Update on review into mental health inpatient services

  • 5th February 2024

Mental health services are coming under scrutiny following the deaths of three people last year

The Healthcare Services Safety Investigations Body (HSSIB) has published its terms of reference in a bid to help improve patient, staff, and community safety following the deaths of Barnaby Webber, Grace O’Malley-Kumar, and Ian Coates at the hands of mental health patient, Valdo Calocane, in June 2023.

HSSIB and its predecessor, the Healthcare Safety Investigation Branch (HSIB), has worked since June 2023 to determine the scope of the investigation and has been reviewing relevant evidence.

The investigation will probe Nottinghamshire Healthcare Foundation Trust’s involvement with Calocane, who was treated for paranoid schizophrenia before he carried out the killings.

The review, which was commissioned by the Health and Social Care Secretary, will provide further answers for the victims’ families affected by the horrendous and tragic killings in Nottingham in June 2023, as well as focus on wider issues in mental health care provision in Nottinghamshire, including at Highbury Hospital and Rampton Hospital.

The aims of the investigation include:

  • Learning from inpatient mental health deaths
  • Improving patient safety
  • Helping to provide safe care during transition from children and young people to adults in mental health services
  • Creating conditions for staff to deliver safe and therapeutic care

And the findings, which will include consideration of patient and staff safety regarding allegations of sexual assault and rape, will be published over the course of the year to drive improvements in patient safety and NHS mental health services.

The investigation will conclude by the end of this year and HSSIB will engage with patients, families, and carers, as well as local and national healthcare organisations, as part of its probe.

Health and Social Care Secretary, Victoria Atkins, said: “Families, staff, and the public deserve answers when things go wrong in mental health settings.

“This review will identify ways we can improve mental health care, protect patients and the public, and create a safe working environment for staff.”


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