Unsafe hospital discharge putting mental health patients at risk, ombudsman warns

The unsafe transfer of mental health patients from hospital care back into the community is putting them at risk of readmission and suicide, the health ombudsman has warned.

It also identified failings around planning and communication when patients are discharged, and has urged the Government to strengthen the Mental Health Act.

The report by the Parliamentary and Health Service Ombudsman (PHSO) analysed more than 100 complaints between 2020 and 2023 where it had identified failings in mental health care.

Some issues included patient’s families not being told about their discharge from hospital, a lack of communication between the multiple teams caring for patients, failings in the assessment of requests to leave hospital, and poor record keeping.

Ombudsman Rob Behrens said: “The overwhelming majority of professionals in mental health services are hard-working and demonstrate their commitment and care on a daily basis.

“However, 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.”

One such story is that of Tyler Robertson, 22, from Hebburn.

After expressing suicidal thoughts to his family and the police, he was taken to an emergency department, but was discharged later the same day.

His family was not involved in the decision, but the ombudsman found clinicians should have approached the family as the level of risk may have been different if they were consulted.

Mr Robertson was given information of support organisations but the contact details were out of date for most of them. He killed himself in July 2020, less than six weeks after leaving the hospital.

Mr Robertson’s mother Nicola, 43, described her son as “the class clown in school” who was “always laughing”.

“But it was just a mask,” she said. “At home, we saw his struggles.

“He had never been diagnosed with a mental illness, but he had problems with his mental health from a very young age where he was either very happy or very down.”

She has since set up the support group Suicide Affects Families and Friends Everywhere (SAFFE).

Mr Behrens added: “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.”

The report comes after the Care Quality Commission (CQC) announced a rapid review into mental health services in Nottingham following the killings of students Grace O’Malley-Kumar and Barnaby Webber, both 19, and school caretaker Ian Coates, 65, in June last year.

Knifeman Valdo Calocane had paranoid schizophrenia and had been in and out of hospital with mental health problems.

The 32-year-old was given a hospital order at his sentencing for manslaughter by diminished responsibility last week.

It also comes after a previous PHSO report from 2018 which highlighted issues around inappropriate transfers and aftercare.

Six years on, the ombudsman is now calling for a “holistic, joined-up, person-centred approach” to care.

The report said the ombudsman recognises “the immense pressure on the NHS and wider services”, but made a number of recommendations, including that NHS England introduces 72-hour follow-up checks for mental health patients discharged from emergency departments.

The follow-up is currently only given to those who have been discharged from inpatient services.

People discharged from mental health settings should also be able to select a nominated person to discuss decisions in transitions of care, the PHSO said, while patients and their carers should feel “empowered to give feedback, including through complaints”.

It also called for the Department of Health and Social Care (DHSC) and NHS England to engage with patients to assess the potential impact of the national statutory guidance on discharge from mental health settings.

“Crucially, patients, their families and carers must be listened to and involved with decision-making,” Mr Behrens added.

“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.”

Saffron Cordery, deputy chief executive at NHS Providers, said that “listening to service users and their families is vital”.

“However, to really get to the root of the problem, we need to ensure mental health services – and wider services that people with mental health conditions rely on – are adequately funded and supported over the long term,” she added.

“Investing in staff and the tools they need, as well as community-based services, would help people leave hospital safely, when ready, and ensure they are better supported at home.”

Lucy Schonegevel, director of policy and practice at the charity 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.”

DHSC and NHS England have been approached for comment.

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