'Dead on a railway track': Mental health services 'still not learning' from mental health inpatient deaths

'Dead on a railway track': Mental health services 'still not learning' from mental health inpatient deaths
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'Dead on a railway track': Mental health services 'still not learning' from mental health inpatient deaths
Published: Jan, 29 2025 13:01

Mental health services are not learning from inpatient deaths in England, a new report has found, citing a culture of fear and blame within the services. The report from the Health Services Safety Investigations Body (HSSIB) revealed critical gaps in the safety and investigations process for patients who died both in the care of services and within 30 days of being discharged.

It found a "culture of blame" where individuals - including patients, families and organisations - fear the safety investigation process. In turn, investigations were found to often not consider the emotional distress of all affected, which compounded harm, while legal processes may also "unintentionally shut down opportunities for learning", which fostered a culture of defensiveness.

The report also revealed systemic issues in mental health facilities, including inconsistent discharge planning, limited access to crisis services and inadequate community therapy provision. These gaps contributed to poor patient outcomes. Many families said they felt marginalised from the process that looked into why their loved ones had died, feeling like it was a "tick-box" exercise for the organisation.

Some family members described organisations as having "gaslighting, bullying" and "toxic environments", as they were forced to re-live the death of their family member over and over again. Adults with ADHD have shorter life expectancy, study finds. Mental health of working-age population appears to be getting worse.

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