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A knife attack might have been prevented if the perpetrator had received better mental health care, an investigation by England’s Parliamentary and Health Service Ombudsman (PHSO) has found.  In November 2020, a 31-year-old man stabbed a man in his thirties, just one month after being discharged from the care of Kent and Medway NHS and Social Care Partnership Trust, now called Kent and Medway Mental Health NHS Trust. He was arrested and later detained under the Mental Health Act. After the attack he was diagnosed with schizophrenia.   The Parliamentary and Health Service Ombudsman (PHSO) found a series of failings by the Trust in the 12 months leading up to the stabbing. These included poor care planning and discharging the patient without reviewing his risk level.  The Ombudsman concluded that these failings might have contributed to the man’s mental health decline. Had he received safe and appropriate care, the stabbing might not have occurred.  PHSO has repeatedly raised concerns about systemic failings in mental health services. In 2024, the Ombudsman published a report highlighting failures in transferring people with mental health conditions out of services. The report found failures in planning, communication, and continuity of care, and called for services to be more holistic, joined up, and person-centred. 

The 'Please, Write to Me' guidance from the Academy of Medical Royal Colleges provides information and advice to encourage and support healthcare professionals to communicate directly with patients in writing.  This guidance was first published in 2018. As a result, many clinicians began writing directly to patients in plain English following outpatient clinic consultations. This has since been recommended as best practice by professional and NHS bodies, the General Medial Council, and the UK Government. This update extends the guidance to include writing a section of discharge summaries directly to patients following a hospital admission. This guidance and governance safeguards should also be applied when developing and using AI systems to create clinical documents for use in training and practice.

Every year millions of children in England spend time in hospital. Most children are in hospital only for a short period, often just after they are born or during brief periods of illness. However, for a number of children, hospital becomes a place they spend months and sometimes years of their lives. For the first time, this report shows how long children spend in hospital over their childhoods through new analysis of NHS data. This report sets out why children are waiting to be discharged and what their experience of delayed discharge is like. For some children, time they spend in hospital waiting to be discharged is avoidable. That is particularly true for two groups of children. First, children with serious and complex medical needs. While advances in modern medicine are making a monumental difference in giving them a stronger chance in life, the systems that surround these children – community and primary care, children’s social care, palliative care, housing and education – have not kept pace. The Children’s Commissioner’s office has focused on what this means for children who are waiting in hospital, ready to be discharged. Second, for some children admitted to hospital with social, emotional, behavioural and/or mental health needs. For children admitted with these needs but who do not meet the criteria for inpatient mental health services, their experience waiting in hospital for the right care and support in the community is similarly rooted in challenges facing health, social care and education which has resulted in them being let down, and being admitted to hospital in crisis - waiting for the right therapeutic support in the community. This report brings together data on how long children spend in hospital across their childhoods, alongside the voices and experiences of families, health and care professionals working in hospitals, hospices, community nursing teams and care providers. It sets out the issues facing children whose hospitals stays are being prolonged or more frequent because the support they need to be in the community is not in place.

To gain a rich understanding of the experience of discharge, it’s important to look at different sources of feedback. This could be existing data including national surveys, local data or complaints. Using different sources can help to give you a clearer picture of any themes in the feedback and where to focus your co-produced improvements. NHS England have set out a 4-step process to triangulating feedback (link below), with a focus on the experience of discharge for people who use services and their unpaid carers, which has been shown to correlate strongly with overall experience of care.

Transitions in care are high-risk moments for patient safety; whether from hospital to home, mental health settings to community, or across specialties. In this episode of the Voices for Safety podcast, research experts Dr Natasha Tyler, Dr Richard Keers, and Professor Tom Blakeman dive into why transitions in care can present patient safety challenges and the emotional toll on patients and carers. From medication errors to emotional readiness for discharge, they explore research insights that could reshape the future of safer care transitions.

Delays in discharging patients from hospital affect people’s physical and mental health, and make it harder to admit others to hospital. This joint report by the Auditor General for Scotland and the Accounts Commission warns this has a significant effect, despite impacting only around three per cent of hospital patients. In Scotland, people medically ready to leave spent 720,000 unnecessary days in hospital in 2024/25. Whilst the full financial impact is unknown, the cost to the NHS in hospital days alone is an estimated £440 million a year. Key statistics highlighted in this report include: 17,915 - Number of times people experienced a delayed discharge in 2024/25 720,119 - The number of hospital bed days lost due to delayed discharges in 2024/25 1 in 9 - Proportion of beds occupied due to delayed discharges in 2024/25 3.2% - Delayed discharges as a proportion of adult inpatient discharges in 2024/25 Report recommendations Jointly, the Scottish Government, NHS Scotland, the Convention of Scottish Local Authorities (COSLA), Healthcare Improvement Scotland, integration authorities and their partner NHS boards and councils, should: Over the next 12 months, develop a consistent approach to evaluating and reporting on initiatives to improve delayed discharges, such as discharge without delay and the Lothian Partnership, and sharing best practice and areas for improvement. Evaluation should be reported annually and include assessing effectiveness, value for money, and whether the initiatives are improving the balance of care. This evaluation should be used to update current discharge planning guidance. In the next six months, publish guidance to clarify and strengthen the role of integration joint boards and health and social care partnerships in the governance and delivery of the health and social care service renewal framework. Over the next 12 months, provide guidance on, and better promote public awareness of the benefits of, establishing a power of attorney or a guardianship order. Over the next 12 months, work together to develop and action an implementation plan to share learning and practice from digital solutions used for tackling delayed discharges, early intervention and prevention, Jointly, the Scottish Government and Public Health Scotland should: Produce a clear estimate of the total costs of delayed discharges and the savings being made through initiatives to reduce delayed discharges. This should be completed within the next 12 months, updated regularly and reported in the annual analysis of delayed discharge performance.

In this joint blog by the Patient Association, Sarah one of their callers and Debs, the helpline advisor who took her call, explore what safe discharge from hospital looks like, and what might help should anyone find themselves in an unsafe situation.

In April 2025, the Care Quality Commission (CQC) asked National Voices to explore people’s experiences of care after leaving hospital, with a focus on older people living with frailty and people from groups experiencing health inequalities. Using a mixed‑methods approach, we combined a follow‑up questionnaire with in‑depth interviews to understand what helps or hinders good recovery at home. The research examines four areas: transitions from hospital to community, support to stay well at home, barriers to accessing quality health and social care, and the impacts of unmet needs.

The Scottish Government needs a delivery plan that clearly explains to the public how it will reform the NHS and address the pressures on services. Despite increasing funding and staffing, the NHS in Scotland is still seeing fewer patients than before the Covid-19 pandemic. Auditors found that: commitments to reducing waiting lists and times have not been met the number of people remaining in hospital because their discharge has been delayed is the highest on record and NHS initiatives to improve productivity and patient outcomes have yet to have an impact and lack clear progress reporting.

This is one of a series of Health Services and Safety Investigations Body (HSSIB) and on the theme of patient safety in mental health inpatient settings. This investigation explored the issue of out of area placements (OAPs) – that is, scenarios where a patient is placed in a mental health inpatient setting that is a long way from their home or usual place of residence. This report examines the reasons for OAPs, the harms caused by them and how patients can be kept safe if an OAP is necessary. In particular it focuses on inappropriate OAPs. These are where a patient is unable to be cared for in their local NHS mental health acute inpatient setting and has to be sent to another, normally independent, mental health provider for ongoing treatment and care. These OAPs can be significant distances from a person’s residence. The investigation recognises that other OAPs exist for specialised commissioned services such as those for patients with eating disorders, but these were not considered in this investigation. The investigation has been informed by work carried out in the other investigations in the series, in particular ‘Creating conditions for learning from deaths and near misses in inpatient and community mental health services’. Findings Relating to patient, family and carer experiences The investigation found that harm (including dying by suicide, physical, psychological, distress and anxiety) was happening to patients, families and carers because of OAPs and the impact of being far away from their normal support network. There was also significant anger, frustration and loss of trust in the mental health system as a result of their experiences. Patients, families and carers rarely want an OAP and their choice and opinions are not always taken into consideration when decisions about sending someone to an OAP are made. The investigation found that OAPs can increase patients’ length of stay in hospital and therefore contribute to harm to patients. Patient, family and carers’ wishes and preferences, as required in the Mental Health Act 1983: Code of Practice, are not documented by health and care staff or routinely monitored during Care Quality Commission inspections. This leaves patient, families and carers feeling they are not listened to and increases anxiety, frustration and anger, leading to harm for people and creating distrust in the system. Advocacy services are vital for a patient to be able to put forward their views for consideration in decision making about their care, but advocacy is not always offered to patients. Relating to conditions in the health and care There is a national drive to reduce OAPs, but there continues to be an increasing trend in their use. OAPs may be the only option for patients if they are acutely unwell and need admission to inpatient services and there are no beds available in their local NHS mental health hospital. If OAPs are not utilised in this situation, people will remain unwell in the community and potentially present a high risk of harm to themselves or others. The rules, governance and legal framework within which health and social care organisations work differ. This can create friction in the system, preventing integration and pooling of funds across organisations, slowing down discharge and patient flow, and is a significant factor in the use of OAPs. It is impossible to look at the mental health inpatient system in isolation; consideration must be given to other health and care services such as community mental health services, social care and social housing provision by local authorities. When patients are sent to OAPs, the sending hospitals do not maintain responsibility for the welfare or clinical oversight of those patients. Limited patient flow through mental health and other services reduces trusts’ ability to discharge patients from hospital, which can increase the use of OAPs. NHS mental health trusts do not always have local authority social workers embedded in their organisations, as used to be the case under previous working arrangements. Embedding social workers within trusts was viewed by social workers and healthcare staff as a benefit to patients and improved patient flow and discharge planning. Some NHS trusts are undertaking some of the functions of local authorities relating to social housing, in order to enable patients to be discharged and reduce the need for OAPs. Beds and patients are managed in an impersonal way without seeing patients as having individual requirements. They are both treated as “commodities” when deciding on the need for an OAP because of the pressure on services and need for acute mental health beds. Crisis resolution and home treatment teams can have a significant influence in the early discharge of patients, that then creates a bed for the most mentally unwell patients in the community. Hospitals that send patients out of area sometimes rely on Care Quality Commission rating to base OAP decisions on, but many of these ratings are out of date and may not reflect the current situation. Many acute mental health patients have neurodevelopmental conditions and would benefit from early testing when they are in contact with community and acute mental health settings. Early assessment makes sure people are placed on the right pathway and may reduce admissions to acute mental health settings and the need for OAP. HSSIB makes the following safety recommendations HSSIB recommends that the Department of Health and Social Care includes the documenting of patient, family and carers’ wishes and preferences within the Mental Health Bill. This will ensure all patient, family and carer voices are considered in decisions relating to where the patient identifies they would like to be close to, for example the patient’s home or a family member, specifically when an out of area placement is needed. HSSIB recommends that the Department of Health and Social Care works across government to review the statutory instruments, business processes and regulations that govern mental health services, social care and housing services impacting on mental health out of area placements and creates a proposal for the future accountability and integration of health and social care. This is to ensure that they are operating to consistent statutory, financial and regulatory frameworks. By addressing system integration and nd local authorities will define accountability and reduce or prevent out of area placements. HSSIB makes the following safety observations NHS organisations can improve patient safety by maintaining clinical and welfare oversight and responsibility for patients being treated in an out of area placement. This can ensure harm is minimised and that patients are returned to their sending hospital as soon as possible. Mental health inpatient services can improve patient safety by offering advocacy to all mental health inpatients at the point of admission, and ensuring that the patient’s decision about whether or not to have an advocate is continually reviewed as their treatment continues and needs may change. This can ensure that patients’ needs and views are taken into account by health and social care staff when decisions about their care are being made, particularly when in an out of area placement. Crisis resolution and home treatment teams can improve patient safety by joining quality networks for crisis resolution and home treatment teams and could consider using continuous clinical reviews of mental health acute inpatients. This can ensure that appropriate patients are discharged early and could maximise acute care bed availability for patients in the community who are at high risk because of their mental health problem, and reduce the need for out of area placements. Health and social care organisations can improve patient safety by working together and embedding mental health social workers from the local authority in mental health acute hospitals. This can ensure that patients’ holistic health and social care needs are considered throughout their acute mental health admission and on into the community, and improve efficiency of working, patient flow and discharge and reduce the use of out of area placements. Mental health services can improve patient safety by reviewing their community mental health services to see if they meet the needs of their population with the aim of keeping as many people as possible out of inpatient services and thus preventing the use of out of area placements. Healthcare services can improve patient safety by conducting assessments for neurodevelopmental conditions such as autism and attention deficit hyperactivity disorder, where it is safe and clinically indicated, at the earliest opportunity when a person is in contact with community and acute mental health services. This can ensure that patients are put on the appropriate pathway early. This can prevent harm that may be caused by receiving inappropriate treatment and reduce admissions to mental health inpatient settings, thus reducing the need to use out of area placements.

The purpose of this study was to look at reported patient safety events at the interface between hospital and care home including what active failings and latent conditions were present and how reporting helped learning. Two care home organisations, one in the North East and one in the South West of England, participated in the study. Reports relating to a transition and where a patient safety event had occurred were sought during the Covid-19 virus prepandemic and intrapandemic periods. All reports were screened for eligibility and analysed using content analysis. The findings highlight potentially high levels of underreporting. The most common safety incidents reported were pressure damage, medication errors, and premature discharge. Many active failings causing numerous staff actions were identified emphasizing the cost to patients and services. Additionally, latent conditions (failings) were not emphasized; similarly, evidence of learning from safety incidents was not addressed.

Community hospitals play a very important role in supporting patients but, unlike with larger hospitals, little has been known until now about how they struggle with delayed discharges. Following a freedom of information request, the Nuffield Trust reveals the number of patients experiencing delays leaving community hospitals, and highlights the capacity challenges such hospitals face.