Sharing HSSIB learning on mental health and patient safety

Patient safety and psychological safety go hand in hand in mental health care. When harm occurs, the response that follows can either strengthen trust and learning, or deepen fear and distress. HSSIB’s investigations consistently highlight the importance of a systems‑based, trauma‑informed approach to learning – one that focuses on improvement, not blame.

Why this matters

• Harm takes many forms. In mental health care it can be physical (such as self-harm or missed deterioration) or psychological (not feeling listened to, restrictive practice, feeling unsafe).
• How organisations respond shapes culture. Blame, confusion or defensiveness discourage people from speaking up. Compassionate, fair and transparent responses support better learning and safer care.
• Most safety problems are ‘system’ problems. Staffing, environment, pathways, transitions, digital tools and accountability all interact. Simple reminders or individual fixes are rarely enough on their own.

HSSIB, mental health and patient safety

HSSIB carries out independent, systems-based patient safety investigations. We publish what we learn and make safety recommendations that aim to reduce risk across health and care.

In our work on mental health inpatient settings, we brought together learning from multiple investigations. This highlighted common themes, risks and opportunities to improve mental health care. We’ve also examined safety for people experiencing a mental health crisis and gaps in legislation to keep patients safe.

If you’re working under the Patient Safety Incident Response Framework (PSIRF), a lot of this learning will feel familiar: compassionate engagement, proportionate responses, a focus on systems (not scapegoats), and oversight that supports improvement rather than performance alone. We’ve now started a series of investigations using PSIRF to identify learning for organisations.

Key learning themes from HSSIB investigations

Learning culture

Moving from fear and defensiveness to compassion and transparency

One theme we see (and many teams will recognise) is how fear of blame changes what happens after harm. If an investigation feels punitive or hard to understand, learning becomes defensive and the same conditions remain.

HSSIB has made a national safety recommendation to clarify expectations for meaningful, restorative learning from patient safety events and deaths in mental health services – grounded in high-quality, transparent investigations and a culture of compassion.

Involvement

Patients, families and carers are central to safety learning

Many people told HSSIB they did not feel heard or involved in important decisions about their care. This can leave lasting psychological harm and increase the risk of physical harm.

Involvement is not a ‘nice extra’. It’s vital to safe care and should be built into learning and investigation processes from the outset.

Environment and therapeutic care

Safety is shaped by where – and how – care is delivered

The everyday reality of wards and services matter: physical environment, routines and whether care feels genuinely therapeutic.

HSSIB has seen people cared for in environments that do not meet their needs. When care settings are not therapeutic or appropriate, teams can end up firefighting – sometimes with more restrictive or reactive responses that can harm patients.

Transitions and system interfaces

Risk concentrates at handovers

Risk tends to spike where systems interact: handovers, discharge, out-of-area placements and transitions between teams or organisations.

HSSIB investigations highlight interfaces where accountability is unclear and makes recommendations to improve safety across care pathways, not just within individual services.

What “good” can look like in practice

Engagement is planned, not improvised

People know who to contact, what will happen next and when they’ll get an update – including patients, families and staff.

Learning looks at the whole system

Investigations explore work-as-done, tools and processes, information flow and environmental factors – not just what an individual did on a difficult day.

Therapeutic care is protected

Teams can explain how the environment, staffing model and daily routines support recovery and reduce the need for restrictive interventions.

Practical actions to support improvement

For frontline teams

• Accessible information. Make information about service users easy to access to support engagement and decision-making.
• Personalised care. Identify early what adjustments service users might need to engage in triage and referral processes.
• Staff awareness. Enhance staff knowledge of how community mental health services can help service users who require additional support.
• Support for colleagues. Provide protected time, resources and assistance to help staff manage the emotional demands of their role.

For leaders, governance and patient safety teams

• Support those involved in investigations. Consider what emotional support is available, including time and space for facilitated, reflective conversations.
• Inclusion of patients and families. Adopt a person-centred care approach that prioritises people’s needs, preferences and rights .Actively involve families in care planning and decision-making.
• Understanding barriers to learning. Consider the impact of legal processes and how this might be a barrier to learning from deaths.

Recommended resources

HSSIB resources

• Mental health inpatient settings (overview of investigations, learning and safety recommendations).
• Mental health crisis (safety issues for people experiencing a mental health crisis who come into contact with urgent and emergency care services).
• Mental health investigations under PSIRF (exemplar investigations in mental health settings).

Other resources

• NHS England Patient Safety Incident Response Framework (overview and supporting guidance).

Closing thought

Our investigations are made possible by the patients, families and NHS staff who share their experiences – often in the most difficult and sometimes tragic circumstances. We thank them for their willingness to be involved.

Our purpose is to make healthcare safer for everyone. This is especially vital when people are at their most vulnerable, including when they are experiencing poor mental health.