Phoebe Averill

Patient safety incidents are a leading cause of death and disability worldwide. To date, the patient safety movement has primarily focused on the safety of physical healthcare provision. As such, the evidence base for improving safety in mental health services is insufficient.

A small, yet accumulating body of work has explored what ‘safety’ looks like in the context of acute inpatient mental healthcare, providing valuable insights about the nature of the safety problems service users face within these settings.

However, many mental healthcare encounters take place outside of hospital settings, and there is insufficient evidence about the types of safety and quality of care problems service users experience in community-based mental health services. Consequently, evidence about the principal risks to safety is scarce and there is a lack of conceptual clarity over what constitutes a patient safety problem in this context.

This research project sought to address this evidence gap by triangulating different sources of evidence to better understand the nature of the safety problems in community-based mental healthcare provision, and how the safety of care may be improved.

First, a narrative review explored conceptual and practical issues in applying patient safety principles to community-based mental healthcare.

Next, a systematic scoping review identified and synthesised existing literature on patient safety in community-based mental healthcare settings, as well as evidence for interventions to improve safety in this context.

After which, patient safety incidents reported to a national database by UK community mental health services were then analysed to provide a descriptive overview of safety problems. This included their contributory factors, and the severity of harm caused as judged by incident reporters.

A final study involved in-depth interviews and focus groups with service users, carers, and mental healthcare providers, to identify stakeholder perspectives on the range and nature of safety challenges in community-based mental health services.

Phoebe gave a lightning talk about her research project at our 2022 annual event, THIS Space.

Research articles

Averill, P., et al. (2025) Patient safety incidents within adult community-based mental health services in England: A mixed-methods examination of reported incidents, contributory factors, and proposed solutions Psychological Medicine 

Averill, P., et al. (2024) What does ‘safe care’ mean in the context of community-based mental health services? A qualitative exploration of the perspectives of service users, carers, and healthcare providers in England. BMC Health Services Research

Averill, P., et al. (2023). Conceptual and practical challenges associated with understanding patient safety within community-based mental health services. Health Expectations.