In the Netherlands there are 250,000 to 300,000 persons with a serious mental illness (SMI). About 20,000 of them need acute care because of their condition. The problems of vulnerable persons with an SMI are often chronic, multiple and episodic. Because of this fragmented system, in complex situations the focal point is not the person with an SMI but the organisation offering the care. The Board investigated, among others, seven cases where safety is at risk.

Investigation publication

Access to adequate care

The Dutch Safety Board has observed that unsafe situations for persons with an SMI and their environment occur frequently. This is why the Board investigated which factors contribute to the development of such situations. The Board has concluded that the safety of both vulnerable persons with an SMI and their environment is insufficiently secured. Among other reasons, this is because the care and services provided to this group of people does not meet their care needs sufficiently. Vulnerable persons with an SMI also tend to have problems with their relationships, housing, finances, work and physical health. These problems are largely episodic in nature. This makes them dependent on their social environment as well as on mental health and social workers at different moments, in different life areas and to varying degrees. Because of their mental disorder these individuals are not able to effectively take the reins of their situation. When they cannot take care of themselves, for example during a crisis, someone else needs to protect them and take over these responsibilities from them.

To increase the safety of persons with an SMI and their environment, it is necessary for the care and support to fit with the complex and episodic care needs of individual patients. To this end, financial restrictions in laws and regulations should be removed. This can be done by widening access to existing financing resources, such as opening the Long-Term Care Act to vulnerable persons with an SMI, as well as by experimenting with new, domain-transcending financing resources. Mental health and social workers also need to take more advantage of their professional latitude to secure the safety of persons with an SMI and their environment. This requires that professional groups, institutions and care professionals from the various domains discuss how to detect, exchange and manage safety risks earlier, as well as recognise and openly discuss dilemmas that affect the safety of patients and their environment. Lastly, mental health and social workers should also be supported to a greater extent in their ability to take responsibility for offering personalised care to individuals with an SMI. To this end, it is necessary to make it easier for mental health and social workers to accumulate sufficient knowledge and skills, to assist them in dealing with dilemmas and to structure the preconditions for them to want to, be able to and dare to offer personalised services.


The government, mental health services (ggz), advocacy organisations and health insurers are currently working on a wide structural improvement of the care and support for persons with an SMI. In July 2018 a global agreement was signed for the entire ggz that included arrangements to offer people the mental health care that they require, adapted to their individual needs. Additionally, the Forensic Care Act was implemented on 1 January 2019 and the Dutch Mandatory Mental Healthcare Act (Wvggz) and the Care and Compulsion Act (in Dutch: Wet zorg en dwang) will be implemented on 1 January 2020. The ggz and forensic care will further be working with a new product structure starting in 2020, and the Long-Term Care Act (in Dutch: Wet langdurige zorg) is expected to be open to persons with psychiatric disorders in 2021. Various collaborative partnerships are working on development and implementation projects to improve the care and support for persons with an SMI. Their goal is to offer patients the care and support that fits with their care needs at the right moment.

The Dutch Safety Board considers it important for the involved parties to follow the recommendations by joining the ongoing initiatives for improvement. Improving the safety of persons with an SMI and their environment requires an approach that is tailored to the specific care and support needs of these persons. To that end, it is necessary for all involved parties from the various domains to pull together in order to secure effective care and support within the system.

To be able to structurally offer adequate and safe care to persons with an SMI that fits their multiple care needs, specific arrangements are necessary. The Board therefore makes a recommendation to the Minister and State Secretary for Health, Welfare and Sport.



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