HSIB publish investigation report into the transition from child and adolescent mental health services to adult mental health service

The HSIB has published a report to support new learning culture around mistakes in the NHS, reviewing the transition of mental health care services.

Executive summary

The Healthcare Safety Investigation Branch (HSIB) has just published its second full investigation report to support a new learning culture around mistakes in the NHS. The investigation reviewed the transition of care from child and adolescent to adult mental health services to understand how variations in the transition impacts the safe and effective care of young people. As a result of the investigation a number of recommendations have been made to national NHS organisations to make the transition smoother and safer for young people.

In detail

This investigation followed the Healthcare Safety Investigation Branch being notified of an 18-year-old who died by suicide shortly after transitioning from child and adolescent to adult mental health services. The investigation identified a number of possible issues regarding the transition process and made some significant key findings. HSIB went on to make six safety recommendations to three national NHS organisations with the intention of preventing future, similar events:

  1. Within the long-term plan, NHS England to work with partners to identify and meet the needs of young adults who have mental health problems but do not meet the current criteria for access to adult mental health services. 
  2. NHS England to require Clinical Commissioning Groups to demonstrate the budget identified for current children and young people’s services - those delivering care up to the age of 18 – is spent only on this group.
  3. NHS England and NHS Improvement to ensure transition guidance, pathways or performance measures, require structured conversations to take place with the young person transitioning to access their readiness, develop their understanding of their condition and empower them to ask questions. NHS England and NHS Improvement must ensure the effectiveness is robustly evaluated. 
  4. Within the long-term plan, NHS England to require services to move from aged based transition criteria towards more flexible criteria based on an individual’s needs.
  5. NHS England and NHS Improvement to work with commissioners and providers of mental health services to ensure that the care of a young person before during and after transition is shared in line with best practice, including joint agency working. 
  6. The Care Quality Commission to extend its remit of its inspections to ensure the whole care pathway, from child and adolescent mental health services to adult mental health services, is examined.

Recommendations

HSIB, which became operational on 1 April 2017, undertook this investigation with the sole purpose of learning. We recommend that all healthcare providers treat the report as a must-read and use this valuable tool as a key component to ongoing strategies around improving learning.

For further information about Weightmans LLP or to discuss any of the issues in this update, please contact Richard Jolly, Partner on 0151 242 7954 (richard.jolly@weightmans.com).

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