HSSIB highlights physical health risks for patients in secure mental health care

The Health Services Safety Investigations Body (HSSIB) has identified opportunities to improve the physical health care of people receiving treatment in secure mental health settings following an investigation into the deterioration of a patient’s physical health.

The investigation examined the care of a patient whose physical health deteriorated while they were being cared for in a low secure mental health unit and who subsequently required admission to an acute hospital.

Published on 30 July, the report explored how the deterioration was recognised and managed, how care was coordinated between mental health and acute services and the role of specialist services in supporting the patient.

HSSIB identified challenges in communication and coordination between mental health services, the acute hospital and specialist sleep services. Different teams had different understandings of the severity of the patient’s deteriorating condition, while there was uncertainty around roles, responsibilities and accountability during the patient’s care in the emergency department.

The investigation identified five areas where the mental health trust involved could develop actions to improve safety.

These included improving opportunities for patients in the low secure unit to make healthy lifestyle choices, including around weight management, smoking cessation and exercise, and ensuring staff have access to a suitable area in which to carry out physical health observations and assessments.

HSSIB also highlighted the need for clearer roles, responsibilities and processes between mental and physical health clinicians when caring for patients with acute agitation, alongside better organisational support for staff and shared learning when patient safety incidents involve more than one healthcare provider.

The fifth area focused on developing personalised approaches to care planning to encourage people detained in inpatient mental health settings to engage with specialist services.

HSSIB said that although the areas for improvement relate to the organisation involved in the incident, the learning has wider relevance for mental health services across England.

The investigation also has a wider purpose. HSSIB has used the case to demonstrate how NHS organisations can use the Patient Safety Incident Response Framework (PSIRF) to investigate incidents and identify opportunities for learning and improvement.

The report is the second of three HSSIB investigations designed to provide examples of patient safety incident investigations under PSIRF. A third report is expected in autumn 2026.

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