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1 in 5 mental health patients don’t feel safe in NHS care, Ombudsman finds

A new survey published yesterday by the Parliamentary and Health Service Ombudsman found that one in five people did not feel safe while in the care of the NHS mental health service that treated them.

Over half of people with mental health problems in England also said they experienced delays to their treatment, while four in ten (42%) said that they waited too long to be diagnosed.

When asked to share details of their experiences, one survey participant said that after they attempted to take their own life, they had to wait over six months to be referred to a specialist mental health team. Another said they felt they had been ‘talked over and about, not to’.

Despite the concerns raised by patients about their treatment in the survey, almost half (48%) said they would be unlikely to complain if they were unhappy with the service provided. Almost 70% of people said they had not been told how to complain by NHS staff.

Concerningly, one in three people (32%) said they did not think their complaint would be taken seriously while a quarter were worried complaining would affect how they were treated. The main reason given (40%) was that they would not want ‘to cause trouble’.

Ombudsman Rob Behrens yesterday said:

'It’s unacceptable that so many patients requiring mental health treatment are left feeling unsafe in the NHS but this survey supports what we see too frequently in our casework. Patients must be supported to speak up when mistakes happen and not left scared that their treatment will be affected if they do so.

‘While the NHS in England must continue to implement its Five Year Forward View for Mental Health, it should also look now at what more is needed to transform mental health services so the people who need them get the care they deserve.’

A real impact on patients

Yesterday’s survey results are reinforced by the tragic case of Erica Henderson who took her own life when she was an inpatient at 2gether NHS Foundation Trust. She was being treated for schizophrenia and epilepsy at the mental health trust and Gloucestershire Hospitals NHS Foundation Trust, but was not observed regularly enough, despite having made several attempts to take her own life.

Even though she told staff at the mental health trust that her frequent epileptic seizures were contributing to her desire to self-harm, the significant risks to her safety were not properly managed. The Ombudsman found that both trusts failed to provide Miss Henderson with the care she needed, with tragic results.

In response to the Ombudsman’s findings, 2gether NHS Foundation Trust is putting in place steps to make sure its risk assessment and safety management procedures meet national guidance and has committed to ensure observations are embedded in its practice. Gloucestershire Hospitals NHS Foundation Trust is also reviewing the management of Miss Henderson’s medication when she became an inpatient for her worsening epilepsy to identify the full learning from this case.

Mrs Saleeb-Mousa, Miss Henderson’s sister, said:

'Failures by the Trusts led to the death of my dearest twin sister, who would not have died if her seizures and mental health issues had been properly addressed.

'Nobody should suffer like that. I complained to the Ombudsman so that other people will never have to go through what she did.’

The YouGov survey, commissioned by the Ombudsman, also comes almost two years after the Ombudsman’s Maintaining Momentum report. The survey results suggest that people accessing treatment for mental health problems in England are continuing to experience the five service failings identified in the report:

  • Failure to diagnose and/or treat the patient
  • Poor risk assessment and safety practices
  • Not treating patients with dignity and/or infringing human rights
  • Poor communication with the patient and/or their family or carers
  • Inappropriate hospital discharge and aftercare of the patient

It also follows the publication of the Ombudsman’s Missed Opportunities report in summer 2019 into the deaths of two vulnerable young men and the significant failings in their mental health care and treatment.

The Ombudsman will shortly be publishing its first annual casework report, which will include some further cases about mental health services that we closed in 2019.

Download the results of our Mental Health survey [.xlsx 43 KB]


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