Mental health: Lessons not being learnt from inpatient deaths, says safety body
A culture of fear and blame, systemic problems with data collection, and lack of patient and family involvement are preventing lessons being learnt from deaths of mental health inpatients in England, a patient safety agency has concluded. The report by the Health Services Safety Investigations Body (HSSIB) examined any learning from investigations into patient deaths in mental health inpatient units and deaths that occurred up to 30 days after discharge.1 Nichola Crust, HSSIB senior safety investigator, said the report painted a “sobering picture” of the NHS “trying to implement meaningful learning and actions to prevent future deaths in a landscape that is fraught with grief and blame . . . with significant systemic issues, gaps, and poor cultures that serve to undermine patient safety in mental health care. In short: the system is still not learning …
