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.
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 also revealed systemic issues in mental health facilities, including inconsistent discharge planning, limited access to crisis services and inadequate community therapy provision.
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.
It found a "culture of blame" where individuals - including patients, families and organisations - fear the safety investigation process.
