The report, published today, brings together common themes from our mental health inpatient investigations published between September 2024 and January 2025. It also includes new findings that fall outside the scope of individual investigations but reflect broader systemic issues.
Key risks
The report identifies key risks across multiple areas that continue to affect the safety of mental health inpatient care. These areas include safety, investigation and learning culture, system integration and accountability, the physical health of patients in mental health inpatient settings, caring for people in the community, staffing and resourcing, digital support for safe and therapeutic care, suicide risk and safety assessment.
A central concern running across all themes is that recommendations to support learning for improvement often does not lead to action. We highlight several reasons for this, including a lack of impact assessments, no clearly identified body responsible for taking forward recommendations, and duplication of similar recommendations across different organisations.
We provide examples from recent investigations where recommendations have not been implemented. For example, the report on mental health transitions from inpatient children and young people’s services to adult mental health services, highlighted several recommendations made to NHS England but where they could not provide evidence of action being taken in response. Within this report, there was also reference to longstanding recommendations to improve the physical health of people with severe mental illness being delayed, and premature deaths continuing to occur as a result.
Fear of blame
In relation to safety learning and culture, we also found that there remains a fear of blame in mental health settings when safety events happen. This contributes to a more defensive culture despite staff actively wanting to learn. In the report there are excerpts from our mental health investigations including ‘the investigation was also told during visits about hostility between teams and services when a patient death occurs’, and ‘unhelpful narratives were described by senior leaders in organisations who themselves described “being the naughty child on the naughty step” and everyone turns in on you.’
Poor integration of health and social care
Another prominent issue highlighted in the report is the fragmentation between health and social care services. The report found that delivery of mental health care is hindered by poor integration and misaligned objectives between systems. Currently the integration of health and social care relies on relationships, with an expectation and hope that they will work well. However, in their absence, a lack of clear accountability can result in poor outcomes for people with mental illness and severe mental illness.
In response, we’ve made a direct recommendation to the Secretary of State for Health and Social Care to oversee the development of a strategy that clearly defines patient safety responsibilities and accountabilities in the context of integrated care – not only in mental health, but also in other areas of healthcare.
Other findings
The report also explores suicide risk assessment, noting that the language often used in these settings can minimise patient experiences and create fear. This can lead to less open communication. Our findings highlight the importance of compassionate, trusting conversations that allow patients to share concerns while feeling supported and safe. We also emphasise the impact of poor culture in the context of suicide risk assessment as it is an area where investigation processes can contribute to a fear of blame and subsequently contribute to defensive practices such as checklists and a ‘tick box’ culture.
Other key findings include:
- There are gaps in the provision of physical health care for people with severe mental illness, including inconsistent health checks, poor emergency responses, and misattribution of physical symptoms to mental illness.
- Integrated care boards cannot consistently draw reliable insights from data at national, system or local level, to optimise and improve services, patient care, and outcomes across mental health pathways of care. This results in variability in service provision which does not always meet the needs of individual patients or local populations.
- Staffing and resource constraints in inpatient and community mental health settings impact their ability to provide safe and therapeutic care.
- A lack of interoperability or integration between digital systems affects the provision of care across mental health, acute and community providers.
Investigator’s view
Craig Hadley, Senior Safety Investigator at the Health Services Safety Investigations Body (HSSIB), said: “This report shines a light once again on the urgent and ongoing issues facing mental health inpatient care and the reoccurring harm that comes with those issues. Too often, we see well-intentioned recommendations fall through the cracks—not because people don't care, but because systems don’t always support change in a meaningful or sustained way.
“Ensuring patient safety in mental health services means understanding what can be realistically delivered within the pressures of day-to-day care, and aligning that with clear priorities, accountability, and follow-through. Our findings call for a more joined-up approach to improvement to ensure that mental health services are safe, effective, and patient-centred.”
