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Sharing insights to drive improvements in mental health care

Public Affairs and Insight Manager

Unveiling plans to transform mental health support in January 2017, Prime Minister Theresa May said: ‘For too long mental illness has been something of a hidden injustice in our country, shrouded in a completely unacceptable stigma and dangerously disregarded as a secondary issue to physical health’.

In 2016, NHS England launched the Five Year Forward View for Mental Health, highlighting areas where mental health care had been falling short, and setting out priorities for action to improve services. 

Mental health has never had a higher profile, and improving mental health care has become a national priority. 

It is in this context that we publish Maintaining momentum: driving improvements in mental health care, which is based on evidence from our complaints casework.

Five common themes

We analysed over 200 complaints made by or on behalf of people with mental ill health, which we either upheld or partly upheld, over a three and a half year period from April 2014 to October 2017. We were able to identify five common themes spanning the entire patient journey:

  • Diagnosis and failure to treat
  • Risk assessment and patient safety
  • Dignity and human rights
  • Communication
  • Discharge and aftercare.

The human impact of failings in mental health care

The cases included in the report show the devastating human impact of failings in mental health care on patients and their families – leading to avoidable harm, death and violation of human rights. 

For example, in the case of Mr O, a mental health professional failed to consider a diagnosis of Post-Traumatic Stress Disorder. This meant that Mr O did not receive appropriate treatment and support and tragically took his own life.

In another case, Mr P was not told of his rights under the Mental Health Act and so did not understand the consequences of refusing his medication. This meant that nurses used unnecessary and excessive force to administer it to him.

Realising the ambitions of the Five Year Forward View 

The cases in our report predate publication of the Forward View. The NHS is already aware of the issues we have seen and has identified what needs to be done to address the problems. Because of this, we have not made any recommendations for system improvement.

We are sharing these cases so that NHS organisations can learn from mistakes and improve frontline service delivery of mental health care. We also hope to see a more prompt and honest approach to the way mental health care providers respond to people’s concerns and complaints.

By shining a spotlight on the potentially catastrophic consequences of mistakes, we want to underline the urgent case for a radical upgrade in mental health care and ensure that no momentum is lost in implementation the Five Year Forward View. We will monitor our casework over the coming years to see if the necessary improvements are being made.

Read the report