Mental health inpatient settings

We recognise that, across health services and system partners, we do not have one clear and coherent picture of mortality data which is required to improve system-wide visibility, co-ordination and collaboration. However, we know that lots of data is collected by providers and commissioners of mental health services, and so we think the best first step towards developing a unified dataset is to consider how we can make the most of the data we already collect.

To most effectively work towards addressing this recommendation, it is important that DHSC brings together the appropriate range of expertise to understand how data is used operationally by various partners to support effective decision-making. Any solutions proposed to develop a comprehensive and unified data set need to account for the needs of all system partners to ensure these solutions are effective and do not encounter unexpected barriers on implementation.

As a first step to meet this recommendation, DHSC convened a meeting in May 2025 with stakeholders including NHS England, CQC, HSSIB, the Independent Advisory Panel on Deaths in Custody, and other system partners to discuss how the health system collectively can best deliver improvements in the recording and reporting deaths in mental health services.

As a result of this meeting, we recognised that, while a uniform dataset is a desirable end-goal, there are challenges which will require long-term actions to address. Many of these challenges were identified in HSSIB's report, including inconsistent definitions, challenges with the timeliness of the data and classification of deaths.

However, in the meeting, system partners also recognised that there is more we can do in the short term with the data we do already have available to improve system-wide visibility, co-ordination and collaboration to improve learning from deaths.

It was agreed that health system partners should focus in the immediate term on triangulating the key data sources that are currently available to develop a comprehensive picture of mortality data in mental health services. This includes identifying what different definitions are currently used in the reporting and recording of mortality data and mapping the flow of existing data between systems.

DHSC will convene a workshop in the autumn to bring colleagues together from across the health system to develop this comprehensive picture. We will use the outcomes from this workshop to identify how to more efficiently use the data we have available.

Actions planned to deliver safety recommendation:

• Creation of a unified data set with agreed definitions for recording and reporting deaths in mental health services to be discussed at a stakeholder meeting convened by DHSC, by May 2025. Additional comments: This meeting has taken place, and it has been agreed that DHSC will convene a further workshop in the autumn to map existing data flows.
• DHSC, CQC, and NHSE to liaise separately to discuss next steps from Mortality Data Working Group and potential timelines, by June 2025. Additional comments: Agreed that DHSC will convene a further workshop in the autumn to map existing data flows.
• DHSC workshop on mortality data, by Autumn 2025. Additional comments: As above. The purpose of this workshop will be to map existing mortality data flows across the healthcare system to inform future action to improve mortality data.
• Mortality Data working group meeting to be reconvened in six months to establish how we can  build on the existing data flows to deliver improvements to mortality data, by November - December 2025.

Response received on 25 August 2025.