Mental health inpatient settings: Creating conditions for learning from deaths in mental health inpatient services and when patients die within 30 days of discharge

As the investigation recognises, the Patient Safety Incident Response Framework (PSIRF) is a significant and welcome improvement in how the NHS responds to patient safety incidents. It prioritises compassionate engagement of those affected by incidents; the use of systems-based approaches to learning; an emphasis on proportionality that balances the need to invest in understanding what happened with the need to effectively and sustainably reduce risks; and the importance of effective and supportive oversight. The PSIRF was published in the summer of 2022 and became mandatory for healthcare provided under the NHS Standard Contract from April 2024. NHS England has emphasised that implementation of PSIRF is not a ‘once and done’ task, but requires ongoing cycles of planning, implementation, review and improvement. NHS England are confident that as PSIRF is being embedded, the four principles that underpin PSIRF are being realised. It is important that we learn from the implementation of the PSIRF. This is why NHS England committed to review and revise the supporting guidance that underpins PSIRF as implementation generated further insight. As such, NHS England has prioritised review and revision of the ‘’Engaging and involving patients, families and staff following a patient safety incident’’ guide in the first instance. Working with a group of patients, families, NHS leads and staff and academic experts, the guide is being revised to take on board insight from the initial phase of PSIRF implementation and also the findings from the ‘Learn Together’ research led by the Yorkshire and Humber Patient Safety Research Collaboration. The revision to the guide includes providing further information on what is meant by meaningful and effective engagement and involvement in the response to patient safety events, including in mental health services (the guide is not specific to any one healthcare sector). It emphasises the importance of high quality and transparent investigations, and other learning response methods, conducted with a specific focus on compassion and working with affected patients, staff and families. NHS England are confident the results of this work will fulfil this recommendation from HSSIB’s report. The Government’s 10-Year Health Plan also sets out important and ambitious reforms to improve the quality and safety of health services. As part of these reforms, a revitalised National Quality Board (NQB) will bring together senior clinical and managerial leaders from the NHS and regulatory bodies, along with patients and patient representatives to oversee quality measurement, transparency, improvement and innovation in the NHS and independent sector. We will create a new National Director of Patient Experience to bring patient voice ‘in house’, overseeing the collection of more informed feedback from patients and carers, and making it publicly available. As recommended in Dr Penny Dash’s Review of patient safety across the health and care landscape, this Director will consider formal support for those who have, or believe they have, suffered unsafe care. We will also significantly improve the complaints process within all NHS commissioners and providers, by improving response times to patient safety incidents and complaints by setting clear standards for both the timeliness and the quality of responses to complaints. We will also expect these to be handled within patient experience and patient complaints teams, not via PALS or external advocacy services to ensure a focus on listening, learning and improvement. Actions planned to deliver safety recommendation: NHS England will review and revise the supporting guidance that underpins PSIRF considering insights generated from its initial phase implementation, by Summer 2026. Additional comments: The revised guide and associated documents have been drafted and are now being considered by NHS England editorial team to determine how best to communicate the information that has been developed. Publication/communication plans will be set out in due course. A revitalised National Quality Board (NQB) will bring together senior clinical and managerial leaders from the NHS and regulatory bodies, along with patients and patient representatives to oversee quality measurement, transparency and improvement. We will create a new National Director of Patient Experience to bring patient voice ‘in house’. We will significantly improve the complaints process within all NHS commissioners and providers to set clear standards for both the timeliness and the quality of responses to complaints. Response received on 26 August 2025. HSSIB comment: Further updates from DHSC regarding additional detail will be published when available.

NHS England Mental Health, Learning Disability and Autism Programme welcomes the recommendations of the HSSIB investigations ‘Mental health inpatient settings: Creating conditions for learning from deaths in mental health inpatient services and when patients die within 30 days of discharge’. The recommendations align with the ‘Culture of Care Standards’ NHS England » Culture of care standards for mental health inpatient services published by NHS England. Mental healthcare inpatient staff who are enabled to recognise the importance of the therapeutic relationship as the single biggest predictor of patient outcomes will be empowered to improve their practice. A greater understanding of what is meant by the therapeutic relationship will facilitate improvements in patient safety across the Mental healthcare system. Actions planned to deliver safety recommendation: Work with key stakeholders to agree a scope for a review of existing evidence base in relation to the therapeutic relationship in MH settings, by June 2025. Organisational lead: MHLDA Quality Transformation Team. Resource in place to deliver actions: Time protected within existing team to undertake this work. Other dependencies identified: Availability of stakeholders. Additional comments: All actions and subsequent timelines are subject to change due to the NHSE restructure. All stakeholder engagement will include lived experience representation. Establish a working group to collate existing evidence base and agree key inclusion points for a document, by September 2025. Organisational lead: MHLDA Quality Transformation Team. Resource in place to deliver actions: Time protected within existing team to undertake this work. Other dependencies identified: MH PRU have been identified as a key partner to help support this work. Availability and capacity of key stakeholders. Additional comments: All actions and subsequent timelines are subject to change due to the NHSE restructure. Create and publish a document that helps define what is meant by the term ‘therapeutic relationship', by December 2025 to start NHSE publication process. Organisational lead: MHLDA Quality Transformation Team. Resource in place to deliver actions: Time protected within existing team to undertake this work. Other dependencies identified: Availability and capacity of key stakeholders. NHSE publications process Additional comments: All actions and subsequent timelines are subject to change due to the NHSE restructure. Response received on 28 April 2025.

NHS England Mental Health, Learning Disability and Autism Programme welcomes the recommendations of the HSSIB investigations ‘Mental health inpatient settings: Creating conditions for learning from deaths in mental health inpatient services and when patients die within 30 days of discharge’. The outcomes of the investigations support our work focused on improving patient safety across the Mental healthcare system by reducing restrictive practices and least coercive care. We recognise the importance of approaching this sensitively and compassionately given the experiences of both staff and patients and the complex decision making that is required to consider people’s human rights, least coercive care and safety. Guidance on how to reduce and respond to non-anchored ligature risks will help staff to support people who hurt themselves with non-anchored ligatures and improve patient safety whilst maintaining a therapeutic environment. Actions planned to deliver safety recommendation: Establish a working group with key stakeholders to collate existing evidence base and agree key inclusion points for the guidance document, by September 2025. Organisation lead: MHLDA Quality Transformation Team. Resources in place to deliver actions: Time protected within existing team to undertake this work. Other dependencies identified: NCISH have been identified as a key stakeholder for this work. Availability and capacity of key stakeholders. Additional comments: All actions and subsequent timelines are subject to change due to the NHSE restructure. All stakeholder engagement will include lived experience representation. Create and publish guidance for staff on how to reduce and respond to non-anchored ligature risks in line with personalised safety planning a least coercive care, by December 2025 to start NHSE publication process. Organisation lead: MHLDA Quality Transformation Team. Resources in place to deliver actions: Time protected within existing team to undertake this work. Other dependencies identified: Availability and capacity of key stakeholders. NHSE publications process. Additional comments: All actions and subsequent timelines are subject to change due to the NHSE restructure. Response received on 28 April 2025.

Since 2023, HSSIB, on behalf of the Department of Health and Social Care (DHSC), has worked with relevant stakeholders and ALBs in a Recommendations to Impact Group. This work will be aligned with wider Government plans for effective monitoring and oversight of government-led inquiries. DHSC will draw on both of these activities to take work forward to design an oversight mechanism that supports the effective implementation and learning from safety recommendations. Any mechanism should enable the tracking, prioritisation and oversight of safety recommendations to implementation. Action planned to deliver safety recommendation: Design a national oversight mechanism to monitor implementation of safety recommendations drawing on work of HSSIB-led Recommendations to Impact Group, by Autumn 2025. Organisational lead: Department of Health and Social Care. Other dependencies identified: Government plans for oversight of government-led inquiries. Response received on 19 May 2025.

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.