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The CQC and NHS
Improvement have worked together to establish how mental health trusts in
England report patient safety incidents of a sexual nature.

In April 2018  the CQC facilitated a co-production event with representatives from NHS Trusts
across the UK to explore current issues regarding sexual safety within mental  health inpatient services.  Though the  data presented on the day is yet to be published, there was an agreement from  all stakeholders represented that improving the sexual safety of service users  should be a priority for all mental health services.

Previously the CQC have stated, “staff have a heightened  responsibility to ensure that patients are safe from sexual harassment and  sexual violence,” for areas which are mixed sex (CQC, 2017).   During 2016/17, the Trust undertook audits of  all mixed sex inpatient areas using the Good Practice Guidance and Self-Assessment  Checklist (NHSIII, publication date?). The Trust believes that this heightened
responsibility extends beyond mixed sex wards into same sex wards where the  risks and vulnerabilities are equally evident.

There is a need to change safety culture to support open  discussions about sexual safety, central to this is the provision of training  and on-going supervision of ward multi-disciplinary teams to feel confident to
support patients. 
A core component of  the training package would be the generation of a reflexive approach to  preventative work, adopting a multi-agency approach (involvement of key  stakeholders).

Many patients accessing mental health inpatient areas  have experienced significant trauma and/or lack capacity in areas regarding  sexual consent.   Care must be taken  regarding the impact and possible re-traumatisation of individuals supported and treated in mental health inpatient areas.
A robust co-produced and evidence based training package which includes
signposting resources and intervention advice will maintain the safety and  wellbeing of both patients and staff.

To ensure accurate measurement of the frequency and  subsequent improvement of this type of incident requires clear guidance  regarding the categorisation of harm for staff to consider.  As part of this proposal the Trust will generate this guidance which will be incorporated into the training; this will  support learning both locally and nationally.

This accurate data and learning will be shared with the  patient safety and experience committee each quarter as part of the patient safety report for oversight and governance.


Eliminating  Mixed-Sex Accommodation. From the Chief Nursing Officer and Deputy NHS Chief
Executive. 10 February 2011

CQC ‘State of Care in Mental
Health Services 2014-17’


  1. Hi

    This is an important issue that needs energy and thought putting behind it.

    I wondered what people who use our services and their families would want us to do about it. I wondered if you had had the opportunity to speak to any of your patients or families and if they were helping you to shape you project?


    Great idea

    Kind regards


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