Mental health hospitals are “so broken” that they are “re-traumatising patients”, a charity has warned.

It comes after an investigation found patient safety is being impacted by staffing issues at mental health facilities, which have limited funds to make units safer.

As part of the probe, the Health Services Safety Investigations Body (HSSIB) met with patients, families and staff across 30 mental health care providers over the course of almost a year.

It found patients did not always feel safe and staff were not always able to develop therapeutic relationships due to workforce challenges like recruiting and retaining experienced workers.

Staff “were not always equipped with the required knowledge and skills to understand and meet the mental and physical needs of patients”, the HSSIB report said.

The investigation was told by managers that nurses were not always equipped with the skills to respond to the physical health issues of patients experiencing mental health problems due to a lack of pre-registration education.

In one case included in the report, a patient became unwell after swallowing a foreign object and died the next day.

According to the HSSIB, a coroner highlighted a ‘repeated theme’ where staff were unclear about vital signs and the actions they should take depending on physical observation tools such as an early warning score.

Dr Sarah Hughes, chief executive of the mental health charity Mind, said: “This report reveals the brutal truth about the state of mental health hospitals, which is that they are now so broken they are ‘re-traumatising’ patients.

“What should be places of recovery have, for too many people, become places of pain and fear. Compassionate and therapeutic care is now, in many cases, the exception not the norm.

“This is made even harder by the outdated Mental Health Act that doesn’t give people nearly enough say over their care.”

Nick Woodier, senior safety investigator at the HSSIB, said: “Our investigation highlighted that therapeutic care is absolutely crucial to ensure patients feel safe and are safe during their time in mental health units or wards.

“We describe cases in our reports where patients had come to harm or feared for their safety, and this is distressing for them and their families.

“The staff we spoke to at units across England endeavour to spend time with patients and to support them through the developing of therapeutic relationships.

“However, many felt that the challenges they faced on a daily basis meant there was not always the opportunity to take the time needed, and that patient safety and their recovery was affected as a result.

“Mental health providers do recognise the risks to patient safety, but told us that addressing them is sometimes beyond their control, for example due to the lack of an available workforce or limited funds to make environments safer.

“Our findings and safety recommendations show what needs to be prioritised at a national level to reduce the likelihood of harm to patients and support the future delivery of safe and therapeutic care.”

Dr Hughes added: “No-one under the care of the state should have their psychological, physical or sexual safety put at risk, or lose their life due to system failure.

“We know that good care does exist, with the report noting that staff often want to make changes to deliver the best care they can, against a backdrop of surging demand and crumbling estates.

“But a lack of resources means they are being set up to fail. Decades of underfunding and a lack of long-term planning have left inpatient wards facing chronic staffing issues and buildings that are not fit for purpose.”

Dr Hughes described the HSSIB’s findings as “an important first step in addressing the crisis in our mental health hospitals”, but added: “It is 2024, yet you could be forgiven for thinking parts of this report were from 1924.

“This has to change and we at Mind will not stop campaigning until it does.”

A spokesperson for the Department of Health and Social Care said patient safety is paramount, and anyone being treated in an inpatient mental health facility deserves safe and high quality care.

They added: “This Government will reform the Mental Health Act, to ensure that people with the most severe mental health conditions receive better, more personalised treatment that is appropriate, proportionate, and compassionate to their needs.

“We will work also with the NHS to transform care and recruit 8,500 more mental health workers across children and adult services to reduce delays and provide faster treatment.”