A blurred hospital corridor with bright ceiling lights.

Mental health inpatient settings


This series of investigations was announced by the Secretary of State for Health and Social Care in June 2023.

Proposed investigations:

  • Learning from inpatient mental health deaths, and near misses, to improve patient safety.
  • The provision of safe care during transition from children and young person (CYP) to adult, inpatient mental health services.
  • Impact of out of area placements on the safety of mental health patients.
  • Creating the conditions for staff to deliver safe and therapeutic care – workforce, relationships, environments.

We can look at inpatient mental health care in both the NHS and the independent sector in England.

Read the terms of reference for these investigations.

Engagement with national partners

We are talking to our national partners across the healthcare system in England, as well as to organisations that represent healthcare staff, patients and families. This is to understand the current landscape in inpatient mental health care.

Organisations we’re talking to include:

  • care providers
  • regulators
  • professional bodies
  • voluntary and charitable organisations that represent patient and family groups
  • members of Parliament (MPs).

This will ensure that we have identified and will address the most serious risks to mental health inpatients. Within each investigation area we will identify recommendations and other learning that will lead to changes in the safety culture and how safety is managed within mental health services.

How we work

The mental health care sector has experienced multiple investigations and inquiries in recent years. HSSIB is uniquely positioned as an independent safety body to contribute to a system level understanding of the challenges in providing care in mental health inpatient settings.

Any evidence we gather during the investigations is given full protection from disclosure. It is crucial that those impacted by poor care and those who work on the frontlines of mental health inpatient settings can share their experience, reassured that HSSIB will use this information to improve care and not to find blame or fault with individuals or organisations. With this protection, patients, families and healthcare staff can share their concerns without the fear of retribution.

HSSIB has legal powers to make sure investigators can access premises and collect evidence relevant to the investigations, including asking people to speak with us. However, we would always prefer to work with the consent of organisations and individuals to support our investigations. We aim to work collaboratively across the healthcare system to improve inpatient mental health care for everyone.

Contact us

If you would like to contact us about this investigation, please email enquiries@hssib.org.uk.