Blurred hospital corridor with staff member walking.

Provision of mental health care to patients presenting at the emergency department

HSIB legacy content

HSIB legacy content

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

National investigation

In England, it is estimated that 5% of all hospital emergency department attendances are primarily due to mental ill-health. The Five Year Forward View for Mental Health is attempting to address this situation by increasing the presence of liaison mental health services in acute hospitals. This investigation reinforces the need for emergency mental health care 24 hours a day, seven days a week.

Investigation summary

The reference case in this investigation is Diane, a 57-year-old woman who died by suicide. The early investigation focused on her last four presentations at her local emergency department, the last one being the day before she died. The investigation also examined her interactions with local healthcare services spanning two years. 

Identifying the opportunities missed in Diane’s care fed into a broader investigation, examining the integration of mental health liaison services into the emergency department. It also looked at how staff assess, understand and manage risk when patients present in mental health crisis.

Investigation report