Vulnerable patients with mental health conditions are being badly let down by the NHS, causing them and their families needless suffering and distress, according to a Parliamentary and Health Service Ombudsman report published today.
The Ombudsman has also found that NHS mental healthcare staff can lack the capacity, skills and training they need to do their job effectively, and do not always have the support they need to learn from mistakes.
Following an analysis of over 200 mental health complaints upheld by the Ombudsman, the report highlights five common failings that are compromising patients’ safety and dignity:
- Failure to diagnose and/or treat the patient: One investigation found that a woman was treated with anti-psychotic drugs for a psychotic episode but had a life-threatening reaction to them. Her physical symptoms were dismissed and tragically she died.
- Inappropriate hospital discharge and aftercare of the patient: In another case, a young man who had a complex history of mental health problems died from a drug overdose after being discharged from the local community mental health service, without a care plan in place.
- Poor risk assessment and safety practices: The report reveals how a young person suffering from bipolar disorder and on the autism spectrum was physically assaulted by another patient in a residential home, causing them immense fear and distress. A risk assessment, which could have easily prevented the assault, was not carried out.
- Not treating patients with dignity and/or infringing human rights: Another investigation found that a woman suffering from a psychotic episode was not given sanitary products while she was menstruating so she was forced to use a plastic cup. This was deeply humiliating for her and did not respect her dignity and well-being.
- Poor communication with the patient and/or their family or carers: The report tells how a woman who had a history of bipolar disorder had her new born baby taken from her unnecessarily and without explanation, causing her immense distress.
Parliamentary and Health Service Ombudsman, Rob Behrens, said:
This report shows the harrowing impact that failings in mental healthcare can have on patients and their families.
‘Too many patients are not being treated with the dignity and respect they deserve and this is further compounded by poor complaint handling.’
The report’s findings provide fresh impetus to deliver on the recommendations set out in the Five Year Forward View for Mental Health and reinforce conclusions made by the Care Quality Commission in its 2017 report.
The Ombudsman added:
The cases we have identified demonstrate the importance of maintaining momentum in improving mental health services, to ensure patients receive the safe, effective care they need and prevent the same mistakes happening to others.’
The Ombudsman will continue to closely monitor its casework and if mental health services are improving, there should be a reduction in the types of complaints in the report over the next few years.
Brian Dow, Director of External Affairs at Rethink Mental Illness, said:
This judicious report from the Ombudsman reflects what our supporters have been telling us for years: that our overstretched services are failing them time and time again.
These findings underline the desperate need for reform and the sometimes devastating consequences of a struggling system. We do now have a blueprint for change but this will need drive and funding to achieve its aims, or we will continue to hear stories like these.’
Notes to Editors:
1. The Parliamentary and Health Service Ombudsman provides an independent and impartial complaint handling service for complaints that have not been resolved by the NHS in England and UK government departments. We look into complaints where someone believes there has been injustice or hardship because an organisation has not acted properly or has given a poor service and not put things right. We share findings from our casework to help Parliament scrutinise public service providers and to help drive improvements in public services and complaint handling.
2. The Ombudsman’s report Maintaining momentum: driving improvements in mental health care is based on the analysis of 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.
3. In 2016-17 there were 14,106 complaints made to NHS mental health trusts, with around 65% being upheld or partly upheld by the local organisation.
4. In 2016-17, the Parliamentary and Health Service Ombudsman completed a further 352 investigations into NHS mental health trusts and found failings in 130 (33%) of these cases. We also saw failings in a further 37 complaints which were either already accepted by the organisation, or where we were able to resolve the complaint without completing a full investigation.
5. The independent Mental Health Taskforce published the national strategy the Five Year Forward View for Mental Health for the NHS in England in February 2016.
6. The Care Quality Commission (CQC) report, The state of care in mental health services 2014 to 2017, presents findings from their programme of comprehensive inspections of specialist mental health services.