Inside the safety watchdog’s mental health investigations

The Health Services Safety Investigations Body’s (HSSIB) recent investigation examines the patient safety risks in mental health inpatient settings. 

We have recently shared details of their emergency department report, but we thought it would be helpful for readers operating in the mental health arena be reminded of the range of their other reports that are available and coming out. 

Last year HSSIB published an overarching report of investigations directed by the Secretary of State for Health and Social Care into mental health in patient settings. It followed the publication of five previous reports by them.

The aim was to examine patient safety risks identified. They acknowledge that the delivery of mental health inpatient care is complex and influenced by many interacting factors. They also highlight that their findings may also be applicable to other healthcare services.  

Their findings covered many areas including:

Safety, investigation and learning culture

• Despite a commitment for a just culture and restorative learning a fear of blame contributes to a more defensive culture.
• Many recommendations do not lead to implemented actions due to lack of impact assessment resulting in unintended consequences, no clear recipient and duplicated recommendations. They noted that the Thirlwall Inquiry prepared a table of recommendations from over 30 inquiries coded to indicate whether they had been implemented or not.

System integration and accountability

• Integration currently relies on relationships and hope that they work well.
• At varying levels of the health and care system there is not a clear understanding of ICSs, ICBs and their remits.  
• ICBs are unable to fully mitigate healthcare risks when contributing factors are outside their control and sit across the wider ICS.
• Significant variance in how different ICBs and LAs work together.

Physical health

• Misattribution of physical symptoms to mental health.
• ICBs lack data and analytical capability.
• Variation in how physical checks carried out.

Digital support for safe and therapeutic care

• A lack of interoperability or integration between digital systems.
• EPR functionality often not available or does not meet staff needs.

Suicide risk and safety assessment

• Doing tasks overshadow meaningful interactions with patients.

The overarching report sets out safety recommendations for both DHSC and the Secretary of State:

For DHSC: HSSIB recommends that the Department of Health and Social Care continues to work with the ‘recommendations but no action working group’ and other relevant organisations, to ensure that recommendations made by national organisations specific to mental health inpatient settings are reviewed. This work should consider the mechanisms that supported or hindered the implementation of actions from these recommendations. This may help the Department of Health and Social Care understand what has worked when implementing actions from recommendations and enable learning about why some recommendations have not achieved their intention.

So far, the response logged on HISSB’s website, as of August 2025, is as follows:

“DHSC is taking forward work to design an oversight mechanism that supports the effective implementation and learning from safety recommendations. The mechanism will enable the tracking, prioritisation and oversight of safety recommendations to implementation. This work builds on the work of the HSSIB-led Recommendations to Impact Group and wider government plans for the oversight of government-led inquiries. It also aligns with the outcome of the Dash review published on 7 July and its findings and recommendations relating to the oversight and prioritisation of recommendations.

As part of this work, DHSC is working with the cross-organisational Recommendations Working Group (DHSC, HSSIB and NHS England) to review a cohort of recommendations made by national organisations specific to mental health services, including mental health inpatient settings. A project will be established in partnership with NHS England leads for mental health policy and patient safety policy to conduct the review and identify what actions if any have been taken in response to the cohort of recommendations. The review will allow us to pilot the proposed approach for a recommendations’ hub, which is intended to form part of the national oversight mechanism and provide useful learning about the barriers and enablers to implementation. The National Quality Board (NQB) will be responsible for reviewing, analysing and taking forward recommendations as outlined in the 10-year health plan and the Dash review of patient safety across the health and care landscape.”

Action planned to deliver safety recommendation

“Undertake a review of a cohort of mental health recommendations to understand what actions have been taken in response and identify any barriers or enablers to their implementation, by November 2025. Other dependencies identified: Work programme to implement Dash recommendation that the NQB takes responsibility for the oversight of implementation of recommendations and that it builds and maintains a repository of recommendations from multiple sources.”

For Secretary of State: HSSIB recommends that the Secretary of State for Health and Social Care directs and oversees the identification and development of a patient safety responsibilities and accountabilities strategy related to health and social care integration. This is to support the management of patient safety risks and issues that span integrated care systems.

So far the response logged on HSSIB’s website, as of August 2025 and March 2026, is as follows:

“Cleary defined roles, responsibilities and accountability mechanisms are important elements of the governance and oversight arrangements in health and care services for ensuring patient safety.

The changes we are making as part of the 10-year health plan will improve quality and safety by making it clear where responsibility and accountability sit at all levels of the system, and between health and social care partners.

Our plans for a NbH service will rebalance our health and care system so that it fits around people’s lives, and not the other way around, moving away from a one size fits all approach and giving people more power and choice over the care they receive. Under the leadership of the Health and Wellbeing Board, NbH plans will be developed by local government, the NHS and its partners, setting out how integrated teams of professionals across the health and social care spectrum, will work together to provide comprehensive care in the community.

Integrated Care Boards (ICB) will continue to play an important role in local accountability relating to patient safety risks. NHS England have set out a ‘blueprint’ to clarify the ICB role as strategic commissioner to deliver the 10YHP. Alongside this we will give Mayors (or their delegated representative) a seat on ICBs to better align the opportunities for strategic planning between the NHS and Local government.

In response to Dr Penny Dash’s review we will rationalise the safety regulatory landscape to ensure a more consistent focus by the Care Quality Commission (CQC) and give specific responsibility for reviewing, analysing and taking forward recommendations to the National Quality Board (NQB).

Our approach cannot be at the expense of patient voice and patient experience. It is why we will bring patient voice 'in house', giving it greater profile within the reformed DHSC. We will also put patient experience at the heart of the NHS with a new national director who will oversee the collection of more informed patient feedback and lead on improving the NHS complaints system. We will improve response times to patient safety incidents and complaints by expanding use of AI tools to support faster collection of complaints data. We will publish easy-to-understand league tables, ranking NHS providers against key quality indicators.”

Actions planned to deliver safety recommendation

1. Publish the National Framework for neighbourhood Health. By: Later in 2025/26.
2. Amend legislation to allow Strategic Authority Mayors as members of ICB, by April 2027. Other dependencies identified: English Devolution and Community Empowerment Bill to receive Royal Assent. NHS Reform Bill must also receive Royal Assent. Subject to will of Parliament.
3. Following Dr Dash’s review, we will rationalise the safety regulatory landscape to ensure a more consistent focus by CQC, by April 2027 (TBC).
4. Give specific responsibility for reviewing, analysing and taking forward recommendations to the National Quality Board (NQB). By when: TBC.
5. Within a reformed DHSC, we will incorporate the functions of Healthwatch England to put patient voice at the heart of everything we do, by April 2027 (TBC). Other dependencies identified: subject to will of Parliament.
6. A new national director will oversee the collection of more informed patient feedback and lead on improving the NHS complaints system. By when: TBC. Additional information: Resources in place for early scoping of patient experience directorate.
7. Publish easy-to-understand league tables, ranking NHS providers against key quality indicators. By when: League tables are due to be published in the autumn. Additional information: League tables went live on 09.09.25.
8. Improve response times to patient safety incidents and complaints by expanding use of AI tools to support faster collection of complaints data. By when: TBC. Other dependencies identified: Related to national director to oversee patient feedback.
9. Legislate to transfer HSSIB functions to CQC as part of a wider effort to simplify the regulatory landscape, by April 2027 (TBC). Other dependencies identified: Subject to will of Parliament.

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