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Care delivery within community mental health teams

HSIB legacy content

HSIB legacy content

This investigation was carried out by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.


The purpose of this investigation was to support improvements in the work of community mental health teams (CMHTs). Specifically, the investigation looked at the following four areas:

  1. assessing a patient’s risk of self-harm or suicide
  2. considering menopause as a risk factor for mental health conditions
  3. engaging with families
  4. caring for people with a first episode of psychosis.

The investigation uses, as an example, a real patient safety incident in which a woman died by suicide while under the care of a CMHT; this is referred to as ‘the reference event’ and was used to examine national issues.

Reference event

The reference event relates to a 56-year-old woman (Ms A), who came into contact with mental health services for the first time in September 2019 following a suicide attempt.

Ms A spent a month in hospital, and was then discharged home under the care of a community mental health team (CMHT) with a diagnosis of psychotic depression.

At the end of May 2020, Ms A was again admitted to hospital following a second suicide attempt. She again stayed in the hospital for about 4 weeks before being discharged home under the care of a CMHT.

Ms A was seen by CMHT workers regularly throughout July, and had a telephone review with a consultant psychiatrist.

At the end of July, Ms A’s family became increasingly concerned about her mental state and were unable to make contact with her. On 2 August, Ms A was found deceased at home having died by suicide.

The national investigation

The national investigation sought to understand how people at risk of suicide are cared for by community mental health teams (CMHTs), and the factors that contribute to care being delivered outside of national guidelines.

Specifically, the national investigation looked at the areas of:

  • assessing a patient’s risk for self-harm or suicide
  • identifying menopause as a risk factor for mental health
  • engaging with families
  • managing a patient with a first episode of psychosis.


  • While national guidance says that a patient’s risk of harm should not be stratified into categories such as high, medium or low, such stratification remains common in many trusts. This is because other methods of assessing and documenting risk are not available, and because staff fear being blamed if a patient comes to harm without a risk assessment, including risk stratification, having been completed.
  • Current research only demonstrates a link between menopause and low mood, and not between menopause and more severe mental health symptoms.
  • Women are frequently prescribed antidepressant medication when hormone replacement therapy may be a more appropriate treatment for their symptoms.
  • Menopause is not routinely considered as a contributing factor in women with low mood who are assessed by mental health services, and staff do not receive training in this area as standard.
  • While there is a significant amount of national guidance relating to family engagement when treating patients with mental health conditions, mental health practitioners often find it difficult to know how and when to engage with families with complicated relationships or when the patient withdraws their consent for information sharing. There is a lack of training in this area to support staff with decision making.
  • National guidance raised the upper age limit for referral to the Early Intervention in Psychosis pathway in 2016. Some trusts continue to prioritise younger patients for a variety of reasons – including funding, capacity and misconceptions about whether an older person can actually be experiencing a true first episode of psychosis in later life.
Read the full report