The Guardian view on mental health: saving lives requires money and monitoring | Editorial

Lessons are not being learned from the deaths of hundreds of mental health patients, despite the warnings of coroners

More than 270 mental health patients have died over the last six years after failings in NHS care. These cases are more devastating to those who loved these people because in many cases the deaths could have been prevented; better care might have saved them. Too often, services did not respond to the concerns of GPs, families, and patients themselves. The Guardian’s figures, drawn from coroners’ warnings – known as reports to prevent future deaths – are if anything conservative. A forthcoming report on the issue from the NHS ombudsman is expected to raise similar issues.

There is no doubt that services are overstretched. In one in six of the cases, coroners linked the deaths to the lack of staff, beds and specialist services, or to long delays for treatment. Mental health services have been desperately underfunded for too long, and the promised increase in spending is insufficient given the historic shortfall and the surge in demand. The current government, and the coalition before it, promised to prioritise mental health; these figures show how little progress has been made. A leaked green paper recently revealed that the promise of a maximum four-week wait for children (currently left as long as 18 months without care) will not be fully implemented until 2021 due to lack of staff and funding. A dearth of early intervention also leads to heavier demand for more expensive crisis services. It is impossible to provide adequate care without adequate resources. But funding is not a guarantee of quality. Cash alone cannot ensure that agencies and staff communicate as they should (the issue cited most frequently in these coroners’ warnings); nor can it foster a culture of learning from errors. Some NHS bodies are clearly failing to apply the necessary lessons – even when warned about them in the bluntest possible terms.

At least some of these deaths were doubly avoidable. Had mistakes or shortcomings in treating previous patients been addressed, they might not have been repeated to such terrible effect. Similar problems are occurring across regions, reflecting in part the localised nature of NHS provision and the difficulty of ensuring that improvements are applied across the board.

Yet in other, still more disturbing cases, coroners say that they have alerted the same trusts to the same problem before. One describes his “considerable sadness” that a death followed a similar case he had examined. His initial warning led to a promise that every patient presenting with evidence of a mental health problem or after reported self-harm or suicidal behaviour would be referred for a mental health assessment. But “the assurances given were not fulfilled in practice” and several staff members treating the second patient were not even aware of the new policy. He notes that the assurances he has received from the trust are to a large extent those given previously, adding: “In view of the history I am concerned that without such an auditing process, failures of care may take place as identified above.”

The Liberal Democrat MP Norman Lamb, a former health minister, says warnings are not enough: we must ensure that they are followed up. He’s right. While trusts have a duty to respond to these reports, some do so in only cursory fashion. Others take them more seriously, but fail to follow through on promised improvements. Putting the Care Quality Commission in charge of monitoring progress, and ensuring that lessons are applied across the board where necessary, is the least we owe to the families of these patients, and to the patients of the future.



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