Healthcare Inspectorate Wales (HIW) will undertake a review of electroconvulsive therapy (ECT) services across Wales. The review will provide independent assurance about the quality, safety, effectiveness and governance of ECT services, while identifying opportunities for improvement, national learning and more consistent service delivery.
ECT is a specialist treatment used primarily for severe depressive illness and some other severe mental health conditions, particularly where a rapid clinical response may be required or where other treatments have not been effective. As ECT involves anaesthesia and an induced seizure, it requires robust clinical, legal and operational safeguards.
Key safeguards include appropriate assessment and clinical decision-making; informed consent and compliance with the Mental Health and Capacity Acts, competent and supported staff, safe facilities and equipment, physical health monitoring, recovery and follow-up, and effective governance, audit and quality assurance.
HIW intelligence and early scoping have identified the value of obtaining a clear national picture of how ECT services are delivered across NHS Wales. The review will consider consistency and variation between services, how patient rights and experiences are reflected in care, how outcomes are monitored, and how health boards assure themselves about service quality and safety.
The review will consider the Health and Care Quality Standards 2023, relevant mental health and mental capacity legislation, the Royal College of Psychiatrists Electroconvulsive Therapy Accreditation Service (ECTAS) standards, and applicable NICE guidance. It will not duplicate or replace ECTAS accreditation. Instead, it will provide independent assurance from an all-Wales perspective and support shared learning across NHS Wales.
Scope
The aim of the review is to consider how effectively are ECT services across Wales led, governed and delivered to provide safe, consistent, person-centred care.
The review will seek to answer the following questions:
- How effective are leadership and governance arrangements for ECT services?
- How are consent, capacity, legal safeguards and patients' rights supported within ECT services?
- How do ECT services ensure they have sufficient workforce capacity and an appropriately trained, competent and supported workforce?
- What is the experience of people receiving ECT, and how are they involved in their care and treatment?
- How do ECT services use evidence to monitor quality and support improvement?
The review will also consider consistency in service provision across Wales through the key lines of enquiry, identify examples of notable practice, and explore opportunities to support improvement and shared learning across the NHS in Wales.
Out of scope
The review will not:
- Investigate or determine individual complaints
- Investigate individual practitioners or re-perform local management functions.
- Provide or replace formal ECTAS accreditation
- Make a judgement about whether a specific individual should or should not have received ECT
- A sample of patient records may be reviewed to assess the quality and consistency of assessment, consent, treatment, monitoring and follow-up documentation. This will inform thematic findings and will not constitute a retrospective investigation of individual clinical decisions.
Methodology
To answer the review questions, HIW will gather and triangulate evidence from a range of sources. The methodology will be proportionate, used consistently across health boards and sufficiently flexible to explore local risks, areas of concern and notable practice.
Policy, intelligence and document review
- Review relevant legislation, national standards, clinical guidance and professional standards
- Review existing HIW intelligence and relevant previous inspection findings
- Consider available national and local data, including activity, outcomes, incidents, risks, complaints, patient feedback and audit findings
- Request and review health board information on governance, workforce, clinical arrangements, legal compliance, patient rights, outcomes and improvement.
- Use the documentary review to develop focused lines of enquiry for the fieldwork.
Site visits and observation
- Visit NHS Wales ECT suites using a consistent evidence collection framework
- Observe facilities, privacy and dignity arrangements, equipment, medicines management and emergency preparedness
- Consider how the environment supports safe, person-centred treatment and recovery.
Interviews and engagement
- HIW will undertake interviews, focus groups or other engagement, as appropriate, with:
- Executive and operational leads
- Clinical directors and service managers
- Consultant psychiatrists and lead consultant anaesthetists
- Nursing, recovery and other relevant clinical staff.
Patient record review
- Review a proportionate sample of records against agreed criteria
- Consider assessment, information provision, consent or statutory authorisation, treatment planning, physical health monitoring, treatment administration, recovery, outcomes and follow-up
- Use anonymised, thematic findings to identify consistency, risks, strengths and improvement opportunities.
Patient voice and experience evidence
- Gather and consider the experiences and perspectives of people who have received ECT, and where appropriate their families, carers and advocates.
- Use accessible and inclusive approaches to engagement to maximise participation and reduce barriers to involvement.
- Consider the engagement methods, such as one-to-one conversations, where these provide appropriate and meaningful insight into people's experiences of care and treatment. This can extend to carers and family members.
- Consider how effectively services support people to understand their treatment options, exercise their rights and participate in decisions about their care.
- Explore how services obtain, analyse and act upon feedback from patients and carers to support continuous improvement.
Working with other organisations
HIW aims to collaborate with relevant stakeholders throughout the review. This will include engagement with NHS Wales health boards, clinical and professional networks, specialist advisers, patient and carer representatives, advocacy organisations, and other organisations with relevant expertise or intelligence.
Stakeholders will be involved at key stages to inform the methodology, support appropriate patient engagement, identify opportunities for joint working, minimise unnecessary duplication and test emerging themes. Specialist clinical peer reviewers will support the delivery and quality assurance of the review.
Timescales
Planning and scoping will take place during September and October 2026, with the formal evidence-gathering phase beginning in November 2026. The proposed timeline is:
| Activity | Timescale |
| Planning and preparation: finalise the Terms of Reference, methodology, review tools, stakeholder arrangements, information request and reviewer calibration. | September to October 2026 |
| Information request, health board self-assessment, documentary review and intelligence analysis. | October 2026 |
| Site visits, patient record reviews and engagement with staff, patients, carers and stakeholders. | November / December 2026 |
| Analysis and triangulation of evidence; consideration of emerging findings and any immediate assurance issues. | November 2026 |
| Drafting, internal quality assurance, stakeholder engagement and factual accuracy process. | January 2027 |
| Final sign-off and publication of the national report. | Spring 2027 |
Analysis and reporting
The review will conclude with publication of a national report. The report will set out the evidence considered, national themes, variation in service provision, areas of good or notable practice and recommendations where improvement is required. Findings will be supported by a clear evidence trail and quality assurance process.
If urgent concerns are identified during the review, HIW will raise these promptly with the relevant healthcare provider and, where appropriate, Welsh Government or another relevant organisation, such as ECTAS. HIW may also share interim learning or emerging themes where this would support timely improvement.
Publication and engagement
HIW will use appropriate communication and engagement channels to explain the review and how people can contribute. Following publication, HIW will consider follow-up activity, learning events and other opportunities to support improvement and shared learning across NHS Wales.
Personal Data
This review forms part of HIW’s work to provide independent assurance on the quality and safety of healthcare services in Wales. The Health and Social Care (Community Health and Standards) Act 2003 (Part II, Chapter 4) gives HIW powers to carry out inspections, reviews and investigations of the NHS and services provided for the NHS.
Where HIW processes personal data, this will be in accordance with applicable data protection legislation, including the Data Protection Act 2018 and UK General Data Protection Regulation. Further information is available in HIW’s privacy policy on its website.