Keeping children and young people with mental health needs safe: the design of the paediatric ward

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

This investigation looks at the care of children and young people with mental health issues who are admitted to a paediatric ward in an acute hospital – that is, a ward for children and young people in a hospital that typically treats physical health conditions. Specifically, it focuses on the risk factors associated with the design of paediatric wards in acute hospitals caring for children and young people with mental health needs. The investigation recognises there are multiple factors that may come together to impact on the care of children and young people with mental health needs who may be admitted to an acute paediatric ward.

Children and young people with mental health needs may be admitted to an acute paediatric ward because they need treatment for a physical health condition, or because issues with their mental health have escalated. They may be required to stay on the paediatric ward as a place of safety while they await a mental health assessment, to receive mental health treatment and/or until a mental health and/or social care placement is found. However, acute paediatric wards are traditionally designed for the treatment of children and young people who need physical health care and are not typically designed to keep those with mental health issues safe.

In 2023, 1 in 5 children and young people in England aged between 8 and 16 years showed signs of having a probable mental health disorder. Between 2021 and 2022, 39,926 (11.7%) of admissions to an acute inpatient ward, for children aged 5 to18 years old, were due to mental health conditions. The percentage is higher for females aged 11 to 15, who account for 28.3% of all acute inpatient admissions for this age group. NHS England has recognised that there is a need to transform and improve children and young people’s mental health services. The NHS strategic direction is that most children and young people with mental health needs will be supported in the community, avoiding hospital and mental health inpatient admissions where possible.

However, the high levels of children who present with both physical and mental health difficulties, as well as the high incidence of neurodivergence, means that there will remain a significant proportion of children and young people on the acute paediatric ward presenting with mental health, learning, cognitive, communication and/or behavioural difficulties. It is therefore essential that the design and delivery of care on paediatric wards is able to effectively meet the varied and often complex emotional, social and physical needs of the children and young people it serves.

NHS England aims to build a culture where mental health is valued equally to physical health, in which the paediatric ward can be the right place of care for children and young people with mental health needs.

The investigation used a real patient safety incident, referred to as ‘the reference event’, as an example of care for children and young people with mental health needs admitted to an acute paediatric ward.

The patient, Leah, was a young person who had a history of trauma. Leah was taken to her local hospital’s emergency department (ED) by her social worker because she was expressing suicidal thoughts.

Leah was admitted to a paediatric ward in the acute hospital while awaiting a mental health assessment under the provisions of the Mental Health Act (1983). After being assessed, Leah was detained on the paediatric ward under section 2 of the Act.

During her stay she had episodes of violence and aggression where she attempted to self-harm and to harm staff. Staff attempted to keep her safe by removing most of the items (clinical and non-clinical) from her room and by using physical restraint techniques and sedation. Leah left the paediatric ward without permission (absconded) on several occasions; on two of these occasions, she took paracetamol tablets and needed medical treatment for an overdose.

The incident was referred to the Healthcare Safety Investigation Branch (HSIB) by the Trust that runs the hospital where Leah was cared for, and the investigation sought to:

• understand the paediatric ward design factors that impact on the safety of children and young people with mental health needs in acute NHS hospitals
• identify opportunities to adapt the design of paediatric wards in acute hospitals to help support children and young people with mental health needs and those caring for them
• explore the management of risk associated with paediatric ward design in acute hospitals and adaptations that have been made locally.

The investigation produced an interim report which highlighted the significant risks associated with caring for children and young people who exhibit certain high-risk behaviours when staying in an acute paediatric ward. This could include instances of self-harm, suicide attempts or acts of physical aggression towards others. Such behaviours present risks to the safety and wellbeing of the individual, and of other patients, family members and staff on paediatric wards. The interim report suggested actions for integrated care boards and NHS organisations to help facilitate a systemwide response to these risks.

• Paediatric wards had features which were particularly challenging for children and young people with mental health needs, such as being noisy, busy, and brightly lit.
• There was limited national guidance about how paediatric wards should be adapted for children and young people with mental health needs.
• Paediatric wards in acute hospitals tended to focus on adapting their environments to improve the physical safety of a room for children and young people with a mental health need. Rooms would be stripped of items deemed to be a risk.
• Evidence indicated that removing items and creating a more restrictive environment can create more conflict situations including increased aggression, physical and verbal abuse, rule breaking, medication refusal, leaving the hospital without permission (absconding), and self-harm.
• There are opportunities to better support children and young people on acute paediatric wards by improving the environment to support therapeutic care and patient safety.
• Nationally, there was variability in the design of rooms that had been created on paediatric wards to support children and young people with mental health needs.
• Evaluating the learning from innovations and adaptations that individual hospitals around the country have made to their acute paediatric wards for children and young people with mental health needs can improve patient safety.
• There is a gap in the communication, escalation and management and oversight of risks associated with the acute paediatric ward environment for children and young people with mental health needs.
• There were differing views among paediatric ward staff, mental health experts and local, regional, and senior leaders in healthcare about whether children and young people with mental health needs should be cared for on an acute paediatric wards.