Today HSIB supports World Mental Health Day, highlighting the stories behind two of our national investigations and the improvements being made to mental health care across the NHS.

Last year we published two reports and their associated safety recommendations. These focused on mental health and shone a light on some of the biggest issues faced by people accessing mental health services and how this affects them, their families and frontline staff in the NHS.

Devastating impact of suicide

Our transition from child and adolescent to adult mental health services (CAMHS to AMHS) report, published in July 2018, focused on the case of an 18-year old college student who tragically took his own life whilst in the transition from CAMHS to AMHS. The investigation that followed showed that young people would benefit from a flexible, managed transition to adult mental health services which has been carefully planned with them.

Last November, we told Diane’s story in a report looking at the provision of 24/7 mental health liaison services in emergency departments. Diane had died by suicide the day after presenting at her local A&E, and the investigation identified opportunities that were missed in her care.

Keith Conradi, HSIB Chief Investigator, said: “Both stories showed the devastating impact of suicide and also showed a bigger picture about what needed to be improved in the system to stop these things from happening again. We identified how transitions at such a key stage in life need to be flexible, smoother and safer for young people. We recognised how distressing A&E can be for those suffering a mental health crisis, and also the immense pressure on staff when they are in a busy environment with little guidance.

“World Mental Health Day serves to remind us of the role we can take in making sure people have a better experience when accessing care. We will continue to make this a priority through any investigation that focuses on these issues.”

Further investigations

This year, we’ve launched one investigation looking into medication omission in mental health hospitals with a report due in 2020. We will also publish a report this Autumn on the under-recognised risk of propranolol, after a 25-year old female died following an overdose of that medication.

Safety recommendations

Since the publication of the two reports in 2018, all the bodies and organisations agreed our safety recommendations and have sent us full responses setting out what they have done and will do in response.

Read our mental health safety recommendations and the responses in full on our investigation pages:

World Mental Health Day

World Mental Health Day is observed on 10 October every year to raise awareness of mental health issues around the world. The theme for this year’s day is suicide prevention. It’s a World Health Organization initiative that encourages those involved in mental health issues to talk about their work and what more needs to be done to make mental health care a reality for people worldwide.