Mental health inpatient settings

Join us at a free webinar on Wednesday 14 May 2025, 2-3.30pm, to discuss this series of patient safety investigations. Find out more and register to attend.

This series of investigations was announced by the Secretary of State for Health and Social Care in June 2023, launched in January 2024 and completed in January 2025.

We carried out four directed investigations under the mental health inpatient settings theme:

• Creating conditions for the delivery of safe and therapeutic care to adults in mental health inpatient settings.
• Out of area placements.
• Supporting safe care during transition from inpatient children and young people’s mental health services to adult mental health services.
• Creating conditions for learning from deaths in mental health inpatient services and when patients die within 30 days of discharge.

Whilst carrying out the four directed investigations we identified aspects of care that were apparent in multiple investigations, or that were outside of the scope of an individual investigation. This learning will be shared in a fifth report.

During the investigations, our teams visited over 40 mental health care areas, spanning 30 mental health care providers. They spoke to and met with over 100 patients, families and carers, as well as numerous staff working in mental health services.

We also engaged with national stakeholders, subject matter advisors and other relevant organisations, including mental health charities, allowing us to build a full picture of care delivery and people’s experiences of mental health care across the country.

Across the four investigation reports, we have issued a total of 17 safety recommendations to national bodies. We have also made 23 safety observations and included specific learning points for mental health providers and integrated care boards (ICBs) to encourage improvement across health and care, locally, regionally and nationally.

The perspectives of patients, families and staff were central to our investigations. Patients and families provided powerful testimony on how they had experienced care and where they felt urgent improvement is needed. Across all the investigations, it was clear they often felt their voice was not heard, and they were not involved in crucial decision making about the care of themselves or their loved ones. Our reports emphasise that lack of patient and family involvement often contributes to psychological and physical harm.

Our investigations also highlight that patients are regularly cared for in environments which are deemed not to be therapeutic and do not meet their needs. This is crucial for their safety, wellbeing and recovery. Providers told us their ability to deliver therapeutic care is limited by workforce and funding pressures and every day they face the challenge of how to prioritise.

Collaboration between services was found to be an ongoing concern. The investigations emphasise that care cannot be looked at in terms of just mental health providers, it often spans health, social care, local authority provision and education. Partners are often not working together in a consistent and integrated way as they have competing operational and financial priorities, creating friction. All organisations should be supported by a system that gives equal weighting to safety across the patient pathway.

We recognise the highly complex and emotive nature of mental health care, and whilst we have identified a number of significant systemic and cultural issues, we also saw many dedicated people working across these services, determined to drive improvement.