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Safety of mental health patients leaving care put at risk, Ombudsman says

Mental health patients are being failed as they leave inpatient care leading to a continuous revolving door of care and discharge, England’s Health Ombudsman has warned.

06/02/24

Safety of mental health patients leaving care put at risk, Ombudsman says

The Parliamentary and Health Service Ombudsman is calling on the Government to strengthen and bring forward reforms in the Mental Health Act.

In a new report that examines issues in transferring people with poor mental health out of inpatient and emergency care, the Ombudsman found a range of issues including families not being informed about a patient’s discharge from hospital care, poor record keeping and a lack of communication and joint working between the multiple teams caring for a patient.

The report finds this can lead to poorer outcomes for that patient, including increased risk of suicide. Without proper support in the community, people can become stuck in a revolving door in and out of inpatient services.

The report follows previous research, carried out in 2018, from the Ombudsman which highlighted a range of issues around mental health care including inappropriate transfers and aftercare. Six years on, the Ombudsman found the same failings around transfers and aftercare are still happening, putting patients at risk.

The new report comes after the Parliamentary and Health Service Ombudsman (PHSO) analysed over 100 cases involving people with a mental health condition and failures in their care. It then focused on six cases involving failures in the planning, communication, or care of a person with a mental health condition being transferred from inpatient services or emergency departments back into the community.

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

“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.

“We need to see a holistic, joined-up, person-centred approach. Crucially, patients, their families and carers must be listened to and involved with decision-making.
The Ombudsman has urged the Government to take action by strengthening the bill for a Mental Health Act and prioritise pushing it through Parliament.

He also made several other recommendations including requiring a follow-up check within 72 hours for people discharged from emergency departments, and that the views of patients and their support network are listened to and actively taken into consideration when planning transitions of care.

“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,” Mr Behrens added. “The lack of progress on the Mental Health Act is deeply disappointing, we must see that strengthened and prioritised.”

Lucy Schonegevel, Director of Policy and Practice at Rethink Mental Illness, said the report puts a welcome spotlight on how services can improve the support they offer people going through the transition back into the community.

“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.

“Learning from the lived experience of people severely affected by mental illness and their carers is key, but we also need Government to deliver on its commitment to bolster the workforce so staff are less stretched, and bring forward long-overdue reform of the Mental Health Act to improve the standard of care offered to people when they’re at their most unwell and vulnerable.”

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