A new HSSIB report highlights ongoing failures to act on safety recommendations, with repeated issues across inpatient mental health care services
The Health Services Safety Investigations Body (HSSIB) report brings together findings from mental health care inpatient investigations published between September 2024 and January 2025. The work highlights new findings that fall outside the scope of individual investigations but reflect broader systemic issues.
Widespread concerns about the state of mental health care
The report identifies key risks across multiple areas that continue to affect the safety of mental health inpatient care. These areas include safety, investigation and learning culture, system integration and accountability, patients’ physical health in mental health inpatient settings, caring for people in the community, staffing and resourcing, digital support for safe and therapeutic care, suicide risk and safety assessment.
A primary concern across all themes is that recommendations to support learning for improvement often do not lead to action. The researchers noted several reasons, including a lack of impact assessments, no clearly identified body responsible for taking forward recommendations, and duplication of similar recommendations across different organisations.
One example of recommendations not being implemented is the transition from inpatient children and young people’s mental health services to adult services. Several recommendations were made to NHS England, but they could not prove any action had been taken.
The report also references longstanding recommendations to improve the physical health of people with severe mental illness, which have been delayed, and premature deaths continue to occur as a result.
Fear of blame amongst staff
The investigator’s findings reveal a fear of blame in mental health care settings when safety events happen, leading to a defensive culture. It was also reported that ‘the investigation was also told during visits about hostility between teams and services when a patient death occurs’, and ‘unhelpful narratives were described by senior leaders in organisations who themselves described “being the naughty child on the naughty step” and everyone turns in on you.’
Fragmented health and social care services
The report found that the delivery of mental health care is hindered by poor integration and misaligned objectives between health and social care services.
The integration of health and social care relies on relationships, with an expectation and hope that they will work well. However, in their absence, a lack of clear accountability can result in poor outcomes for people with mental illness and severe mental illness.
HSSIB has recommended that the Secretary of State for Health and Social Care develop a strategy defining patient safety roles and responsibilities across integrated care, including mental health and other healthcare areas.
Staff constraints impact the ability to provide safe care
The report also found:
- Gaps in the provision of physical health care to people with severe mental illness, including inconsistent health checks and poor emergency responses.
- Integrated care boards cannot consistently draw reliable insights from national, system, or local data to optimise and improve services, patient care, and outcomes across mental health pathways of care. This leads to variability in service provision, often not meeting the needs of individual patients.
- Staffing and resource constraints in inpatient and community mental health settings impact their ability to provide safe and therapeutic care.
- A lack of interoperability or integration between digital systems affects care provision across mental health, acute, and community providers.
Craig Hadley, Senior Safety Investigator at the Health Services Safety Investigations Body (HSSIB), said: “This report shines a light again on the urgent and ongoing issues facing mental health inpatient care and the recurring harm that comes with those issues. Too often, we see well-intentioned recommendations fall through the cracks—not because people don’t care, but because systems don’t always support change in a meaningful or sustained way.
“Ensuring patient safety in mental health services means understanding what can be realistically delivered within the pressures of day-to-day care and aligning that with clear priorities, accountability, and follow-through. Our findings call for a more joined-up approach to improvement to ensure that mental health services are safe, effective, and patient-centred.”
Responding to the new overarching report on mental health inpatient settings from the Health Services Safety Investigations Body (HSSIB), Rebecca Gray, mental health director at the NHS Confederation, said: “This report sets out several important lessons that will resonate with most of those running or working in mental health services.
“Providing care to those who become severely mentally unwell is about balancing a range of risks within a system that has limited resources and ensuring that the individual, their needs and safety are not lost sight of in that effort.
“We recognise the challenges in providing safe and therapeutic care. There is a risk, particularly where there are low numbers of available staff, that wards are operated solely on the basis of safety and teams feel unable to provide a therapeutic environment of care. Our members are working hard to deal with the continued rise in demand and the pressures this creates for inpatient care.
“The mental health care sector – like the rest of the NHS – has long been starved of capital investment. That is why we are calling for the government to use the upcoming Spending Review to increase capital investment and open up much-needed new routes for mutual investment from the private sector.
“One of the main aims of the Mental Health Bill – currently passing through Parliament – is to provide more therapeutic care, with the ‘Culture of Care’ and inpatient quality improvement programmes already beginning to address these issues. We look forward to working with the government and our members to implement the reforms more widely.”
