Source · HSSIB Patient Safety Investigation
Safety issues for people experiencing a mental health crisis who come into contact with urgent and emergency care services
HSSIB’s introductionMental health crisis describes when a person feels at breaking point and where they need urgent help. We have launched two investigations that explore the patient safety issues associated with care pathways for people experiencing a mental health crisis who come into contact with urgent and emergency care services. To date we've published an interim report and an investigation report around care of patients in emergency departments.
Published 16 September 2025
Published
Mental health
Emergency care
Access to care
Indexed content
3 recommendations
Safety Recommendations
HSSIB recommends that the Department of Health and Social Care urgently reviews the current legal framework and addresses the current legislative gaps in emergency care for people in mental health crisis and clarify the extension of legal powers for health professionals to hold someone in the emergency department. This will safeguard people who are currently arriving at the emergency department in a mental health crisis and the staff who care for them to support safe, consistent and legally compliant care.
No response is indexed for this recommendation.
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.
HSSIB recommends that the Department of Health and Social Care/NHS England works with relevant national stakeholders, to ensure people in mental health crisis in emergency departments are kept safe by addressing the findings of this report. This programme of work should provide further support and/or guidance to address: clear expectations for roles, responsibilities and accountability for clinically appropriate, co-ordinated Mental Health Act assessment pathways; effective shared care, governance and escalation arrangements and processes to identify, escalate and review delays related to assessment, bed availability and onward care; arrangements to assess, plan for and assure the capacity, capability and resilience of the workforce, including access to relevant specialist and statutory professionals; agreed measures and reporting arrangements to monitor workforce and pathway pressures, evaluate improvement actions, identify variation in access, waiting, experience, use of restrictive interventions, and address inequalities between population groups. This will support safe care by addressing issues in relation to clinical ownership, transfer of care, governance and escalation of patients in mental health crisis in emergency departments.
No response is indexed for this recommendation.