A report from the Health Services Safety Investigations Body has found that A&E departments have increasingly become the default location for people in mental health crisis.

People experiencing a mental health crisis are too often being cared for in emergency departments that are not designed, equipped or resourced to meet their needs.

A report from the Health Services Safety Investigations Body (HSSIB) has found that A&E departments have increasingly become the default location for people in mental health crisis due to gaps elsewhere in the urgent and emergency mental health care system. As a result, people can experience prolonged waits, overcrowded environments, a lack of privacy and unmet basic needs, which increase the distress and risk for patients, families and healthcare staff.

The investigation found that many A&E departments are managing risks and needs beyond their intended role. Staff described increasing pressure, burnout, compassion fatigue and moral distress associated with caring for people who require specialist mental health support in environments unsuited to their needs.  In some cases, delayed admission to mental health inpatient services, prolonged stays in A&E and lack of support following discharge were not consistently recognised as patient safety issues or monitored to drive improvement.

“People who come to an emergency department in a mental health crisis may be at their most vulnerable. They need timely, compassionate and joined-up care that recognises their distress, protects their dignity and helps keep them safe,” said Nichola Crust, senior safety investigator at HSSIB.

“Our investigation found that emergency departments are often caring for people in crisis in spaces that were not designed for prolonged mental health care. Long waits, limited privacy, unsuitable environments, gaps in information sharing and inconsistent approaches to care can increase distress and make it harder to understand and respond to a person’s changing risks and needs,” she added.

Safety recommendations

The investigation concludes that improving care for people experiencing a mental health crisis requires action to support safe, therapeutic care in A&E departments alongside wider changes across the urgent and emergency care pathway.

It made two safety recommendations.

First, that the Department of Health and Social Care (DHSC)/NHS England works with relevant national stakeholders to set out and support national minimum operational service standards and built design expectations for emergency departments. This will help reduce unwarranted variation and meet the therapeutic needs of individuals who attend emergency departments in a mental health crisis.

Second, that there should be further support and guidance to address particular points raised in the report – that there are clear expectations for roles, responsibilities and accountability for clinically appropriate, co-ordinated Mental Health Act assessment pathways; effective shared care, governance and escalation arrangements and processes to identify, escalate and review delays related to assessment, bed availability and onward care; arrangements to assess, plan for and assure the capacity, capability and resilience of the workforce, including access to relevant specialist and statutory professionals; and agreed measures and reporting arrangements to monitor workforce and pathway pressures, evaluate improvement actions, identify variation in access, waiting, experience, use of restrictive interventions, and address inequalities between population groups.

“We think developing clear standards of care would help everyone – clinicians, patients, families and the public and we welcome these recommendations,” said Dorit Braun, chief executive of Making Families Count, commenting on the recommendations.