Latest news with #HSSIB
Medscape
13-05-2025
- Health
- Medscape
Mental Health Units Repeating Safety Failings, Warns HSSIB
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.'
Western Telegraph
23-04-2025
- Health
- Western Telegraph
NHS staff fatigue factor in patient harm and deserves urgent attention
Excessive workloads, long shifts of 12 hours or more and inadequate breaks are among the factors contributing to staff fatigue, according to the Health Services Safety Investigations Body (HSSIB). Medication errors, impaired decision-making, reduced attention or vigilance, and rude or disrespectful behaviour by workers are the most common consequences, its report said. The patient safety body warned that fatigue 'contributes directly and indirectly to patient harm' but said there is 'little evidence' to help understand the size and scale of the risk as it called for a review to help capture the related data. Fatigue is more than just being tired - it can significantly impair decision-making, motor skills and alertness Saskia Fursland, HSSIB Examples of patient safety issues heard by HSSIB investigators included one staff member who failed to perform a pregnancy scan accurately, which they felt contributed to safety issues for the mother and baby at birth. The probe heard the member of staff had a health condition and had not slept well, but this was worsened by staffing issues and a high workload. Fatigue 'was not considered as part of the safety event learning and that they were not involved in the investigation', according to the worker. Another example was of a young patient given the wrong chemotherapy infusion. The HSSIB heard the two members of staff who checked the medication were almost nine hours into a 12-and-a-half-hour shift and a trust investigation found that fatigue was 'likely to have been a factor'. Staff fatigue is not routinely captured as part of patient safety event reporting or routinely considered as part of patient safety event learning, the HSSIB report said. It also highlights that there are no specific questions about fatigue in the NHS Staff Survey, which includes responses from more than 700,000 workers. Awareness of the risks that staff fatigue poses to patient safety is beginning to grow within healthcare, but our investigation found that understanding remains inconsistent and fragmented Saskia Fursland, HSSIB However, in the 2024 poll, two in five staff reported feeling worn out by the end of a shift, while one in five said every waking hour is tiring. The issue is also impacting staff safety, with some exhausted staff involved in fatal car accidents or near misses while driving home from a shift, the HSSIB said. The report claims staff are fatigued for a variety of reasons, such as excessive workloads, long shifts, not enough rest time and inadequate breaks. There were also personal factors such as menopause, pregnancy and religious practices, as well as lower-paid staff picking up extra shifts or an additional job to make ends meet. The HSSIB warned fatigue is perceived by trusts and staff as an 'individual risk, with limited organisational accountability', leading to a 'blame culture'. Saskia Fursland, senior safety investigator at the HSSIB, said: 'Fatigue is more than just being tired – it can significantly impair decision-making, motor skills and alertness. 'We must move away from viewing fatigue as an individual issue and putting the onus on personal responsibility and instead treat it as a system-level risk that deserves urgent attention.' The probe also found that there are 'barriers' to understanding the risks posed by fatigue, including the 'norms' around working long hours in the health service. As the NHS prepares for reform, the report underscores the need for strong, unified action to protect both patients and healthcare professionals from the risks associated with fatigue Saskia Fursland, HSSIB It said some staff 'spoke of deeply entrenched and historical beliefs where working long hours was seen as a 'badge of pride', particularly among senior staff'. Others told HSSIB investigators 'that it was seen positively for staff to stay beyond their contract hours and that it was sometimes actively encouraged by healthcare organisations'. Organisations also have 'limited ability' to address these risks amid constraints to the workforce and finances, the report added. The HSSIB recommends that NHS England and the Department of Health and Social Care should review processes to help capture data related to staff fatigue in order to understand risks and inform the development of a future strategy to tackle the issue. Ms Fursland added: 'Awareness of the risks that staff fatigue poses to patient safety is beginning to grow within healthcare, but our investigation found that understanding remains inconsistent and fragmented. 'This challenge is further compounded by limited data and the absence of co-ordinated national oversight – factors that significantly hinder effective risk management. 'As the NHS prepares for reform, the report underscores the need for strong, unified action to protect both patients and healthcare professionals from the risks associated with fatigue.' Steps to protect and enhance staff wellbeing and reduce the risk of fatigue must be a priority at every level Saffron Cordery, NHS Providers Responding to the report, Patricia Marquis, executive director of the Royal College of England, said it 'lays bare the daily reality for nursing staff'. 'They are overstretched, understaffed and regularly work beyond their hours caring for too many patients,' she added. 'This drives dangerous levels of fatigue which not only harms patients but also follows staff home, with sometimes devastating consequences. 'Nursing fatigue is deadly and in health and care services should be treated as a public safety emergency.' An NHS spokesperson said: 'NHS staff are working incredibly hard to meet rising demand for care, but we know that this can take a toll on their wellbeing and we're committed to tackling burnout by ensuring staff get the support they need, so they can continue to provide safe and effective care for patients. 'Staff should always feel confident to report patient safety concerns, including those that are linked to fatigue, and we will work with local NHS systems to address any issues – while there is more we could and should do, the NHS is offering more flexible working options than ever before, and there is a range of mental health support available for staff, including access to wellbeing resources.' Saffron Cordery, interim chief executive of NHS Providers, added: 'Steps to protect and enhance staff wellbeing and reduce the risk of fatigue must be a priority at every level, and HSSIB is right to highlight the potential risks associated with staff fatigue in implementing national initiatives on workforce challenges and care delays.' A Department of Health and Social Care spokesperson said the Government 'inherited a broken NHS with an overworked, demoralised workforce' and the report 'highlights the profound consequences this can have for patients and staff alike'.
The Guardian
10-04-2025
- Health
- The Guardian
England's ‘complex' health and care system harming patients, report says
Navigating England's 'complex' health and care system is 'extremely difficult' and carers and patients are experiencing burnout, distress and harm as a result, a damning report says. There were frequent failures by NHS and care organisations in coordinating care for people with long-term health conditions, the Health Services Safety Investigations Body (HSSIB) found. Figures show 41% of adults and 17% of children have at least one long-term health issue. The report said patients unable to navigate the health and care system were getting sicker as a result, missing vital appointments, and their care could be delayed or forgotten about, meaning they may need more intensive and expensive treatment in future or longer stays in hospital. Patients and carers had to retell their health history to different health and care providers, the research showed. The system was not joined up and information did not flow well across health and care organisations, patients and carers told the investigators. This was making people exhausted and feeling burned out, frustrated, angry and guilty, the report says. Some patients' and carers' physical and mental health was deteriorating because of the extra burden of navigating the health and care system. Some people were disengaging with the health and care system because they were exhausted and frustrated, which the report says could result in their health deteriorating further. Neil Alexander, a senior safety investigator at HSSIB, said: 'Long-term care is complex and we acknowledge the challenges faced by providers, especially at a time of extreme pressure on resources. However, our investigation emphasises that if care is not properly coordinated, those with long-term conditions and their carers can suffer mental and physical deterioration and harm. Patients can need more intensive treatment or longer stays in hospital, placing further pressure on services. 'The stories and experiences shared with us provided powerful testimony as to the impact on people. Patients and carers were open about their feelings of anguish and exhaustion, their anger, sadness and loss of trust in a system they felt sometimes was fighting against them. Many told of the frustration at not being able to speak to the specialist and dedicated staff who would be able to help them.' He added: 'This is why our findings and recommendations are aimed at national organisations and the emphasis is to improve the capacity and capability of the workforce to deliver personalised, coordinated care. The administrative burden on patients, carers and staff would be reduced, but most importantly it will relieve the fear and anxiety at being left to cope alone without the right support.' The report also raises concerns about out-of-hours care, including an 'information gap' where health and care providers do not have all of the right information when needed. Sign up to First Edition Our morning email breaks down the key stories of the day, telling you what's happening and why it matters after newsletter promotion Investigators found there was wide variation in how the current role of 'NHS care coordinator' was implemented. The HSSIB has called on ministers to ensure patients and carers have a single point of contact when needed. The Department of Health and Social Care has been contacted for comment.
The Independent
09-04-2025
- Health
- The Independent
Navigating health system can lead to ‘burn out' for some patients
Some people with long-term health problems feel 'burnt out' as a result of trying to navigate a 'difficult and complex' health and care system, according to a new report. The health safety watchdog has highlighted how people who are unable to navigate the system on their own can be 'forgotten about' as they miss appointments or they care is delayed. The Health Services Safety Investigations Body (HSSIB) said that the health and care system 'frequently fails to support care co-ordination'. It warned that people's care can be impacted when they are unable to coordinate their own care. ' People who are unable to navigate the health and care system can experience deterioration of health, miss appointments or their care may become delayed or forgotten about, meaning they may need more intense treatment in the future or longer stays in hospital,' the authors wrote. Patients are forced to frequently repeat their health history to different health or care workers, they said. And the authors highlight concerns over out of hours care including an 'information gap' where health and care providers do not have all of the right information when needed. 'Patients and carers can feel exhausted, burnt out, frustrated, angry and guilty, among other emotions. Patients and carers' physical and mental health may deteriorate because of the extra burden of navigating the health and care system,' they added. The authors highlight how the NHS has made a definition of an 'NHS care coordinator' but they said that there is variation in how the role is implemented. HSSIB called on the Government to review the role to ensure people have a single point of contact when needed. Figures from the Health Survey for England show that 41% of adults and 17% of children had at least one long-term medical condition. Neil Alexander, senior safety investigator at HSSIB, said: 'Our investigation emphasises that if care is not properly co-ordinated, those with long-term conditions and their carers can suffer mental and physical deterioration and harm – patients can need more intensive treatment or longer stays in hospital, placing further pressure on services.' 'The stories and experiences shared with us provided powerful testimony as to the impact on people – patients and carers were open about their feelings of anguish and exhaustion, their anger, sadness and loss of trust in a system they felt sometimes was fighting against them. 'Many told of the frustration at not being able to speak to the specialist and dedicated staff who would be able to help them. 'This is why our findings and recommendations are aimed at national organisations and the emphasis is to improve the capacity and capability of the workforce to deliver personalised, coordinated care. 'The administrative burden on patients, carers and staff would be reduced, but most importantly it will relieve the fear and anxiety at being left to cope alone without the right support.' Department of Health and Social Care spokesperson said: 'This government inherited a broken healthcare system and we recognise the difficulties that people with long-term conditions can face in accessing care. 'We want a society where every person receives high-quality, compassionate continuity of care and can access the specialist services they need. 'Through our 10 Year Health Plan, we are shifting our health service from sickness to prevention and from hospital into community. This includes plans for neighbourhood health centres, so care for those with long-term conditions can be carried out in the community, in one place.'
