NHS patient safety watchdog launches investigation into community mental health care

Healthcare Safety Investigation Branch inquiry follows death of Frances Wellburn, who took own life in August 2020

Frances Wellburn had long-term mental health problems and was admitted to hospital in September 2019 (Rebecca Wellburn)

The NHS patient safety watchdog has launched an investigation into community mental health care following the death of a 56-year-old woman, The Independent can reveal.

The Healthcare Safety Investigation Branch (HSIB), which has recently been hit with its own scandal and has been stripped of it maternity investigation powers, has begun examining how patients in crisis with severe mental health needs are assessed by NHS services.

The investigation came after warnings from multiple coroners over the poor assessment of suicide risk in people in mental health crisis in the last year and followed the death of Frances Wellburn, who took her own life in August 2020 while under the care of Tees, Esk and Wear Valleys Foundation NHS Trust (TEWV).

Wellburn had long-term mental health problems but suffered a crisis and was admitted to hospital in September 2019.

Following discharge, she was not referred to a specialist NHS service for people experiencing psychosis because clinicians incorrectly believed she was too old for the service, according to a TEWV investigation report seen by The Independent.

Despite being assessed as a “medium risk”, Wellburn was not contacted by mental health teams for three months.

In June 2020, she was admitted to an inpatient unit for three weeks, but her health deteriorated, and she later took her own life.

Separately, coroner warnings in three prevention of future deaths reports published last year found mental health staff failing to risk assess people who later took their own lives.

In one example, concerning a soldier who died in November 2020, a coroner said: “No risk assessment was completed on the issue of moving mental health appointments to virtual during the Covid-19 pandemic and how the patient could be kept safe in the event of deterioration in his mental health. There was no plan in place for patients that required urgent assessment/review due to deterioration in their mental health.”

In another, a coroner raised concerns in several inquests that mental health services in Nottinghamshire had placed “great reliance upon their interpretation of a patient’s intention and/or a patient’s denial of ongoing suicidal intention”.

The HSIB’s investigation will look into how patients’ risk is assessed when receiving care in the community and how services interact with families and other health services. It will also examine how mental health services consider menopause when assessing women’s mental health and referrals to early intervention psychosis services.

Wellburn’s sister Rebecca Wellburn told The Independent: “My sister’s death has been a tragedy for our family. It’s some comfort to us that the learning from what happened will be used nationally.

“I hope the investigation will increase awareness of mental health risks at the time of menopause, as well as explore the wider issues of what happened to Frances.

“There’s so much to learn from the circumstances leading up to Frances’s suicide. I hope this will lead to recommendations that strengthen mental health support in the community and lead to stronger partnership working with families and carers.”

In December 2021, the Care Quality Commission warned patients’ experiences of community mental health services had dropped to their lowest point in four years. Those with the most challenging mental health needs reported having the worst experiences, the care regulator found.

The HSIB is facing a major scandal of its own after an external review found bullying, racism and sexism were prevalent within the organisation, for reported by the Health Service Journal. On Wednesday health secretary Sajid Javid announced a new special authority would be taking over maternity investigations going forward.