This report highlights failings that have occurred in specialist mental health services in England, and the devastating toll this takes on patients and their families.
The examples of injustice shown here shocking and tragic. They also show a failure by local NHS organisations to investigate complaints effectively.
We do not expect any service that deals with the complex issues presented in this report to run flawlessly. But it is vital that, when someone raises concerns, an effective and robust investigation is carried out.
The organisation involved should find out what happened, acknowledge their mistakes, put things right and make sure these failings are not repeated.
We recognise that NHS England has started to address these issues as it implements its plan for the Five Year Forward View for Mental Health. For that reason we are not making systemic recommendations in this report.
We expect the number and severity of complaints to reduce over time if the plan brings about the step change in service provision that is its ambition.