The report sets out an investigation which examined how mental health providers learn from deaths in inpatient units and those up to 30 days after discharge. In the investigation, we’ve considered learning from deaths which covers multiple processes including:
- the Learning from Deaths Framework
- coroner's inquests
- investigations following patient safety events.
Our comprehensive findings evidence significant challenges in maintaining safety, conducting effective and timely investigations and ensuring system wide learning. We identified that, whilst investigations and patient safety event analysis aim for transparency and learning, they are often of variable quality. For example, local investigations often have incomplete information to inform the findings, or they do not routinely undertake observations of clinical work to understand how care is delivered in practice. Importantly, the report captures the conditions that need to be met for effective learning. The term 'learning' in patient safety events and investigations is yet to be fully defined. This lack of clarity about what we mean by learning was a barrier in itself.
Fear of investigations and impact on families
A key finding in the investigation was that there is a culture of blame where individuals, including patients and families, and organisations fear safety investigation processes. The report highlights patient safety investigations often do not consider the emotional distress experienced by all affected, resulting in compounded harm. Bereaved families described having to fight to be involved in investigations with some describing the investigation process as “worse than the actual death because they were reliving the death [of their family member] over and over again.” Many families shared with HSSIB they feel marginalised and excluded from the investigation process, experiencing them as a ‘tick box’ exercise and without a culture of transparency, learning and accountability.
In relation to cultures, staff said that in their experience of being involved in investigations, the ones that went well were those where people felt safe to talk openly and honestly. However, the investigation heard from many staff in mental health services a perception that “someone needs to be held accountable” for inpatient deaths by catastrophic self-harm or suicide. Inquests were described by some staff as “scary”, “adversarial”, and they felt a “sense of impending doom when faced with a request to attend an inquest.
Oversight and accountability
We also examined the mechanisms of oversight and accountability and the mechanisms for capturing data on death. We found there are challenges in each area which prevents the implementation of meaningful changes. We emphasise there is limited follow up on recommendations from inquests and patient safety investigations and that mental health providers report deaths and near misses in varied ways, using different definitions and methods. This inconsistency means it is hard to identify patterns or risks.
During the investigation, we heard from mental health providers about specific areas where investigations had not effectively addressed ongoing concerns about mental health inpatient care. When we examined further, we found there are gaps in discharge planning, crisis service accessibility, and access to community therapy that were potentially contributing to poor patient outcomes.
The investigation found there is significant variability in therapeutic engagement and a lack of personalised care which has left some patients feeling hopeless and disconnected. Families voiced concerns over this lack of care and restricted involvement in care decisions, which affected their ability to support their family member, leading to guilt and anger that they could not stop their family member dying.
Need for systemic approach
The report emphasises the need for a systemic approach to safety investigations and learning for improvement with a focus on collaboration, transparency, and oversight, with a shift from procedural practices to a culture rooted in empathy, person-centred care and active involvement of families. Our report sets out five safety recommendations aimed at supporting this shift. The recommendations focus on supporting high quality and transparent investigations, better oversight of recommendations, balancing safety with therapeutic environments and developing a consistent set of data on patient deaths.
Investigator’s view
Nichola Crust, Senior Safety Investigator at the Health Services Safety Investigations Body (HSSIB), says: “Our report provides insight into the complexity and ambiguity that surrounds learning from inpatient deaths. It highlighted the limitations of what healthcare systems are currently able to achieve. It was clear from our investigation that they’re aiming to implement meaningful learning and actions to prevent future deaths in a landscape that is fraught with grief and blame, and also are dealing with significant systemic issues, gaps and poor cultures that serve to undermine patient safety in mental health care. In short: the system is still not learning effectively from deaths.
“The report contains many powerful excerpts from patients, families, carers and staff – it was hard to hear the pain, anger, guilt and distress they felt as they recounted their experiences. Emphasis on fairness, transparency and support for both families and staff is needed, and also their stories show the importance of learning and accountability, rather than blame.
“This report has been published at a crucial time for reform in the NHS and we would expect the findings of this report to contribute to the government’s long term plans in relation to mental health settings. Whilst the report does paint a sobering picture, it also does pinpoint the opportunities for improvement, through our findings and safety recommendations. We emphasise areas that should be prioritised to remove the barriers and limitations to learning – only then will the system see an improvement in patient safety, a reduction in compounded harm and ultimately a reduction in deaths in inpatient care.”
