Mental health patients and nursing staff are being failed by a system “buckling under the weight of demand and decades of underinvestment”, nursing leaders have warned.
Their comments came in response to the publication of the Health Services Safety Investigations Body (HSSIB)’s final report in its series of investigations focusing on mental health inpatient services in England.
“These shocking findings show that patients are being put at risk by a failure to invest in mental health nursing”
Stephen Jones
The review, which began January 2024, was commissioned by former health and social care secretary, Steve Barclay, to try and improve patient safety and boost the quality of mental health hospital care.
Now, the HSSIB has brought together themes from the four investigations published between September 2024 and January 2025 as part of the review, and set out recommendations for the current government to take forward.
Nursing Times has broken down some of the key findings.
Challenges with staffing and resourcing
The report warned that staffing and resource constraints in inpatient and community mental health settings were impacting the ability to provide safe and therapeutic care to patients.
The investigation heard from providers that wards aimed to staff for “safety”, which means having a minimum number of nurses on shift to protect patients from harming themselves or others.
Challenges for staff included the emotionally demanding nature of their work. The report warned that this was leading to staff burnout and sickness, and further strain on services.
The HSSIB noted that it had heard evidence from the Royal College of Nursing, which said the mental health nursing workforce in England was experiencing “crisis-levels of workforce shortages and retention issues”.
The college further echoed that nurses were experiencing “high levels of stress and burnout due to increased workload and high demand for services”.
Fear of blame and defensive culture
The HSSIB investigations uncovered a “fear of blame” in mental health settings when safety events happen.
It warned that this “contributes to a more defensive culture despite staff actively wanting to learn”.
Pressures on organisations, particularly after a safety incident, could create a divisive “us versus them” mindset between leadership and frontline staff.
Senior leaders said they sometimes felt like “the naughty child on the naughty step and everyone turns in on you”, the review heard.
Meanwhile, the review found that many recommendations to improve mental health inpatient services were often not implemented.
There were several reasons for this, including a lack of impact assessments, no clearly identified body responsible for taking forward recommendations, and duplication of similar recommendations across different organisations.
Disparities in physical health care
The report concluded that there were gaps in the provision of physical health care for people with severe mental illness, including “inconsistent health checks, poor emergency responses and misattribution of physical symptoms to mental illness”.
It noted that many national reports and research had made recommendations to improve the physical health of people with severe mental illness, but that recommendations were delayed in implementation.
Variation in the knowledge, skills and experience of staff who undertake physical checks was also identified, while patients were found to not always be supported in terms of health education.
This has been a subject of contention this year, with some health leaders calling for mental health nurses to be better equipped at providing physical healthcare to patients.
Other findings and recommendations
The HSSIB set out many other findings from across the four investigations it had published.
One finding was that there is fragmentation between health and social care services.
The report warned that there was a clear lack of accountability across health and social care services for people with mental illness and severe mental illness.
It also flagged that inpatient bed days were taken up by people who no longer need them, because those clinically fit to be discharged were delayed in being transferred to their home or suitable residence.
The reviews also explored suicide risk assessments, with the final report warning that the language used in these situations can minimise patient experiences and create fear – leading to less open communication.
Further, the report said ‘doing’ tasks like ticking checklists were overshadowing meaningful, empathetic ‘being’ interactions with patients.
Just two recommendations were set out in the final HSSIB report, directed at the Department of Health and Social Care.
The first was for the department to work with the ‘recommendations but no action working group’ to ensure that recommendations made by national organisations specific to mental health inpatient settings were reviewed.
The second was for the health and social care secretary, Wes Streeting, to direct and oversee the development of a ‘patient safety responsibility and accountabilities strategy’ to strengthen integration between health and social care.
It said this would support the management of patient safety risks and issues that span integrated care systems.
Craig Hadley, senior safety investigator at the HSSIB, said the report had highlighted “the urgent and ongoing issues facing mental health inpatient care”.
He added: “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.”
Stephen Jones, head of nursing practice at the Royal College of Nursing, said the findings showed mental health patients and nurses “being failed by a system buckling under the weight of demand and decades of underinvestment”.
“These shocking findings show that patients are being put at risk by a failure to invest in mental health nursing and should serve as a message to the government of the need for proper funding,” he argued.
“Everyone deserves safe care, no matter their needs or where they live. But poor integration with social care, housing and other community services means the standard of care varies across the country and makes the job of staff much harder.
“The result is mental health patients being forced to roll the dice when they need to access services.”
Mr Jones called for the upcoming 10-year plan for the NHS, due imminently, to “properly transform mental health care”.
“We need urgent and sustained investment in the mental health services and the nursing workforce to turn peoples’ lives around and ensure everybody gets timely care in the right place,” he added.
A Department of Health and Social Care spokesperson said: “Patient safety is paramount, and we know that mental health patients have not been getting the high-quality care and treatment they deserve.
“That’s why this government is investing an extra £680m in mental healthcare this year, hiring more support workers, delivering more talking therapies and opening new mental health crisis centres around the country.
“We are also modernising the Mental Health Act to ensure patients receive better, more compassionate treatment, appropriate to their needs.”
More from the HSSIB mental health inpatient review:
