The Healthcare Safety Investigation Branch (HSIB) has today published its latest report highlighting the variation in mental health care across emergency departments and setting out four recommendations aimed at improving patient care. 

  1. Develop a sustainable funding model for 24/7 mental health support in emergency departments (ED)
  2. Standardise national guidance on the initial assessments given to patients in ED
  3. Bring a renewed focus on reviewing and amending self harm guidance
  4. Ensure equal weighing is given to the physical and mental health needs of patients and measure this through hospital inspections

The investigation followed HSIB being notified of the case of Diane, a 57-year-old woman who died by suicide. The early investigation focused on her last four presentations at her local emergency department, the last one being the day before she died. The investigation also examined her interactions with local healthcare services spanning two years. 

Identifying the opportunities missed in Diane’s care fed into a broader investigation, examining the integration of mental health liaison services into the emergency department. It also looked at how staff assess, understand and manage risk when patients present in mental health crisis. 

Keith Conradi, Chief Investigator said:In publishing this report, we’ve highlighted the systemic issues in funding and integrating mental health liaison services into the emergency department. The investigation also showed that there is a lack of clear guidance and process for staff already working in a pressured environment. 

“Every presentation at the emergency department represents the opportunity to provide the safest possible care to those in mental health crisis. By working closely with Trusts, the family, and a range of subject matter experts we’ve developed four robust recommendations and directed them at those best placed to take forward at a national level.” 


Research has shown that currently only 35%* of people get the urgent mental health care they need in the emergency department and that referral rates to liaison services fluctuate between 22% and 88%**. HSIB’s investigation identified that there was a variation in provision across England and no consensus on commissioning models. It also highlighted that liaison services are most effective when permanently integrated into the emergency department. Recognising the aims of the Five Year Forward View*** a recommendation has been made to NHS England to develop a sustainable funding model to support 24/7 services. Recently, in the 2018 budget, the Chancellor also announced a £2bn real-terms increase in funding to ensure mental health support in every large A&E department. 

Analysis of tools, measures and guidance showed that there was an inconsistent approach to the assessment of mental health conditions, when compared to the process for physical conditions. A joint recommendation has been made to the Royal College of Psychiatrists and the Royal College of Emergency Medicine around standardising national guidance on initial assessments for staff working in the emergency department. 

There is a strong link between self-harm and suicide, and hospitals in England deal with 220,000 episodes of self-harm each year****. The investigation found that national guidance on self-harm lacked consistency and coherence. A recommendation has been made to the National Institute for Health and Care Excellence (NICE) focusing on reviewing and amending guidance. 

As part of the Care Quality Commission (CQC) parity of esteem programme, mental health inspectors are included as part of the inspections in emergency departments. They also recognise that those inspections should ensure patients’ physical and mental health needs are cared for until they leave the emergency department. A recommendation has been made for the CQC to review and update inspection criteria for emergency departments, reflecting a parity of care. 

Over the course of the investigation the team worked collaboratively with 70 individuals. They also carried out seven site visits to Trusts across England and analysed a range of data, reports and other literature. 


Notes to editors 

At the request of the next of kin, Diane’s name has been included in the report. The family have asked not to be contacted by the media. 

References from report 

*Page 16, section 3.2.4 (Research has shown)

**Page 16 section 3.2.7 (Systemic risk

***Page 10 section 1.1.15 (The Five Year Forward View for Mental Health

****Page 16 section 3.2.6 (Systemic Risk

Recommendations, observations and safety actions 

Safety recommendations 

  1. NHS England ensures there is a sustainable funding model for 24/7 urgent and emergency mental health liaison services in acute general hospitals with emergency departments.
  2. National Institute for Health and Care Excellence review and amend guidance for the management of self-harm in the emergency department.
  3. The Royal College of Emergency Medicine, in conjunction with the Royal College of Psychiatrists develops and disseminates national guidance for emergency department practitioners to standardise the conduct of the initial assessment of a person presenting following a mental health emergency.
  4. The Care Quality Commission reviews and updates its inspections criteria for emergency departments to ensure equal weight is given to the quality of care provided to people with urgent mental health problems as they do to people with urgent physical health. This would be consistent with its commitment to parity of esteem for mental health. 

Safety observations 

  1. The data regarding mental health presentations is not sufficiently robust to allow for demand for mental health services to be adequately assessed and the impact of service provision to be measured.
  2. Initial assessment of patients, on arrival at an emergency department may benefit from inclusion of key factors from the Royal College of Emergency Medicine guideline. 

Safety action 

The National Institute for Health and Care Excellence has changed the wording of clinical guideline CG16 to reflect the findings of the investigation. 

Consideration should be given to introducing the Australian Mental Health Triage Scale, as it is a comprehensive assessment scale that provides an effective process for rating clinical urgency so that patients are seen in a timely manner. Do not use the Australian Mental Health Triage Scale to predict future suicide or repetition of self-harm.  

Media contacts 

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