The health ombudsman says that discharge of mental health patients from care is not being managed properly, and calls for urgent reform of the Mental Health Act
“Delaying the transfer of someone out of hospital can cause harm, but so can inappropriately discharging people too soon. Too often, the focus is on transferring patients out of inpatient services quickly. No doubt this is at least partly due to the huge strain the NHS and mental health services are under. But the priority must always be patient safety. We know that unsafe transfers can have devastating consequences, such as patients being stuck in a re-admission cycle and, tragically, suicide." Rob Behrens, parliamentary and health service ombudsman
Early release of mental health patients in England is putting them at risk of suicide, according to a new report.
The report, issued by the parliamentary and health service ombudsman (PHSO), looked at 100 patient cases between 2020 and 2023 where failings in mental health care had been identified.
The failings include poor record-keeping relating to patients’ discharge, family members not being informed about when a patient would be discharged from hospital, and incorrect decisions being made when patients were transferred from inpatient care or emergency departments into the community.
The report recommended that the government introduce its planned reforms of the Mental Health Act as a priority. It said: “We are disappointed by the lack of government progress to bring the desperately needed proposed reforms into law. The long-overdue mental health bill is an opportunity to overhaul the way the system works when people are in a mental health crisis and make it fit for the 21st century.”
In the decade up to 2020, 14% of all mental-health patient deaths by suicide happened within three months of discharge from inpatient care, according to a report by the National Confidential Inquiry into Suicide and Safety in Mental Health.
The ombudsman’s report highlights the case of 22-year old Tyler Robertson, who killed himself in July 2022, six weeks after being discharged from an emergency department within the South Tyneside and Sunderland NHS foundation trust. He had presented at the emergency department with suicidal thoughts, but was discharged the same day. Robertson was given information about support organisations but the contact details were out of date for most of them. The trust should have consulted Robertson’s family before discharging him, the report said.
Rob Behrens, the parliamentary and health service ombudsman, urged the government to implement the recommendations made in the report: “The stories in our report show the human tragedies that happen when mistakes are made and how important it is for people to speak up and make complaints so that they don’t happen again.
“Delaying the transfer of someone out of hospital can cause harm, but so can inappropriately discharging people too soon. Too often, the focus is on transferring patients out of inpatient services quickly. No doubt this is at least partly due to the huge strain the NHS and mental health services are under. But the priority must always be patient safety. We know that unsafe transfers can have devastating consequences, such as patients being stuck in a re-admission cycle and, tragically, suicide.
“Mental health patients are among the most vulnerable in our society and I urge the government to act on the recommendations in this report to keep them safe and prevent these same failures from happening again. The lack of progress on the Mental Health Act is deeply disappointing; we must see that strengthened and prioritised.”
Lucy Schonegevel, the director of policy and practice at Rethink Mental Illness, said: “Someone being discharged from a mental health service, potentially into unsafe housing, financial insecurity or distanced from family and friends, is likely to face the prospect with anxiety and a sense of dread rather than positivity. Mistakes or oversights during this process can have devastating consequences.
“This report puts a welcome spotlight on how services can improve the support they offer people going through the transition back into the community, by improving communication and the ways in which different teams work together to provide essential care.
An NHS spokesperson said: that the NHS long-term plan is committed to increasing funding by £1bn a year to transform community mental health services, so that people are supported to remain well after discharge.
The report from the health service ombudsman makes for a sobering read. It highlights six cases that show failings relating to discharge from mental health services, which it says represent a broader trend of issues in planning, communication and care, both during and after discharge. Although not all failings in discharge result in suicide, there is a clear need to manage the process more effectively and to make sure that patients who are mentally unwell are discharged to appropriate care in the community and that families are involved in the process. Although services are under strain, patient safety, as the ombudsman says, must always be a priority.