Discharge from mental health care: making it safe and patient-centred (PHSO, 1 February 2024)

Summary

In this report the Parliamentary and Health Service Ombudsman (PHSO) looks at patient safety concerns relating to the care and discharge of mental health patients. Its findings are based on the analysis of more than 100 complaints that the Ombudsman has investigated between April 2020 and September 2023 where it found failings in care that involved mental health care.

Content

The report highlights a number of areas of concern across six case studies, including:

• Families not being updated or informed about patient’s discharge from hospital care.
• Poor record keeping.
• Lack of communication and joint working between the multiple teams caring for a patient.
• Failings in assessing requests to leave hospital. 

Recommendations

The report makes five recommendations:

1. We note the Department of Health and Social Care’s (DHSC) national statutory guidance on discharge from mental health settings. As it is implemented, DHSC and NHS England must engage with people and services to assess the impact the guidance has on them. In particular, they must make sure that Integrated Care Systems account for the different professionals that should be involved in the discharge multi-disciplinary team (MDT).
2. NHS England should extend the requirement for a follow-up check within 72 hours of discharge for people from inpatient mental health settings to include people discharged from emergency departments.
3. NHS England and integrated care boards (ICBs) should make sure that people who are being discharged from mental health settings can choose a nominated person to be involved in discussions and decision-making around transitions of care.
4. NHS England should make sure that patients and their support network are active and valued partners in planning transitions of care and are empowered to give feedback, including through complaints.
5. The Government must show its commitment to transforming and improving mental health care by introducing the Mental Health Bill to Parliament as a priority.