Date Published: 21 July 2006

UK National Patient Safety Agency: Analysis of mental health patient safety incidents

Mental health services need to redouble their efforts to ensure the safety of patients. This is the message the UK government will be sending to services in response to a report published today by the National Patient Safety Agency (NPSA).

The report, With safety in mind; patient safety in mental health services, provides the first detailed analysis of patient safety incidents from any national incident reporting system worldwide.

The analysis covers almost 45,000 mental health incidents reported to the agency's National Reporting and Learning System (NRLS) by mental health staff between November 2003 and the end of September 2005. It includes data from 75% of specialist mental health service providers in England and 80% of combined trusts in Wales. It also includes new analysis of clinical negligence claims, data from death registrations, hospital activity and national surveys.

Most incidents reported to the NRLS from mental health settings were associated with no or low harm, but 2% reported severe harm or death, usually as a result of suicide. The four most common incident types, accounting for over 84% of mental health service reports, were: patient accidents, disruptive / aggressive behaviour, self-harming behaviour, and absconding or missing patients.

The report also provides evidence of the effectiveness of existing interventions, such as the implementation of collapsible curtain and shower rails, which have prevented inpatient service users from committing suicide.

Of the 45,000 incidents, there were 122 reports relating to sexual safety, representing about 0.3% of all reports. These included allegations of rape, consensual sex, exposure, sexual advances and touching.

In response to the information on incidents relating to sexual safety, the National Director for Mental Health Professor Louis Appleby has launched a review into the most serious allegations. In addition, he will also be asking every mental health trust to review their procedures to ensure that they have in place measures to protect the sexual safety of inpatients.

Professor Louis Appleby said:

" Although the vast majority of NHS patients receive safe and effective care, any incident where the safety of a patient is compromised is one incident too many. We must investigate and learn from all these incidents, so that we can make systems safer and more reliable in preventing harm.

_ I am concerned about a number of serious sexual allegations highlighted by this report. The information we have on individual cases is limited, therefore I have ordered a review to ensure that appropriate action was taken. I will also be asking mental health trusts to ensure that they have the appropriate procedures in place to protect the safety of patients.

_ The Government takes the safety of patients very seriously. That's why we have introduced a number of initiatives, such as requirements to provide separate single sex accommodation. Because of significant investment, we have already made real progress in improving the general safety of in-patient services and driving up standards of care.

_ This report shows that there are still many challenges to overcome and I expect to see action to ensure that the process of improvement continues."

Professor Richard Thomson, Director of Epidemiology and Research at the NPSA, said:

" The NRLS provides information on the sorts of things that go wrong in patient care. This report describes a range of safety incidents occurring in mental health settings and also describes a range of initiatives being pursued by the NPSA and other organisations, including local services, to address these events. Incidents range from falls through self harm to violence and aggression. The allegations of incidents which compromise sexual safety are in particular being taken very seriously. The NPSA will be working with the National Institute for Mental Health in England (NIMHE) on further actions to improve safety in this context.

_ Mental health service users, especially when acutely ill, are vulnerable to a range of risks, sometimes as a result of their own behaviour or the behaviour of other patients. Sometimes they are vulnerable because of weaknesses in the systems within which they receive care. We must also acknowledge the challenges that staff working in psychiatric wards face, which include the risk of violence.

_ Mental health services have a responsibility to protect patients from inadvertent harm. This report seeks to raise the profile of safety in mental health and to stimulate a wide body of action across the NHS to make care safer for all patients."

Main source: National Patient Safety Agency (NPSA), UK -

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