Source · HSSIB Patient Safety Investigation
Mental health crisis care: care of patients in emergency departments — HSSIB
HSSIB’s introductionPeople 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.
Published 17 September 2026
Published
Mental health
Emergency care
Access to care
Indexed content
1 recommendation
2 observations
Safety Recommendations
HSSIB recommends that the Department of Health and Social Care/NHS England works with relevant national stakeholders, to set out and support national minimum operational service standards and built design expectations for emergency departments. This will help reduce unwarranted variation and meet the therapeutic needs of individuals who attend emergency departments in a mental health crisis.
No response is indexed for this recommendation.
Safety Observations
Organisations with responsibilities for regulation, oversight and assurance of urgent and emergency mental health crisis care can improve patient safety by using the findings of this report to review how they monitor the safety and effectiveness of care for people in mental health crisis who attend emergency departments.
Organisations with responsibilities for regulation, oversight and assurance of mental health crisis care can improve patient safety by reviewing the extent to which patients, families and carers are involved in care and decision making for people in mental health crisis who attend emergency departments. Understanding why family and carer involvement is not consistently achieved will help organisations identify opportunities to improve assessment, safety planning and discharge processes, to help keep people safe.
HSSIB suggests safety learning for integrated care boards
Safety learning for integrated care boards ICB/2026/022:
HSSIB suggests that integrated care boards can improve patient safety by ensuring that people with lived experience, families and carers are involved in the design, delivery and governance of urgent and emergency mental health crisis care. This involvement can help to inform decisions, improve services and identify safety risks that may not be visible through operational data alone.
Safety learning for integrated care boards ICB/2026/023:
HSSIB suggests that integrated care boards can improve patient safety by supporting sustained relationships and effective joint governance arrangements between acute and mental health providers, and other organisations involved in urgent and emergency mental health crisis care. These relationships can help partners develop a shared understanding of local demand, pathway gaps, escalation routes and the impact of delays on people in crisis, families and staff.