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Avoidable Harm

Systemic    |    Relational

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1. barriers or burdens caused

by systems and bureaucracy

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  • Inaccessible and inflexible processes and decision making.

  • Poor or damaging assessment processes with little clarity about what to expect.

  • Lack of information or explanation about entitlements, staff roles, available support and limitations.

  • Burdensome personal budget administration. 

  • Inaccessible or intimidating complaints processes.

  • Having no access to or knowledge of care plans.

  • Problems with care plan reviews.

  • Excessive pressure to demonstrate need or not being believed. 

  • Support plan and care budget decisions delayed due to bureaucratic processes. 

  • Administrative errors. 

  • System inability to address multiple or ‘complex’ needs.

  • Poor working conditions and high turnover of staff leading to problems with continuity. 

  • Lack of appropriately qualified and trained staff.

"The whole process of applying for social care has been very brutal. And it’s been very harming...that level of animosity and not being believed [and] your integrity, your account questioned."

"They make decisions without...involving the people who it directly involves, so not the carers, not the patients, they just make the decisions sitting behind closed doors."

Please visit us on a desktop!

A model of service user experiences of avoidable harm in mental health social care, the impacts of harm caused and service user recommendations for ways to minimise harms.

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Principal Investigator: Dr Sarah Carr

Co-Investigator: Dr Angela Sweeney

Co-Investigator: Tina Coldham

Research Assistant: Georgie Hudson

Design & illustrations: Traumascapes

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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.

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