Background
These three investigations provide examples of mental health investigations under the Patient Safety Incident Response Framework (PSIRF).
PSIRF sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety. The PSIRF is a contractual requirement under the NHS Standard Contract and as such is mandatory for services provided under that contract, including acute, ambulance, mental health and community healthcare providers.
Our report on investigating under PSIRF identified challenges experienced by investigators in mental health settings in using system-based tools in their investigations. Like our sepsis investigations, we will use the PSIRF system-based tools and guides to demonstrate how these can support learning from incidents in mental health settings. The learning from these investigations will be widely applicable, to all mental health services across England.
Summary of investigations
The three investigations focus on the barriers and enablers to providing safe care to mitigate the risk of harm in the different scenarios. Evidence from intelligence gathered suggests that investigations into the following incidents may be the most helpful:
- An incident involving attempted suicide while under the care of community services.
- An incident involving a person who experiences a physical health problem while in an inpatient mental health care who then requires admission to an acute hospital.
- An incident involving a person who self-harms while in inpatient mental health care.
These incidents are those most frequently reported or reflect key health inequalities for people with mental health problems in contact with healthcare services.
The investigations will be carried out at different NHS mental health trusts across England and will provide exemplars of patient safety incident investigations (PSIIs). Any safety learning proposed will be aimed at the specific NHS trust where the incident occurred.
We will publish each report as it is completed. Currently, two of three investigation reports has been published:
- Mental health: attempted suicide while under the care of community services
- Mental health: physical health deterioration while under the care of a low secure unit
We expect to publish the third report in Autumn 2026.
Areas for improvement
Mental health: attempted suicide while under the care of community services
The investigation of attempted suicide while under the care of community services identified four areas for improvement which the mental health trust could develop safety actions to address.
Area for improvement 1
Making information about service users easily available and accessible across providers to support effective initial engagement and decision making.
Area for improvement 2
Early exploration of adjustments that individual service users might need to engage in the triage and referral processes.
Area for improvement 3
Staff knowledge and insight into how community mental health services can support service users who may require prescription medication and who use drugs and/or alcohol.
Area for improvement 4
Organisational support for protected time, resources and assistance for staff to mitigate and respond to the distress and demands they experience in their role.
Mental health: physical health deterioration while under the care of a low secure unit
The investigation of physical health deterioration while under the care of a low secure unit identified five areas of improvement which the mental health trust could develop safety actions to address.
Area for improvement 1
The opportunities available for people to make healthy lifestyle choices, including weight management, smoking cessation and exercise, while detained on the low secure unit.
Area for improvement 2
Access to a suitable area within the low secure unit for staff to carry out physical health observations and assessments.
Area for improvement 3
Clarify clinician roles, responsibilities, and processes, including those for prescribing, between mental health and physical health staff when caring for patients with acute agitation, to help effective assessment in the emergency department.
Area for improvement 4
Trauma-informed organisational support for staff, and shared safety learning for patient safety events where care spans more than one healthcare provider.
Area for improvement 5
The ability to identify and apply a personalised approach to care planning to encourage people detained in inpatient mental health settings to engage with specialist services.