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National Patient Safety Agency

Guidance issued on improving patient safety in mental health and learning disability services




Today (26 November), mental health staff in the NHS and independent sector are being provided with targeted guidance developed to improve patient safety.


This comes in the form of two new guidelines by the National Patient Safety Agency (NPSA).


The first is an alert on the resuscitation of patients in mental health and learning disability settings. It applies to all NHS organisations in England and Wales where mental health and learning disability patients are treated and has been developed in partnership with the Resuscitation Council (UK) and NHS mental health services.


The second is a best practice guide outlining seven key areas that mental health organisations and teams can work on to protect the safety of their patients.


The NPSA is launching both of these publications at its first ever national conference on patient safety in mental health in Leeds today.


The alert, a Rapid Response Report, follows a review of the NPSA’s Reporting and Learning System for incidents involving patients choking or experiencing cardiac or respiratory arrest in mental health and learning disability settings between 1 January 2006 and 31 March 2008. The Agency found:


  • 26 incidents where staff did not have the ability to manage the care of patients whom experienced cardiac or respiratory arrests, or where equipment, including basic airways equipment and Automated External Defibrillators, were unavailable.
  • 25 incidents where staff were not able to deliver effective first aid when patients experienced choking – 3 of these incidents were reported as deaths.


Existing guidance from the National Institute of Health and Clinical Excellence (NICE) in 2005 advises that any healthcare setting where the rapid tranquillisation, physical intervention or seclusion of patients is performed must be able to provide Immediate Life Support at a minimum. This means having appropriately trained personnel and equipment (including Automated External Defibrillators, oxygen, cannulae and first-line medications) within three minutes of access.


Following these performance and system concerns the NPSA is issuing the Rapid Response Report to remind all nursing and medical staff of the standards already set by NICE and the Resuscitation Council (UK).


Kevin Cleary, Medical Director at the NSPA said:


“The incidents reported to the NPSA reveal that there are still wide variations in resuscitation practices which need to be addressed. Although we are aware that many organisations are already implementing the recommendations set by NICE and the Resuscitation Council (UK), our alert is an opportunity for all mental health and learning disability settings to review their training programmes, equipment availability and staff competencies so that the safety of patients is further improved.”


Paul Farmer, Chief Executive of Mind, said:


"We fully support the NPSA's Rapid Response Report and urge all organisations where mental health patients are treated to take these actions on board. Evidence shows that people with mental health problems are more at risk than the general population of physical conditions such as coronary heart disease, diabetes, and respiratory diseases so it's vital that healthcare settings have life saving plans in place to reduce risk. Sadly, we have seen cases where physical restraint has been used on patients with tragic consequences and resuscitation equipment was not available or staff were not adequately trained. It is unacceptable that NICE's guidelines on this are not being followed."


The second publication that the NPSA is launching today – Seven Steps to Patient Safety in Mental Health – suggests clear strategies that mental health organisations should adopt locally to improve the safety of their patients and meet their clinical governance targets, such as by improving the involvement of clinicians, managers, patients and their carers in the planning of safer care.


Speaking of the new Seven Steps publication, Dr Ben Thomas, Head of Mental Health and Learning Disabilities at the NPSA said:


Seven Steps to Patient Safety in Mental Health sets out clear guidance which can be followed by all organisations to help implement good practice in the delivery of safer mental health services. In this guidance we emphasise the importance of working in partnership so that safer care can be provided in the wide range of settings where service users receive care”.


The conference is to be attended by clinicians and managers in mental health settings and will focus on the developments in the reporting of patient safety incidents as a means of identifying potential risks and how they are managed.





Notes for editors:



  • The NPSA mental health event, “Patient Safety in Mental Health: Driving Seven Steps for Safer Services” will take place on Wednesday 26 November at Hilton Leeds City Hotel, Leeds. It is being hosted by Leeds Partnerships NHS Foundation Trust and supported both by the Department of Health and the Welsh Assembly Government. There is limited capacity for media attendance. If you are a journalist and would like to attend, contact the NPSA Press Office to book your place.



  • Seven Steps to Patient Safety in Mental Health is a best practice guide describing the seven key areas of activity that mental health organisations and teams can work through to protect the safety of the service user they care for. The seven steps are:

  • Build a safety culture

  • Lead and support your staff

  • Integrate your risk management activity

  • Strengthen reporting in mental healthcare

  • Involve and communicate with service users and the public

  • Learn and share safety lessons

  • Implement solutions to prevent harm.


  • Rapid Response Reports are page-long notices which are based on evidence of harm to patients and identify clear actions for healthcare staff to reduce risks of recurrence. Since June 2007, 14 have been issued to NHS organisations in England and Wales. For more information visit: www.npsa.nhs.uk/nrls/alerts-and-directives/rapidrr.


  • The National Patient Safety Agency is a Special Health Authority of the NHS. It encompasses three divisions; the National Research Ethics Service, the National Reporting and Learning Service and the National Clinical Assessment Service. Each has its own sphere of expertise to improve patient outcomes. The NPSA’s vision is to lead and contribute to improved, safe patient care by informing, supporting and influencing healthcare individuals and organisations. For more information visit: www.npsa.nhs.uk