Ombudsman Report highlights need for improvements in NHS mental health services

The Public Administration and Constitutional Affairs Committee (PACAC) today publishes its report reflecting on the need for action to be taken since the publication of the Parliamentary Health Service Ombudsman’s (PHSO) report ‘Missed opportunities: what lessons can be learned from failings at the North Essex Partnership’.

The report calls on the Government to act on the previous recommendations made by the PHSO in a report documenting serious and significant failings that preceded the deaths of two men under the care of the North Essex Partnership. 

The report also calls on the Government to prioritise patient safety, encourage strong, sustained leadership within the NHS, facilitate a shift towards continuous learning and training, and improve health service investigations, partly by including families in investigations from the outset. 

Chair’s comments

Chair of the Public Administration and Constitutional Affairs Select Committee, Sir Bernard Jenkin MP, said: 

“These two tragic cases must lead to positive change- that is the least we can do for those who have lost their loved ones. The Government must take steps to establish strong, supportive leadership within our health service. It should encourage a fundamental shift in workplace culture, characterised by openness and honesty, where individual staff members feel able to raise concerns about patients’ care where necessary. 

“When investigations are required, it is crucial that families are fully engaged, that their voices are heard throughout, and they are kept informed of all developments. Fostering a continuous dialogue is critical in establishing trust between families and investigators. 

“In today’s report, my Committee is calling on the Government to take our recommendations on board and reform health service investigations, ensuring that the NHS is able to learn from mistakes and prioritise patient safety above all else. The inclusion of a Health Service Safety Investigations Bill in the recent Queen’s Speech will provide a springboard on the road to reforms, when the Bill is brought forward again after the election.”

Key findings

The safety of acute mental health care provision

The Committee calls on the Government and the NHS to prioritise patient safety and make significant improvements in the quality of mental health provision. The Committee recommends that the entire NHS workforce establishes a common understanding of patient safety and that patient safety should form part of ongoing mandatory training and be included as part of continuing professional development.


There is a clear need for more effective leadership within the NHS, and the Committee welcomes the Government’s upcoming publication of the People Plan. The encouragement of effective leadership should be ongoing and drive improvement within the organisation.

Developing a culture of learning

The Committee recognises the need to embed a healthy learning culture within the NHS, encouraging staff to speak up about safety issues and focus on improving the care of patients. Staff must have the resources, training and support to carry out reviews and investigations. The Committee welcomes the inclusion of the Health Service Safety Investigations Branch (HSSIB) in the Queen’s Speech and urges the Government to fully establish the Healthcare Safety Investigations Branch, an independent body that should be given a proper statutory basis. This body will aid local investigations and help cultivate a culture of learning and development. 

It is vital that families are closely involved in investigations and fully engaged throughout. This will help to establish trust, confidence and dialogue.

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