Maintaining momentum: driving improvements in mental health care


I am publishing this report, which documents cases of serious failings in NHS mental health services, because we are at a significant moment for mental health care. Long regarded as a ‘Cinderella’ service within the NHS, it is now a Government priority. The Five Year Forward View for Mental Health, published in 2016, sets out an ambitious vision for transforming mental health care in England.

The big challenge facing system leaders is how to realise these ambitions at a time when acute mental health trusts are facing unprecedented financial and workforce pressures. The cases highlighted in this report starkly illustrate the human cost of service failures.1

These cases are not isolated examples. They are symptomatic of persistent problems we see time and again in our complaints casework and, moreover, they represent failings throughout the care pathway. In the most severe cases, mistakes can lead to avoidable deaths.

The cases of Ms J and Mr O illustrate the potentially tragic consequences of misdiagnosis. Ms J died because doctors failed to diagnose Neuroleptic Malignant Syndrome (NMS), a reaction to the antipsychotic drugs that she was being treated with. Mr O took his own life after clinical staff failed to diagnose Post-Traumatic Stress Disorder (PTSD) and, as a consequence, failed to anticipate the risk of self-harm or suicide.

Even where mistakes do not lead to avoidable death, they can still cause harm or considerable distress to the patient. The case of Ms R, a woman with bipolar disorder, illustrates the damaging consequences of inadequate risk assessment and poor communication. After Ms R gave birth, her baby was taken into care without a full assessment of the risk she posed to her baby or any explanation of why her child was taken away. This caused Ms R considerable stress which in turn affected her sleep, appetite and ability to breastfeed.

Patients who use specialist mental health services are among the most vulnerable in our society. As a result, any serious failings on the part of the organisations providing these services can have catastrophic consequences for them.

I’m encouraged by the scale of ambition in the Five Year Forward View for Mental Health. However, the challenge to NHS leaders is to make those ambitions a reality and ensure that the kind of incidents described in this report become a thing of the past.

Rob Behrens, CBE
Parliamentary and Health Service Ombudsman

1 This is when there has been a failing or failings in the NHS care/treatment someone has received. Service failure can also include an NHS organisation failing to provide care/treatment or a service.