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Update on review into mental health inpatient services

The terms of reference for the Healthcare Services Safety Investigations Body (HSSIB) investigation into mental health settings have now been published which will help improve patient, staff, and community safety.

The HSSIB and its predecessor, the Healthcare Safety Investigation Branch (HSIB), has worked since June last year to determine the scope of the investigation and have been reviewing relevant evidence.

The aims of the investigation include learning from impatient mental health deaths, improve patient safety, helping to provide safe care during transition from children and young people to adults in mental health services and create conditions for staff to deliver safe and therapeutic care.

The findings from the HSSIB investigation, which will include consideration of patient and staff safety regarding allegations of sexual assault and rape, will be published over the course of the year to drive improvements in patient safety and NHS mental health services. The investigation will conclude by the end of 2024.

HSSIB will engage with patients, families and carers, as well as local and national healthcare organisations, as part of its review.

Health and Social Care Secretary Victoria Atkins said:

Families, staff and the public deserve answers when things go wrong in mental health settings.

This review will identify ways we can improve mental health care, protect patients and the public and create a safe working environment for staff.

It follows the launch of a special review by the Care Quality Commission into Nottinghamshire Healthcare Foundation Trust, where Valdo Calocane was treated for paranoid schizophrenia before he killed Barnaby Webber, and Grace O’Malley-Kumar and Ian Coates.

The review, which was commissioned by the Health and Social Care Secretary, will provide further answers for the victims’ families affected by the horrendous and tragic killings in Nottingham in June 2023 as well as focus on wider issues in mental health care provision in Nottinghamshire, including at Highbury Hospital and Rampton Hospital.

Notes to editors:

A Written Ministerial Statement with further information is available here

There will be four investigations which will focus on:

  • Learning from inpatient mental health deaths, and near misses, to improve patient safety.
  • The provision of safe care during transition from children and young person to adult, inpatient mental health services.
  • Impact of out of area placements on the safety of mental health patients.
  • Creating the conditions for staff to deliver safe and therapeutic care – workforce, relationships, environments.

For more information on HSSIB investigations, visit:

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