‘Worse than the actual death…reliving it over and over again’ – bereaved families describe ‘tick box’ investigations into mental health services deaths
The Health Services Safety Investigations Body (HSSIB) has today published its final report in a series of publications focused on mental health hospitals. The investigation looked at learnings from deaths in acute mental health inpatient settings, as well as deaths within 30 days of discharge.
Key findings include:
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The mental health system is still not learning from tragic deaths in inpatient care.
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Bereaved families describe the process of having to fight to be involved in investigations as “worse than the actual death because they were reliving the death [of their family member] over and over again.” Others felt they were marginalised and excluded from the investigation process, comparing them to a “tick box exercise”.
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A culture of blame exists, with many mental health service’s staff sharing a perception that “someone needs to be held accountable” for inpatient deaths by suicide or self-harm.
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Inquests were described by some staff as “scary”, “adversarial”, and felt a “sense of impending doom” when invited to attend an inquest.
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There is limited follow up on recommendations from inquests and patient safety investigations. Mental health providers report deaths and near missed in varied ways – making it hard to identify patterns or risks.
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A lack of person-centred care in mental health hospitals is leaving patients feeling “hopeless, causing them unnecessary distress”. Families shared examples including:
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A patient who was in hospital for 3 years with “no progression, no hope, no exit plan, no therapy”
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Leave for private therapy being cancelled due to low staffing levels
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Patients who had attempted to take their own lives being left with the same item to continue further suicide attempts
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A music loving patient being denied access to her violin or piano
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One mother said her daughter had been “moved around the country like a parcel… it’s never about her; it’s never about her needs”
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Gaps in discharge planning, crisis service accessibility and access to community therapy are potentially contributing to poor patient outcomes.
Minesh Patel, Associate Director of Policy & Influencing at Mind, said:
“Today’s report makes for hugely painful reading. Our thoughts are with the many bereaved families who have tragically lost their loved ones while under the care of mental health services that should have been there to care for them and keep them safe.
“As families struggle to make sense of their loss, their grief is being compounded by a system that fails to listen and fully learn crucial lessons. At the same time, many overstretched staff working within the underfunded system feel terrified by a culture that can be more focused on blame than making genuine systemic change.
“People in a mental health crisis deserve compassionate care, therapeutic interventions and clear treatment plans. But all too often they can’t even get outside for fresh air or see their families. Too many people find themselves isolated in their rooms, feeling hopeless without the help they need to get better.
“We owe it to every person who has tragically lost their life in the mental health system to learn from their death and do better. This will require systemic change. It requires services to meaningfully involve families and carers in learning lessons from the loss of their loved ones. It requires staff to feel safe and supported to have open and reflective dialogue about patient deaths. And it requires the UK government to invest in staff and buildings so care can be delivered safely in a therapeutic environment, as well as wider mental health services to ensure people have the support they need when they leave hospital.”
