A culture of blame and fear across mental health services is preventing staff from learning and reflecting following a patient death, according to a report from the Health Services Safety Investigations Body (HSSIB).
Mental health nurses have described wanting to work openly and honestly with families following the death of a patient, but that fear of litigation was preventing them from doing so.
“Opportunities to both learn from deaths and improve quality of care are being missed”
Saffron Cordery
The findings come from a new report published by the HSSIB, the fourth in its series of investigations focusing on mental health inpatient services in England.
The latest report examined how providers conduct investigations into deaths of patients receiving care in inpatient units, or within 30 days of discharge.
A key finding of the investigation was that there was a “culture of blame” around inpatient deaths, where organisations – as well as sometimes patients and families – were worried about speaking out and getting blame placed on individual staff members.
The report heard from staff that investigations that went well were the ones where everyone felt safe to talk openly and honestly.
However, many staff reported that there was a perception that “someone needs to be held accountable” for inpatient deaths caused by self-harm or suicide.
One senior nurse told the investigation that, when a blame culture arises, there was “fear of litigation”.
The report found that legal processes within organisations following a death of a patient may unintentionally shut down opportunities for learning by creating a “culture of defensiveness rather than reflection”.
Staff reported having a lack of time, permission or safe spaces to support open conversations about patient safety incidents.
Similarly, inquests into patient deaths were described by staff as “scary” or “adversarial”.
Some described feeling “a sense of impending doom” when requested to attend an inquest.
One staff member said: “It really feels like you are in court, and someone will determine whether you are guilty or not.
“Why else would you have a jury unless you are accused of something?”
The investigation also spotlighted the experiences of families who have gone through the investigation process.
Some families described feeling marginalised and excluded from the investigation process, seeing it as a “tick box exercise” and no culture of transparency, learning and accountability.
Concerningly, some organisations were described by bereaved families as “gaslighting, bullying and [having] toxic environments”.
One respondent said the investigation process was “worse than the actual death” of their relative because they were having to relive the death “over and over again”.
Overall, the report warned that patient safety investigations often did not consider the emotional distress experienced by all affected, which it warned compounded the level of harm experienced.
The HSSIB also examined the oversight and accountability when a patient dies in a mental health setting, and the measures currently in place for capturing data on deaths.
It found limited follow-up on recommendations made during inquests or patient safety investigations, as well as lack of national mechanisms to ensure implementation.
Like other reports on this issue, the HSSIB identified inconsistencies in data reporting across organisations, as well as lack of consistent terminology.
It said mental health providers were reporting deaths and near misses in varied ways, using different definitions and methods, which meant it was hard to identify patterns or risks.
Other areas of concern identified in the report included gaps in discharge planning, crisis service accessibility, access to community therapy and staff skilled in mental health.
These gaps had resulted in “people being left in unsafe situations where they may self-harm”, said the report.
Overall, the HSSIB emphasised the need for a “systemic approach” to safety investigations and learning, with a focus on collaboration, transparency and oversight.
It called for there to be a “shift” from procedural practices to a culture across organisations rooted in empathy, person-centre care and active involvement of families.
More from the HSSIB mental health inpatient review:
The investigation set out a series of recommendations, which included calls for clarity on the national expectations for meaningful learning from patient safety events and deaths.
Similarly, it called for a national oversight mechanism to be established that ensured recommendations from public inquiries, investigations and inquests were implemented, monitored and reviewed.
The report also called for the development of a unified dataset, with agreed definitions on how to record and report deaths in mental health services.
Nichola Crust, senior safety investigator at the HSSIB, said providers were trying to implement meaningful learning and actions to prevent future deaths in a landscape “fraught with grief and blame”.
She said it was hard to hear the “pain, anger, guilt and distress” felt by patients, families, carers and staff.
She added: “Emphasis on fairness, transparency and support for both families and staff is needed, and also their stories show the importance of learning and accountability, rather than blame.”
Meanwhile, Ms Crust said the latest report had been published at a “crucial time for reform in the NHS” and called for the findings to contribute to the government’s long-term plans in relation to mental health settings.
She said: “Whilst the report does paint a sobering picture, it also does pinpoint the opportunities for improvement, through our findings and safety recommendations.
“Emphasis on fairness, transparency and support for both families and staff is needed”
Nichola Crust
“We emphasise areas that should be prioritised to remove the barriers and limitations to learning – only then will the system see an improvement in patient safety, a reduction in compounded harm and ultimately a reduction in deaths in inpatient care.”
Responding to the report, the interim chief executive of NHS Providers, Saffron Cordery, said: “The NHS knows it must do more to improve how it learns from the deaths of mental health patients.
“This hard-hitting report sets out in stark detail that, far too often, families and carers are being let down by inconsistencies and variations in practice across the NHS and within trusts.
“Opportunities to both learn from deaths and improve quality of care are being missed. Shortfalls in tackling systemic issues are further compounding these challenges.”
Ms Cordery argued that, when someone dies under NHS care, it was essential that bereaved families and carers “are treated with honesty, respect and compassion”.
She added: “Families need to know, and be confident, that the NHS will recognise and act on any failings in care and deliver meaningful change to help prevent them happening again.”
