When someone experiences a mental health crisis and must stay in hospital, there is an expectation that they are kept safe, and treated with dignity and respect during this confusing and frightening time.

Unfortunately, this is not always the case, as we know through experts by experience, their carers and from tragic high-profile cases in the media over decades that illustrate the devastating consequences of a lack of patient safety.

> Learn more: Your rights when in hospital for a mental health crisis.

What’s going wrong in mental health inpatient safety?

These individual stories and cases collectively form a narrative that shows significant, systemic failings for people in inpatient mental health settings.

The findings of multiple reviews and inquiries, across a national, local and individual case scale echo these experiences and highlight similar problems and inconsistencies across the system.

Analysis of 30 years of Preventing Future Deaths reports (1995-2025) shows that similar recommendations have been made throughout this period, particularly issues with:

• Risk assessment and documentation, with a need for clearer tools, better recording and dynamic review after key events.
• Information sharing and communication between services, across boundaries and with families and loved ones.
• Care coordination and continuity, with a need for a named lead professional, referral follow up and multi-agency working.

These same failings form the basis of Rethink’s asks to improve patient safety for those of us living with severe mental illness.

> Read more: Rethink Mental Illness is always campaigning to improve patient safety.

What needs to change to improve mental health patient safety

To create safe and therapeutic inpatient environments, we need a properly trained and managed workforce from front line staff to those managing whole NHS Trusts, who are held accountable and are able to operate within up to date, clear, helpful guidance and legislation.

Mental health workforce challenges impacting patient safety

The mental health workforce is not sufficient to meet either current or expected increase in the demand on services, both in psychiatric roles and across the wider workforce. We know that the use of agency staff who are unfamiliar with wards, patients and processes often causes disruption to processes such as continuity and care coordination.

Constantly changing staff also prevents people forming therapeutic relationships with staff, which has been shown to be a key factor in recovery. To prevent this, we want to see the use of agency staff significantly reduced.

When current need and workforce means that drawing on agency staff is necessary, robust procedures should be followed to provide appropriate training and information sharing to ensure patient safety.

The workforce must be appropriately trained, with input from experts by experience of severe mental illness and of caring. This must include training on the importance of racial equality, particularly given the disproportionate impact the use of the Mental Health Act has on racialised communities, and specialised training on the role and contribution of carers to improve communication and information sharing.

> Further reading: Rethink Mental Illness is determined to ensure Social Care is not overlooked.

Improving culture in mental health settings to support safer care

Too often we hear that inpatient mental health settings are primarily focused on day-to-day risk management, with little consideration given to the development of a genuinely therapeutic environment that promotes and facilitates recovery. This is often due to constraints created by a lack of staff and resource.

To promote positive culture in inpatient mental health settings, we believe that all staff should see culture development as part of their role and be equipped with clearer tools and better systems for recording risk and documenting events.  

Transitions between services and areas can be confusing and upsetting, and these times are often particularly high-risk for patients. We want to see the practice of inappropriately placing people out of their usual area reduced to zero.

Safe and effective care continuity and coordination with a named lead professional, proper follow-up and multi-agency working can ensure that patients stay actively involved in their care and promote their long-term recovery. 

We hope that through promoting positive cultures, the use of restrictive practices such as physical and chemical restraint will be heavily reduced, in line with the goals of the Use of Force Act. We also want patients to be empowered to know and ask for their entitlements with regard to care standards.

> Learn more: The importance of fighting stigma and discrimination.

Strengthening accountability to improve mental health inpatient safety

There must be robust oversight mechanisms to monitor and evaluate the safety of mental health inpatient settings and make sure there is accountability at every level.

The Health Services Safety Investigations Body (HSSIB) has highlighted the overwhelming amount of reviews & recommendations for inpatient mental health settings and that these recommendations can be at cross-purposes and lack clarity on who is responsible for implementation. This results in a system that is subject to a huge number of recommendations that are not implemented effectively or at all, and no monitoring of the impact of these recommendations.

Recommendations, who is responsible for enacting them and their impact should be consolidated into one place that people working in the system can easily access and understand, and a national accountability mechanism should be established to ensure and monitor their implementation.

We want to see the establishment of a national register, similar to the National Maternity and Neonatal Recommendations register, and the creation of a national oversight mechanism that supports coordination, prioritisation, implementation and oversight of safety recommendations across the system.

Next steps for improving patient safety in mental health services

There are opportunities to take meaningful action to improve patient safety and outcomes. Change starts from the top, and an accountable workforce with a positive culture must operate within up to date and helpful guidance and legislation provided by the government and the relevant governing bodies.

The new Mental Health Act is a big first step on the road to achieving this by improving communication with patients and carers through statutory care and treatment plans and advanced choice documents and creating a clinical checklist for clinicians to work to, for example. However, other laws that affect people in inpatient care must be up to date, work well with each other and must be implemented as efficiently and effectively as possible. 

We believe there are significant parallels between the current situations in the Maternity and Inpatient Mental Health sectors, with each being subject to multiple reviews after tragic cases resulting in a huge number of inquiries and subsequent recommendations.

We would like to convene NHSE, HSSIB, CQC and VCSE representatives from the two sectors to identify any opportunities that exist to bring together learnings to improve patient safety in each respectively.

In some tragic but thankfully rare cases, a person’s mental illness can cause serious risk and harm to others. Improving patient care and safety, including better dynamic risk assessment will support improvements in public safety by ensuring patients are more engaged with services and receive high quality care that facilitates their recovery.

Better care in better environments, centred around the principles outlined above, results in safer care; safer for the public, safer for staff and safer for patients.