Maintaining momentum: driving improvements in mental health care


This report aims to highlight failings that have occurred, and continue to occur, in specialist mental health services in England, and the devastating toll this takes on patients and their families. Not only are the examples of injustice shown here shocking and tragic, they also show a failure by local NHS organisations to investigate complaints effectively.

We do not expect any service that deals with the complex issues presented in this report to run flawlessly. But it is vital that, when someone raises concerns, an effective and robust investigation is carried out to find out what happened, acknowledge their mistakes, put things right and make sure these failings are not repeated.

The complaints in this report predate the Five Year Forward View for Mental Health, the much needed national strategy to improve mental health services in England, which was published in February 2016. Nevertheless, the serious errors we highlight are typical of the complaints we continue to receive. Moreover, they echo the concerns flagged by the Care Quality Commission (CQC) in its 2017 report on the state of mental health care.

We recognise that NHS England has started to address these issues in its implementation plan for the Five Year Forward View for Mental Health. For that reason we are not making systemic recommendations in this report. We expect the number and severity of complaints about the systemic failings highlighted in this report to reduce over time if the plan brings about the step change in service provision that is its ambition.

Although this report highlights cases that demonstrate some significant failings, these only scratch the surface of the challenge to improve our mental health services. 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.

In 2016-17, we completed a further 352 investigations into NHS mental health trusts and found failings in 130 (37%) of these cases.1 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.

As the final stage in the NHS complaints process, we only see examples of when things go badly wrong. There is, of course, a lot of excellent practice in mental health services. The CQC inspects all healthcare providers and has rated 68% of NHS core mental health services as good and a further 6% as outstanding.

Even so, we have a unique view into what happens when failures occur. We see some of the worst injustices and the resulting human impact on patients and their families. It is our role to ensure NHS organisations learn from these mistakes and take the necessary steps to prevent those mistakes from happening again.

1 There are other NHS organisations providing mental health care, but which also provide other services including acute physical health services, as well as independent providers. These are not included in these statistics.