practical examples of how PSIRF approaches can be applied in local investigations.

The investigation examined the care of a patient whose physical health deteriorated while being cared for on a low secure mental health unit and who later required admission to an acute hospital. It explored how physical deterioration was recognised and managed, how care was coordinated between mental health and acute services, and how specialist services supported the patient's care.

Sian Blanchard — Siân Blanchard, Senior Safety Investigator

Investigator's view

Siân Blanchard, Senior Safety Investigator at HSSIB, said: “This report has been developed to show how the NHS can use PSIRF tools and approaches to understand patient safety incidents and identify opportunities for learning and improvement.

“The investigation highlights the challenges that can arise when people with complex mental and physical health needs receive care from multiple services. It shows the importance of effective communication, coordination and shared understanding across organisations.

“While the areas for improvement relate to the organisation involved in this incident, the learning has wider relevance for mental health services across England.”

The investigation highlighted the difficulties of managing physical and mental health needs together, including balancing treatment options while addressing risks associated with both conditions.

The report identified communication and coordination challenges between mental health services, acute hospital services and specialist sleep clinics. Different teams had different understandings of the severity of the patient's deteriorating condition, and there was uncertainty about roles, responsibilities and accountability during the patient's care in the emergency department. The investigation also found limited opportunities for cross-organisational learning and support for staff after the incident.

The investigation highlighted wider system challenges, including pressure on specialist services and difficulties in helping patients in secure mental health settings engage with external healthcare services. The findings show the importance of joined-up working across organisations when caring for people with complex mental and physical health needs.

Areas for improvement

The report identifies five areas for improvement which the mental health trust could develop safety actions to address:

The opportunities available for people to make healthy lifestyle choices, including weight management, smoking cessation and exercise, while detained on the low secure unit.
Access to a suitable area within the low secure unit to carry out physical health observations and assessments.
Clarify clinician roles, responsibilities, and processes, including those for prescribing, between mental health and physical health staff when caring for patients with acute agitation, to help effective assessment in the emergency department.
Trauma-informed organisational support for staff, and shared safety learning for patient safety events where care spans more than one healthcare provider.
The ability to identify and apply a personalised approach to encourage people detained in inpatient mental health settings to engage with specialist services.

Although the areas for improvement relate to the organisation involved in this incident, the learning is relevant to mental health services across England and demonstrates how PSIRF can support system-wide learning and improvement.

This report is part of HSSIB's work to support the NHS to deliver high-quality patient safety investigations and share learning across the healthcare system. Through our exemplar investigations and independent analysis, HSSIB continues to act as a centre of excellence for patient safety investigation, learning and improvement.

Read the report