In September 2026, the Health Services Safety Investigations Body (HSSIB) published the second of two investigation reports into crisis care in emergency departments (EDs). An interim report was published in April 2026.
A related investigation is examining the 999 and 111 responses to mental health crisis and is to report in April 2027. Further themes may then be brought together in a separate, final report.
Summary
HSSIB note that 3% of ED attendances are mental health related (approximately 504,000) but that people experiencing mental health problems are three times as likely to remain in the ED for more than 12 hours.
The investigation sets out their findings in respect of:
People’s experience in the emergency departments: One organisation described a young person waiting in ED for six weeks. The investigation identified uncertainty over legal and professional responsibilities once Mental Health Act (MHA) criteria were met, with teams disagreeing over who should make decisions and provide care.
Workforce, knowledge, skills and resources: The investigation highlighted variation in liaison psychiatry provision, limited availability of AMHPs and section 12 doctors, and delays in MHA assessments.
Oversight and decision making: Governance accountability and escalation of safety concerns are noted to be variable.
Information sharing and systems: Issues around poor interoperability and information sharing are raised.
Interagency working: Section 136 pathways were reported to be more challenging following implementation of Right Care, Right Person.
The detail of this is found in Chapter 3.
Recommendations
Two safety recommendations and two safety observations have been made.
Safety recommendations for DHSC/NHS England
With relevant national stakeholders:
Establish and support national minimum operational service standards and built design expectations for EDs. This will help reduce unwarranted variation and meet the therapeutic needs of individuals who attend emergency departments in a mental health crisis.
Ensure people in mental health crisis in EDs are kept safe by addressing the findings of this report. This programme of work should provide further support and/or guidance to address:
Clear expectations for roles, responsibilities and accountability for clinically appropriate, co-ordinated MHA assessment pathways.
Effective shared care, governance and escalation arrangements and processes to identify, escalate and review delays related to assessment, bed availability and onward care.
Arrangements to assess, plan for and assure the capacity, capability and resilience of the workforce, including access to relevant specialist and statutory professionals.
Agreed measures and reporting arrangements to monitor workforce and pathway pressures, evaluate improvement actions, identify variation in access, waiting, experience, use of restrictive interventions, and address inequalities between population groups.
This will support safe care by addressing issues in relation to clinical ownership, transfer of care, governance and escalation of patients in mental health crisis in EDs.
Safety observations
Organisations with responsibilities for regulation, oversight and assurance of urgent and emergency mental health crisis care can improve patient safety by using the findings of this report to review how they monitor the safety and effectiveness of care for people in mental health crisis who attend EDs.
Organisations with responsibilities for regulation, oversight and assurance of mental health crisis care can improve patient safety by reviewing the extent to which patients, families and carers are involved in care and decision making for people in mental health crisis who attend EDs. Understanding why family and carer involvement is not consistently achieved will help organisations identify opportunities to improve assessment, safety planning and discharge processes, to help keep people safe.
HSSIB also sets out two safety learning points for Integrated Care Boards
The safety watchdog suggests that ICBs can improve patient safety by:
Ensuring that people with lived experience, families and carers are involved in the design, delivery and governance of urgent and emergency mental health crisis care. This involvement can help to inform decisions, improve services and identify safety risks that may not be visible through operational data alone.
Supporting sustained relationships and effective joint governance arrangements between acute and mental health providers, and other organisations involved in urgent and emergency mental health crisis care. These relationships can help partners develop a shared understanding of local demand, pathway gaps, escalation routes and the impact of delays on people in crisis, families and staff.
Local learning
Finally, HSSIB sets out 44 local learning questions for acute providers and psychiatric liaison teams, covering five themes:
People attending EDs: 15 questions
Workforce: 7 questions
Oversight and decision making: 16 questions
Information sharing and systems: 3 questions
Interagency working: 3 questions
Wider concerns and gaps
HSSIB were concerned to learn that from January 2024 to March 2026 there were 27 preventing future deaths reports relating to coroners’ concerns about the care and treatment of people experiencing a mental health crisis who had visited EDs in England. 14 of those related to workforce related themes, including capability, experience, knowledge of guidance, confidence, capacity and interagency working / communication.
The investigation quotes from a bereaved parent describing an ED as a “war zone” and from a trust saying “operationally its bloody… It is literally a blood fight between the acute hospital and the mental health trust”.
HSSIB were told by a consultant psychiatrist that “Harm remains unmeasured and patients’ human rights are being breached and therefore harm is not visible and is therefore unaddressed … these risks are systemic and arise from the way services are planned, commissioned and co-ordinated, rather than from individual clinical decisions.”
NHS estates staff told the investigation that there are currently no health building note standards for the emerging mental health EDs.
The National Confidential Inquiry into Suicide and Safety in Mental Health doesn't currently collect data on patients who died by suicide after contact with an ED. They will broaden its health service contact criteria before suicide to include liaison psychiatry services in general hospitals and one-off psychiatric assessments following ED presentation, and will report these numbers in future reports.
For mental health providers and commissioners seeking support with these issues, please contact Jill Mason to find out how we can support. You can learn more about our team and services here.
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