Early release of mental health patients in England presents suicide risk, report finds | Mental health


Mental health patients in England are being put at risk of suicide and harm due to being discharged too early and other failures, according to a report by the health ombudsman.

A report by the parliamentary health and service ombudsman (PHSO) looked at 100 patient cases between 2020 and 2023 where failings in mental health care had been identified.

Failures that were identified by the report include substandard record-keeping around patients’ discharge, family members not being updated as to when a patient would be discharged from hospital and incorrect decisions of people being transferred from inpatient services or emergency departments back into the community.

One of the recommendations the report made was for the government to reform the Mental Health Act 1983 by introducing a mental health bill to parliament as a priority.

The report 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.”

One of the cases highlighted in the report is 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 the same day he arrived there. The ombudsman found the trust should have consulted Robertson’s family before discharging him.

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 report comes after a 2018 report by the PHSO highlighted issues regarding inappropriate transfers and aftercare.

Rob Behrens, the parliamentary and health service ombudsman, urged the government to implement the recommendations made in the report. He said: “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: “As this report recognises, NHS England is working with patients and families on new standards for inpatient care which will help to ensure that patients are discharged at the most appropriate time.

“[Meanwhile] the NHS long term plan commits to increasing funding by £1bn a year to transform community mental health services so that people are supported to stay well after discharge.”


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