16 Nov 2020

Whilst many such incidents represent ‘near misses’, an event where potential harm was averted, or result in limited harm only, patient safety incidents remain a leading cause of death and disability worldwide.

Background to the study

The patient safety movement has seldom focused on research in mental health contexts. This is especially concerning, as a mental health trust was the first service to be prosecuted for providing unsafe care under legislation introduced following the Francis Report. Relative to the general population, mental health service users suffer greater problems in both mental and physical health domains. For instance, increased suicide risk, cardiovascular illnesses, and metabolic side-effects of psychotropic medications are amongst the factors which contribute to overall excess mortality for this group.

Moreover, characteristics of mental illnesses and the structure of mental health services may increase risks of preventable harm during the care process. For example, patient disengagement from preventative care interventions, difficulties with communicating with different parts of the organisation, and non-disclosure of unsafe behaviours may collectively heighten a vulnerability to receiving unsafe care, by impairing clinicians’ abilities to assess and manage risk.

SLaM building

Project aims

The overarching aim of this doctoral research project is to study the nature of the safety problems experienced by users of community-based mental health services, identify potential areas for intervention, and conduct a small-scale implementation evaluation of an identified intervention.

How the study will be carried out

There will be three stages to the research:

  • A scoping evidence review: to identify the nature, scale and contributing factors to safety problems in the context of community based mental health services
  • Secondary data analysis: a review of safety incidents within community mental health services reported to the National Reporting and Learning Service (NRLS) - to complement and triangulate the findings form the scoping review.
  • A qualitative study (interviews and/or focus groups, depending on timing and feasibility, due to COVID19 impact on data collection) with service providers and users within community based mental health services: to find out their views and interpretations of what constitutes 'patient safety' issues in their work and experience; and to further triangulate the findings from the scoping review and NRLS analysis.
  • A pilot study: to select and evaluate how feasible it is to implement an intervention which addresses patient safety problems that were prioritised by service users and providers.

How service users are involved in the study

The project will engage directly with mental health service users groups within South London and Maudsley Mental Health Trust. Service user group involvement will inform the interpretation of the findings of the evidence review, the prioritisation of safety problems to focus on and the selection and pilot evaluation of a suitable and feasible intervention. 

Potential impact of the study

By identifying and mapping evidence on the nature of the safety problems this population experience, their prevalence, and evaluated interventions to improve safety, this research will produce important new insights. As well as, comparing these findings with analyses of safety incidents reported to the UK’s healthcare incident reporting database, along with interview data from service users, carers, and providers, to form original contributions to the evidence base. Importantly, this research will provide and synthesise preliminary insights within this field, identifying overlap and disparities between existing evidence, formally reported safety incidents, and stakeholder perspectives. Lastly, this pilot study will offer new evidence and direction regarding what might be potentially achieved in this setting with a subsequent larger, interventional study.

The study is funded by The Health Foundation via The Healthcare Improvement Studies Institute (THIS). It was adopted by ARC South London in September 2020 and will be completed by September 2022.