Mental Health Units Repeating Safety Failings, Warns HSSIB

Medscape

13-05-2025

Mental health inpatient services in England continue to ignore critical safety recommendations, putting patients and staff at risk, according to a new report.
The Health Services Safety Investigations Body (HSSIB) based its findings on multiple investigations into inpatient mental health care between September 2024 and January 2025.
The report highlighted persistent systemic failures that have persisted despite previous warnings.
Duplication and Confusion
The report warned that in many cases, there is no clear responsibility for implementing recommendations. Guidance is often duplicated across organisations, causing confusion.
A recurring barrier is the sheer volume of similar recommendations. This has led to a box ticking culture and tokenistic approach to making improvements.
One example cited is a 2023 investigation by the HSSIB into the transition from children's to adult mental health services. Despite clear recommendations made to NHS England, the HSSIB found no evidence of follow-up action.
Furthermore, longstanding recommendations to improve the physical health of people with severe mental illness remain unfulfilled, the HSSIB report stated. Premature deaths continue to occur as a result.
Adults with severe mental illness remain significantly more likely to die prematurely—before the age of 75—than those without, in every upper-tier local authority in England.
Culture of Blame Hindering Progress
A culture of fear and blame continues to hinder progress, according to the report.
Staff told investigators they felt punished or singled out when things went wrong. In one case, a senior leader likened their experience to 'being the naughty child on the naughty step' following a patient death.
Fragmented Systems and Poor Accountability
The report highlights deep fragmentation between health and social care services.
Investigators found that delivery of mental health care services is hindered by poor integration and often depends on personal relationships and misaligned goals. This lack of integration leads to poor accountability and ultimately harms patient outcomes.
The HSSIB has called on the Secretary of State for Health and Social Care to develop a national strategy to define patient safety roles and responsibilities across integrated care systems.
Flawed Suicide Risk Assessments
The report also raises concerns about how suicide risk is assessed.
Clinical language and tick-box checklists can leave patients feeling dismissed or fearful. This discourages open discussion of distress and undermines safety.
In contrast, compassionate conversations based on trust are more likely to improve outcomes, the report noted.
Additional System Problems
The HSSIB report identified further areas of concern:
Physical health: Patients with severe mental illness often receive inconsistent physical health checks. Symptoms may be misattributed to psychiatric causes, delaying treatment.
Data access: Integrated care boards lack quality data to plan or respond effectively.
Workforce: Staff shortages in inpatient and community settings continue to threaten care quality.
Digital systems: Poorly integrated IT systems hamper coordination across services.
Call for Change
The central message of the report is that repeated recommendations are failing to produce meaningful change.
'Too often, we see well-intentioned recommendations fall through the cracks – not because people don't care, but because systems don't support sustained change,' said Craig Hadley, HSSIB's senior safety investigator.
'Our findings call for a more joined-up approach to improvement to ensure that mental health services are safe, effective, and patient-centred.'