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ECT patient safety issues | Signal

Reference number
1162 G
Issue date26 February 2010

This Signal relates to the risks of electroconvulsive therapy (ECT) procedures in mental health and acute settings, including anaesthetic processes and staff training issues.


ECT can be used to treat people with severe depression, catatonia or severe mania1. The treatment involves an electric current being passed through the brain to produce a seizure. This may be done in mental health facilities, usually in dedicated ECT suites, or sometimes in acute hospitals, usually in the anaesthetic room or in recovery. The National Reporting and Learning Service (NRLS) is aware of some issues around these procedures in both acute and mental health settings.


A sample incident reads:
“Patient from xx hospital being given ECT developed acute cardiac arrhythmia. The xxx team response was very poor, not familiar with cardiac arrest box, no preparation for emergency situations, no IV fluids, drugs, syringes at hand etc, no one prepared to take a lead.”


A search of the Reporting and Learning System (RLS) database showed 238 incidents. These included two reported patient deaths and further incidents of patients suffering arrests, or other complications which required intensive care or similar. Some incidents related to anaesthetic problems, including:


  • patient awareness during procedure
  • failing equipment (e.g. leaking ambubag)
  • omitted or insufficient muscle relaxant
  • patient aspiration
  • inadequate patient fasting
  • tooth loss.


Other issues related to the procedure itself include:


  • wrong-side ECT (unilateral)
  • wrong dose and extended patient seizures
  • contact burns from ECT electrodes
  • other injuries.


A particular issue for patients with severe mental health problems was the cancellation or delay of ECT treatment, reported in 69 incidents and which in one case resulted in patient self-harm. Overall, the evidence suggested the need for greater awareness of risks and safe practice for both mental health and anaesthetic staff. There was some overlap with previous NRLS guidance on resuscitation in mental health settings


Since 2003, the Royal College of Psychiatrists has developed a voluntary accreditation scheme (ECTAS) for units carrying out ECTs with published standards and useful resources for trusts, such as detailed outpatient protocols.


The NRLS is sharing the incident data relating to patient harm with the Royal College of Psychiatrists Special Committee for ECT and related treatments, and this will then be taken up with ECTAS. These will help to identify areas for improvement and provide evidence to inform future updating of standards. 


Have you got any incidents to report or investigation to share? 

Where do your patients receive ECT treatment and how well do they meet accreditation standards? 




1. National Institute for Clinical Excellence. Guidance on the use of electroconvulsive therapy. Technology Appraisal 59. NICE, 2003.


Relevant to: Mental health, anaesthesia




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