Safety issues for people experiencing a mental health crisis who come into contact with urgent and emergency care services

This page considers the care of people experiencing mental health problems and mentions mental health crisis including self-harm and suicide. Some readers may find the contents of this summary distressing. If you’re currently experiencing a crisis, information about how to access mental health support can be found on the NHS website.

We have launched two investigations that explore the patient safety issues associated with care pathways for people experiencing a mental health crisis who come into contact with urgent and emergency care services.

Mental health crisis describes when a person feels at breaking point and where they need urgent help. Experiencing a mental health crisis can look different for different people but it can include:

• feeling extremely anxious or having panic attacks
• feeling suicidal
• feelings of wanting to self-harm, or acting on these feelings
• feeling extremely high, fearing others want to harm you, or hearing voices
• other behaviour that seems out of control or irrational and that is likely to endanger themselves or others.

Someone might have a known mental health condition and experience a mental health crisis, or it can be something they have never experienced before. It is usually very frightening for the person experiencing the crisis and those around them.

During our series of investigations into mental health inpatient settings, we heard concerns about the care of people in mental health crisis which may benefit from a HSSIB investigation. We carried out a range of work to help further understand these concerns, including conversations with stakeholders, reviewing available data, and analysing existing literature, including reports to prevent future deaths issued by HM Coroners.

Feedback from stakeholder engagement has been supportive of HSSIB work to explore mental health crisis care and that this will add value in terms of a system focused lens on the safety issues.

Mental Health Crisis: Care of patients in emergency departments

We have now published an interim report as we identified a significant legal, policy and safety gap in the care of people in emergency departments (EDs) in mental health crisis.

During consultation on this report, concerns were shared with HSSIB about the current challenges in relation to the resourcing and configuration of mental health services that exacerbate challenges faced in the ED.

People in mental health crisis may need to be assessed for admission to a mental health hospital in line with the Mental Health Act 1983. Delays in these assessments being undertaken, and/or the lack of availability of mental health inpatient beds once a person has been recommended for admission, can lead to patients remaining in EDs for prolonged periods.

A second report in mental health crisis care in ED will report further on:

• the knowledge, skills, and resources available to emergency departments tocare for patients in mental health crisis, including access to information held by other services;
• how the physical environment in emergency departments impacts on the care provided to patients in mental health crisis;
• staff decision making about when to admit or discharge patients who have presented in mental health crisis

This will include consideration of the impact of protected characteristics and health inequalities in this area of care.

The second report is anticipated to be available in Summer 2026

Interim report findings

• There is an absence of clear legal powers to lawfully prevent vulnerable individuals from leaving the ED while awaiting assessment or admission.
• This legal ambiguity exposes patients to increased risk of harm and/or being unlawfully deprived of their liberty, and places staff in a position of uncertainty when attempting to manage safety.
• For those requiring formal admission to a mental health hospital, an application under the Mental Health Act 1983 cannot be completed until a bed has been identified, which can take days.
• Staff and organisations reported they are often faced with choosing “the least harmful way to break the law” in order to try and keep patients safe.
• EDs are not designed to provide therapeutic mental health care and prolonged stays may worsen patients’ conditions and create challenges in maintaining a safe environment for everyone.

Mental Health Crisis: Ambulance service response via NHS 111 and 999

This investigation intends to:

• Explore how ambulance services triage and prioritise calls about patients in mental health crisis.
• Explore ambulance crew education, training, and assessment of a patient’s capacity when in mental health crisis.
• Explore ambulance crew decision making on when to convey a patient in mental health crisis to hospital, including access to relevant clinical advice and access to information held by other services.

This will include consideration of the impact of protected characteristics and health inequalities in this area of care.

This investigation will launch in spring 2026, following completion of substantive work on the first investigation, and is anticipated to be available in spring 2027.

We are keen to hear from anybody with an interest in this subject matter. This includes patients, families, carers and health and care professionals who may wish to share their experience. If you would like to speak to us about this investigation before we publish the final report, please email enquiries@hssib.org.uk.

If you’re currently experiencing a crisis, information about how to access mental health support can be found on the NHS website.