The terms of reference for a national inquiry into safety issues in mental health hospitals have been published, highlighting safe staffing and working conditions.
Former Health and Social Care Secretary Steve Barclay announced the inquiry last year to improve patient safety and raise the quality of inpatient mental health care in England.
The Healthcare Services Safety Investigations Body (HSSIB) has been working since June 2023 to determine the scope of the review and consider relevant evidence.
This week the government announced the four different studies this will take place as part of the review, which together form the overall mandate.
Reference terms
Learning from mental health deaths and near misses to improve patient safety
- Explore the mechanisms that collect data on deaths and near misses across the mental health landscape, including up to 30 days post-discharge
- Examine local, regional and national oversight and accountability frameworks for deaths in inpatient mental health settings
- Understand how providers ensure timely and effective investigations
Providing safe care during the transition from child and adolescent psychiatric services to adult inpatient mental health services
- Determine and understand age-related considerations for CYP and inpatient adult mental health care
- Consider how approaches to transition between CYP and inpatient adult mental health care are being evaluated to support the recovery of people who use them
The impact of out-of-area placements on mental health patient safety
- Identify factors contributing to the use of out-of-area patient placements
- Evaluate how the needs of users of local mental health services are identified by integrated care councils and trusts and how this enables appropriate local provision
- Consider how local healthcare providers monitor out-of-area patients, including how they support them to return to appropriate services within their local area
Creating the conditions in which staff can provide safe and therapeutic care
- Explore the factors that influence providers’ ability to safely staff their inpatient mental health units
- Investigate the conditions on the psychiatric wards where staff work and the impact the conditions have on the provision of safe and therapeutic care
In a ministerial statement announcing the launch of the mandate, current Health and Social Care Minister Victoria Atkins said: “The investigations will identify risks to patient safety and the HSSIB will seek to address these risks by making recommendations to facilitate the improvement. of systems and practices in the provision of mental health care in England.”
She further revealed that the review in these circumstances would include “considering the safety of patients and staff in relation to allegations of sexual assault and rape”.
Ms Atkins noted that the patient voice “will be an integral part of the HSSIB investigation and report”.
“They have been in contact with patients and families who have experienced poor care, as well as their parliamentary representatives, and are working with patient advocates and the charity sector to organize focus groups to support these investigations,” she said.
The findings of each study will be published over the course of the year and completed by the end of 2024.
This national survey follows the launch of a special Care Quality Commission (CQC) review of mental health services at Nottinghamshire Healthcare NHS Foundation Trust.
It was at this trust where Valdo Calocane was treated for paranoid schizophrenia before he murdered Barnaby Webber, Grace O’Malley-Kumar and Ian Coates.
The inquiry into the trust will provide further answers for the families of the victims affected by the June 2023 murders, and will also focus on wider mental health issues in Nottinghamshire.
Ms Atkins said: “The CQC’s special review will focus on assessing the care provided by Nottinghamshire Healthcare NHS Foundation Trust and identifying where things may have gone wrong.
“This will provide families with much-needed answers and help identify how the quality of mental health care in Nottinghamshire can be improved.”
Ella Devereux