Maintaining momentum: driving improvements in mental health care

How we chose these complaints

We chose the cases in this report after following a rigorous process to identify the common themes in the hundreds of complaints we have received about mental health services in recent years. They cover decisions we made between 2014-15 and 2017-18.

The first step we took was to gain a preliminary understanding of the issues in our casework. We looked at a sample of 150 complaints made by or on behalf of people with mental ill health, which we either upheld or partly upheld, over a two-year period from April 2014 to March 2016.

This report focuses on specialist mental health services because complaints in this area account for a significant majority of our mental health investigations - 71% of the initial sample.

This analysis of our casework data showed that the most common failings were:

  • Failure to treat: Failures in diagnosing and treating illness, either mental or physical, were present in 16% of the sample.
  • Inadequate assessments (including risk assessments): Failings in assessments of symptoms, as well as risk assessments for patient safety and the safety of others, were present in 21% of the sample.
  • Treatment or care plans: This included incomplete treatment or care plans, not involving the patient in developing a plan and not following a care plan. These issues were present in 17% of the sample.
  • Communication: Problems in communication with patients and their families about care arrangements were present in 33% of the sample.
  • Co-ordination of services: Problems in communication between services and co-ordination of care, as well as discharge arrangements where responsibility transferred from one service to another, were present in 15% of the sample.

Following this initial exercise, we carried out further qualitative and contextual analysis.

We read 200 of our investigation reports, including those from the original sample,spanning decisions we made between 2014- 15 and 2017-18 and considered information from external sources, including CQC, the Five Year Forward View for Mental Health and mental health charities, such as Mind and Rethink Mental Illness.

  • Five key themes emerged from this work in respect of the persistent failings we see:
  • Diagnosis and failure to treat
  • Risk assessment and safety
  • Dignity and human rights
  • Communication
  • Inappropriate discharge and provision of aftercare.

We selected the cases in this report because they illustrate these recurrent themes and because the injustice and harm caused by the failings was severe. Not all the complaints we look into are so serious. However, it is important to show the damaging consequences for patients and their families when mental health services get it seriously wrong.

These cases reinforce the concerns highlighted by the CQC and underline why it is so vital the recommendations in the Five Year Forward View for Mental Health are fully implemented.