Safety investigations which occur after a person died during or shortly after care during a stay in a mental health facility are often seen as a “tick box exercise” and could be “compounding harm” for those affected, according to a new report.
The Health Services Safety Investigations Body (HSSIB) said there was evidence that the healthcare system “is not learning” from patient deaths. A new report from the patient safety watchdog highlights how bereaved families have described having to “fight” to be involved in the investigation into the death of their loved one.
Families said they wanted safety investigations into the death of their loved one to “mean something”, but many described their involvement in the process as “tokenistic”. Meanwhile, a family member described the investigation process as “worse than the actual death because they were reliving the death [of their family member] over and over again”.
The report also describes how some families believe a lack of person-centred care can leave patients “feeling hopeless, causing them unnecessary distress”. “The investigation was told that there were key areas within mental healthcare where organisations did not feel they were learning from deaths,” the authors wrote.
This was particularly so in regards to person-centred care and people being treated in the right place. The document features testimony from a mother who said her daughter had been “moved around the country like a parcel… it’s never about her, it’s never about her needs”.
