This digital interface presents service user experiences of mental health social care that can lead to avoidable social and psychological harm, the harm impacts that can arise and their recommendations for harm minimisation. These components form an evidence-based, user-defined model of avoidable harm in mental health social care and its minimisation.
The model was developed in several stages:
A scoping review of peer reviewed journal papers and a ‘grey literature’ review on the experiences of mental health social care service users in England.
A synthesis of the findings from the two reviews to create an initial user-defined model of avoidable harm.
Focus groups to develop the model and to make recommendations for harm minimisation.
An England-wide online survey to further refine the model. The survey asked service users whether they had experienced the harms identified to date, to rank the urgency of addressing each source of harm and order the importance of implementing harm minimisation recommendations.
An expert Advisory Group of people with lived experience of using and/or providing social care and mental health support was consulted at each stage.
The project was carried out by a team of service user/survivor researchers.
This digital interface was created with mental health social care practitioners and educators. The aim is to provide an information resource for all those concerned with mental health social care so they can use the research evidence to minimise risk of avoidable harm and improve service user experiences of services and support.
The site can be used to:
Help social care and social work practitioners and service users recognise, understand and address avoidable harm in mental health social care.
Support mental health social care and social work practitioners to use service user experiential evidence to inform their practice.
Inform the teaching and training of mental health social care and social work practitioners.
Principal Investigator: Dr Sarah Carr, independent researcher.
Co-Investigators: Dr Angela Sweeney, King’s College London and Tina Coldham, independent researcher.
Research Assistant: Georgie Hudson, King’s College London.
Design & illustrations: Traumascapes.
We would like to thank the research participants who so generously shared their experiences with us and the practitioners and educators who helped to create this resource. We would also like to thank the study’s Advisory Group for their vital support and advice throughout the study.
Funding Acknowledgement Statement
This resource is based on independent research funded by the National Institute for Health Research School for Social Care Research (NIHR SSCR). The views expressed are those of the authors and not necessarily those of the NIHR SSCR, the National Institute for Health Research or the Department of Health and Social Care.
We would like to acknowledge the support of the National Institute for Health Research (NIHR) Maudsley Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King’s College London. The views expressed are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health and Social Care.
Ethical approval for the research was obtained from the Social Care Research Ethics Committee (ref: 20/IEC08/0010, July 2020).
Carr, S., Sweeney, A., Coldham, T. and Hudson, G. (2023). Avoidable Harm in Mental Health Social Care. London, UK. https://www.avoidableharm.org/
Scoping Review
Carr, S, Hudson, G., Amson, N., Hisham, I.N., Coldham, T., Gould, D., Hodges, C. and Sweeney, A.
(2022) Service users’ experience of social and psychological harm in mental health social care in
England: Findings of a scoping review. The British Journal of Social Work, bcac209,
BASW. (2021) The BASW code of ethics for social work – Link
CQC. (2018) The five key questions we ask – Link
Department of Health & Social Care. (2022) Care and support statutory guidance on safeguarding – Link
Lawson, J. (2017) Making Safeguarding Personal: what might “good” look like for health and social care commissioners and providers? – Link
Local Government Association. (n.d.) Making Safeguarding Personal toolkit – Link
Faulkner, A. (2012) The right to take risks: service users’ views of risk in adult social
care – Link
Markham, S. (2018) Dealing with iatrogenic harm in mental health – Link
CQC. (2020) Identifying and responding to closed cultures – Link
SWE. (2019) Professional standards – Link
Skills for Care. (n.d.) Code of Conduct – Link
CQC. (2022) The fundamental standards – Link
Local Government and Social Care Ombudsman (n.d.) How to complain – Link
The Care Act 2014 – Setting out responsibility for the integration of care and support between health and LAs – Link
The Care Act 2014 – Safeguarding adults at risk of abuse or neglect within the Care Act 2014 – Link
Safeguarding accountability and assurance framework – Link
Useful resources by the Social Care Institute for Excellence – Link
Professional standards of practice and behaviour for nurses, midwives and nursing associates – Link
Abuse and neglect of vulnerable adults, NHS Basic guidance – Link
If you are at immediate risk, please call 999 for urgent help.
For mental health support
The Samaritans
The Samaritans provide confidential support for people who are experiencing extreme feelings of
distress or despair.
Telephone: 08457 90 90 90 (UK) (open 24 hours a day, every day of the year)
Email: jo@samaritans.org
SupportLine
SupportLine provides a confidential telephone helpline offering emotional support to any individual
on any issue. The Helpline is primarily a preventative service and aims to support people before they
reach the point of crisis. It is particularly aimed at those who are socially isolated, vulnerable, at risk
groups and victims of any form of abuse.
Telephone: 01708 765200
Email: info@supportline.org.uk
Helplines Partnership
Helplines Partnership is the membership body for organisations that provide helpline services in the
UK and internationally. You can search for a helpline in the UK by name, topic area or location.
Telephone: 0300 330 7777
Email: info@helplines.org
Shout
Shout is a free, confidential, 24/7 text support service for anyone in the UK who is struggling to cope.
To start a conversation, text the word 'SHOUT' to 85258.
Mind InfoLine
Mind is a national mental health campaigning and advice charity, which has local associations in
England and Wales.
Telephone: 0300 123 3393
Email: info@mind.org.uk
Rethink Mental Illness
The Rethink Mental Illness Advice Service offers practical help on issues such as the Mental Health
Act, community care, welfare benefits, debt, criminal justice and carers rights. They also offer
general help on living with mental illness, medication, care and treatment.
Telephone: 0808 801 0525
Email: advice@rethink.org
Advice on making a complaint
The Care Quality Commission
How to complain about a hospital, community or mental health service
How to complain about an adult social care service
The Local Government and Social Care Ombudsman
Social Work England
Raising a fitness to practice concern
Mind
Complaining about health and social care
Citizen’s Advice
Taking action about discrimination in health and care services
Different copyright restrictions apply to different components of the site.
The research data belongs to the investigators and associated institutions.
The copyright of individual illustrations belongs to Traumascapes and all rights are reserved to them. To enquire about permissions please email hello@traumascapes.org
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Publication Date
February 2023
Last Updated
October 2024