Closing the gap between physical and mental health care: HSSIB’s latest investigation

How can mental health services ensure that a patient’s physical health does not become secondary to their psychiatric care? That question sits at the heart of the Health Services Safety Investigations Body’s (HSSIB) latest report, published at the end of July, which examines the deterioration of a patient’s physical health while they were receiving care in a low secure mental health unit. As we highlighted in our previous blog earlier this summer, the report forms part of HSSIB’s wider scrutiny of patient safety in mental health care.

At the outset HSSIB emphasise that Patient Safety Incident Investigations (PSII) focus on improving healthcare systems and do not look to blame individuals.

Incident summary

The patient concerned, James, was detained under a section 37/41 Hospital Order. They were prescribed antipsychotic medication and a mood stabiliser for schizoaffective disorder. When they were transferred to the low secure unit (LSU) there were concerns about sleep apnoea.  Healthcare records described a number of challenges in relation to sleep. Due to the patient not wanting to engage sleep assessments were delayed.  Following deterioration of James’ respiratory condition he was escorted to an Emergency Department (ED) but discharged back to the LSU.  Following a further worsening they were again escorted to the ED.  IM lorazepam and Levomepromazine (sedatives) were prescribed.  A respiratory arrest occurred and James required immediate resuscitation.  He was transferred to the ICU.  He was eventually discharged to another LSU approximately two months later.

The investigation produced 12 findings, which HSSIB grouped into five priority areas for improvement.

Five areas for improvement:

1. Opportunities available for people to make healthy lifestyle choices, including weight management , smoking cessation and exercise whilst detained on LSU.
2. Access to a suitable area within the LSU for staff to carry out physical health observations and assessments.
3. Clarify clinician roles, responsibilities and processes, including those for prescribing between mental health and physical health staff when caring for patients with acute agitation, to help effective assessment in the ED.
4. Trauma informed organisational support for staff and shared safety learning for patient safety events where care spans more than one healthcare provider.
5. The ability to identify and apply a personalised approach to care planning to encourage people detained in inpatient mental health settings to engage with specialist services.

HSSIB are working on another report on an incident involving a person who self-harms while in inpatient mental health care. That is expected in the Autumn.

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