This Patient Safety Observatory report collates information from patient safety incidents in mental health reported to the National Reporting and Learning Service. Reports were received from mental health services and other sources, and enabled assessment of the measures required to help prevent incidents reoccurring.
It analyses almost 45,000 incidents reported between November 2003 and September 2005. It includes data from 75 per cent of specialist mental health service providers in England and 80 per cent of combined trusts in Wales.
The analysis includes clinical negligence claims, data from death registrations, hospital activity and national surveys.
- Shows where existing interventions have been effective.
- Highlights recognised topics, such as the challenges to safety on acute wards and the risks posed by medication; these are already reflected in national policy, but more work is needed to implement change.
- Flags existing guidance and resources that can support safety improvement in mental health services.
- Identifies topics where the NHS may need to do further work to better understand the underlying causes of incidents and how to address them.
- Raises the particular issue of sexual safety.
Lists actions to be taken at both national and local levels to further improve safety.