Mental health inpatient settings: creating conditions for learning from deaths in mental health inpatient services and when patients die within 30 days of discharge

Health Services Safety Investigations Body -
This report finds that systemic issues, lack of patient and family involvement and cultures of fear and blame contribute to mental health services not learning from inpatient deaths. The findings evidence challenges in maintaining safety, conducting effective and timely investigations and ensuring system wide learning. It identifies that, whilst investigations and patient safety event analysis aim for transparency and learning, they are often of variable quality.

• Report
• Health Services Safety Investigations Body - news