Premature Mental Health Inpatient Discharge
Patients removed from mental health inpatient bed lists or discharged prematurely without necessary professional review.
Source spread
Where this theme appears
This theme appears across 11 independent accountability sources, so the source mix matters as much as the headline total.
35 PFD reports
3 committee recs
1 PPO rec
1 PHSO rec
26 IMB recs
1 Article 2 learning point
5 DHR recs
10 PHSO decisions
6 LGO/SPSO decisions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Prevention of Future Deaths reports(35)
Maureen Leaver
Concerns: The coroner identified a lack of medical supervision for inpatients and inadequate systems for managing acutely ill elderly patients with complex conditions. There were also concerns about an insufficient understanding of legal duties under the Mental Health Act 1983 and Mental Capacity Act 2005 during patient transfers.
Overdue
Michael Worrall
Concerns: The coroner noted the limited availability of psychological therapy at Avesbury House, raising concerns about potential adverse consequences for patients discharged into the community after discontinuing therapy.
Overdue
Rebecca Overy
Concerns: The immediate transfer of a patient upon turning 18 was detrimental to her mental health, driven by statutory obligations rather than her best interests. The coroner also identified a lack of secure mental health care provisions for young adults aged 18-24 with similar complex clinical needs.
Overdue
Robert Anstice
Concerns: Concerns identified include un-actioned recommendations for support workers and carer assessments, internal communication gaps regarding appointments, and a patient's discharge despite failed contact and without addressing practical barriers to care.
Overdue
Simon Alliston
Concerns: Concerns were identified regarding the discharge of a patient with a mental health history without formal handover, a recorded reason, or agreement from the community team, and that no formal Serious Incident Investigation followed.
Response (SEPT): • The Trust completed a Root Cause Analysis investigation into the patient's care. • The Trust reviewed its Serious Incident reporting process and decided that the default position is to … (AI summary)
Responded
Katherine Bonaventura
Concerns: The coroner noted insufficient consultation with family/carers when detained patients return from leave, often limited to a few words in the patient's presence. There is also no system for a thorough mental state assessment of the patient upon their return to the unit.
Overdue
George Taylor
Concerns: The coroner noted the undesirable practice of sending 8 to 12 psychiatric patients out of county monthly due to a lack of acute beds, identifying a risk that this could lead to a future death.
Response (Department of Health): • The Minister made NHS England aware of the report. (AI summary)
Response (NHS Kernow Clinical Commissioning Group): • NHS Kernow commissions 54 acute mental health assessment and treatment beds and has a contract with Cygnet Hospitals for additional specialist beds. • It is working with partners to … (AI summary)
Responded
Louise Locke
Concerns: The coroner identified concerns regarding a premature discharge from the Community Mental Health Service without adequate risk assessment or support, and the lack of a system to collate information from other agencies. The report also highlights the absence of a consistent multi-agency approach to high-risk individuals and suicide prevention across all areas served by Southern Health.
Response (Southern Health NHS Foundation Trust): • Clinical Service Directors will formulate a standard plan to ensure patients requesting second opinions are not prematurely discharged. • The Standard Operating Procedure for patients attending Emergency Departments for … (AI summary)
Responded
Freda Weston
Concerns: Insufficient doctor and nurse staffing led to significant delays in antibiotic administration and patient review. The report also notes issues with adherence to escalation guidelines, clarity of pharmacy medication details, and immediate shredding of handover sheets.
Response (Weston): • The Trust stated it would not alter its current practice regarding Septrin usage or implement a period of observation after starting Septrin, citing clinical reasoning. • The Trust clarified … (AI summary)
Responded
Dorota Kijowska
Concerns: The outcome of a review meeting was not signed off in writing by those in attendance and was not clearly communicated to the individual concerned.
Overdue
Dean Rowland
Concerns: The coroner noted delays in the deceased's ability to discuss antidepressant medication with a GP and concerns about his discharge from the community mental health team after a single consultation without a follow-up plan, despite prior suicide attempts.
Response (South Staffordshire and Shropshire Healthcare): • The Community Mental Health Team (CMHT) conducted an assessment of Mr. Rowland's needs within expected referral timeframes. • The CMHT determined Mr. Rowland was at low risk for self-harm … (AI summary)
Response (Peel Medical Practice): • The practice has instituted a duty doctor and telephone triage system. • Patients requiring an appointment sooner than a routine slot are offered a callback from the duty team. … (AI summary)
Responded
Ryan Vout
Concerns: The coroner identified insufficient co-ordination in discharge planning from inpatient psychiatric care, including a lack of liaison between professionals and family. Concerns were also raised about the inability to pre-arrange ambulances and the informal nature of risk assessments before executing MHA warrants.
Response (Nottinghamshire County Council): • The issue of improving ambulance provision for Mental Health Act work has been escalated and discussed with health commissioners. • The Crisis Concordat Task and Finish Group is exploring … (AI summary)
Response (East Midlands Ambulance Service NHS Trust): • East Midlands Ambulance Service (EMAS) stated that the ability to pre-book an ambulance for Section 135 or 136 Mental Health Act warrants has always been available. • The Trust … (AI summary)
Response (Department of Health): • The Department of Health noted the coroner's concerns regarding discharge planning and the conveyance of patients under the Mental Health Act. • The government commissioned an independent review of … (AI summary)
Responded
Miriam Roach
Concerns: The coroner noted concerns regarding aftercare and transition arrangements for patients discharged home with a moderate to high risk of self-harm, specifically highlighting the obligations for putting in place contact arrangements for these individuals.
Overdue
Marcus Hance
Concerns: Concerns were raised regarding the individual's inability to access mental health support while receiving dependency treatment, due to a dual diagnosis approach, and their discharge from CMHT following missed appointments.
Response (Cornwall NHS Trust): • The Trust confirmed it would work in partnership with NHS Kernow on the ongoing review of the Dual Diagnosis strategy. • The Trust confirmed it would work in partnership … (AI summary)
Overdue
William Edge
Concerns: The coroner raised concerns that the Home Treatment Team could not revisit a patient in imminent danger due to high demand, exacerbated by inpatient bed capacity issues that divert more patients to HTT management.
Response (NHS England): • The Birmingham and Solihull Clinical Commissioning Group (CCG) established a Quality Improvement Board and a governance framework to oversee CQC improvement plans and manage quality. • The CCG provided … (AI summary)
Response (NHS Birmingham and Solihull ICB): • The CCG increased investment in mental health services and commissioned independent reviews of system capacity and patient journeys. • The CCG committed to a comprehensive review of its serious … (AI summary)
Responded
Eileen Cooke
Concerns: The coroner identified inadequate planning for the patient's discharge, including the absence of a 'best interests' meeting, despite unresolved medical issues. Concerns were raised that precipitous hospital discharges are not uncommon and may compromise patient safety.
Response (Response Mid Yorkshire Hospitals): • The Trust has established processes for the safe discharge of elderly patients, including comprehensive geriatric assessments and multidisciplinary team discussions. • It ensures therapy assessments, access to community services, … (AI summary)
Responded
Colette Dunn
Concerns: A full Mental Health Act assessment was not performed before discharge, despite police concerns about suicidal intent. The coroner also noted a lack of clear inter-agency discharge protocols and insufficient facilities for mental health crisis management in Milton Keynes.
Overdue
Matthew Craven
Concerns: The trust lacked an escalation process for rejected psychiatric referrals and had no agreed target timescales for routine appointments. Concerns were also raised about gaps in documenting referral rationales and insufficient information sharing between different mental health services within the same trust.
Response (Pennine Care NHS Trust): • The Trust stated it would develop an escalation process and protocol for rejected referrals by the end of February 2019. • The Trust confirmed the agreed target timescale for … (AI summary)
Responded
Stephen Kennedy
Concerns: The coroner identified insufficient access to psychological therapy for the deceased due to internal service structures and long waiting lists, alongside a lack of available inpatient acute beds when needed.
Response (Department of Health and Social Care): • The Department committed an additional £2.3 billion investment in mental health services by 2023-24, as outlined in the NHS Long Term Plan. • Over £400 million in supporting investment … (AI summary)
Response (Birmingham and Solihull Mental Health NHS Trust): • The Trust plans to invest in clinical psychology capacity within Home Treatment Teams, aiming to recruit 0.5WTE Clinical Psychologists for each team from September 2019. • A tiered training … (AI summary)
Response (NHS Birmingham and Solihull ICB): • The CCG stated its intention to formalise changes through a Service Development and Improvement Plan (SDIP) for 2019/20, which will require providers to ensure access to psychological therapies. • … (AI summary)
Responded
Sasha Forster
Concerns: The coroner noted insufficient resources prevented SBP staff from collecting a patient when Section 17 leave was revoked, despite it being their legal duty. This reliance placed an unfair burden on the patient's mother to return her to the ward.
Overdue
Denton Duhaney
Concerns: The coroner raised concerns regarding the absence of a psychiatric assessment for Mr Duhaney at Pinderfield's Hospital and a failure to follow discharge protocols when he self-discharged. There were also gaps in communication between the hospital and the community treatment team, leading to a delay in follow-up.
Response (Fieldhead Hospital): • The Standard Operational Policy for Psychiatric Liaison Teams was reviewed and amended to ensure consistent practice across the Trust. • Guidance was produced and disseminated to staff in community … (AI summary)
Responded
Sky Rollings
Concerns: The coroner identified that 18-year-old patients transferring from CAMHS immediately receive adult mental health provisions, despite the lack of a dedicated inpatient provision for individuals aged 14-25. This gap creates a risk of further deaths.
Response (NHS England): • NHS England confirmed that young people are not automatically transferred at 18 and that discharge and admission planning processes are in place. • NHS England noted that the Trust … (AI summary)
Response (North Staffordshire Combined Healthcare NHS Trust): • The Trust initiated a review of its Transition of Young People to Adult Mental Health Service Policy. • The Trust commenced work with partners to support the development of … (AI summary)
Responded
Neil Bastock
Concerns: The decision to rescind the patient's section was made without family involvement or a formal mental capacity assessment, alongside poor treatment continuity. Subsequently, concerning behaviours and family warnings were not sufficiently considered to reassess his voluntary patient status.
Response (Leeds and York Partnership NHS Foundation Trust): • The Trust will review and formalise support and supervision arrangements for locum medics and clinical handover processes. • The Trust will review training for medical staff on mental capacity … (AI summary)
Responded
Theo Brennan-Hulme
Concerns: The coroner noted a persistent culture of bullying and harassment within the Crisis Resolution Home Treatment Team, affecting compassion and referral recognition. There was also no immediate review or discussion of discharge decisions from the Community Team after assessment.
Response (Hellesdon Hospital): • Team members will be allocated time to watch and discuss 'Suicide Prevention Magical Thinking' content in team meetings. • The Trust reported that work had been undertaken to improve … (AI summary)
Responded
Ian Darwin
Concerns: Tees Esk and Wear Valleys NHS Foundation Trust routinely delays serious incident investigations, which may allow hazards to persist and compromise the quality of these investigations. This practice does not align with the nationally recognised 60-working day timeframe for completion.
Response (TeesEsk and Wear Valleys NHS Foundation Trust): • The Trust contracted additional expert capacity and increased internal capacity to address delayed and incoming incident reviews. • The Trust adapted processes for earlier identification of review types, immediate … (AI summary)
Response (Tees Esk & Wear Valley NHS Foundation Trust): • The Trust has contracted additional expert capacity and increased internal capacity to address delayed incident reviews. • Processes have been adapted to facilitate earlier identification of review types and … (AI summary)
Responded
Lauren Bridges
Concerns: Delayed discharge of out-of-area mental health patients was noted due to underfunded local beds and reliance on independent providers. Communication gaps stemmed from varied processes, incompatible IT systems, and no national repatriation standards.
Response (NHS England): • NHS England published renewed guidance in July 2023 to support timely access to high-quality therapeutic inpatient care. • Integrated Care Boards (ICBs) have been tasked with developing 3-year plans … (AI summary)
Response (Dorset Healthcare University NHS Foundation Trust): • The Trust reviewed and enhanced its daily Hospital Overview report, adding a section for patients requiring repatriation. • A Standard Operating Procedure for Enabling Purposeful Admissions was implemented, and … (AI summary)
Response (Department of Health and Social Care): • The Department of Health and Social Care (DHSC) stated its continued commitment to eliminating all inappropriate acute out-of-area placements for adults. • The DHSC made available up to £2.8 … (AI summary)
Responded
Kirsty Taylor
Concerns: The coroner identifies insufficient connectivity between mental and physical health services, particularly for neurodivergent patients, and notes a lack of a comorbidity policy. Further concerns include the pace of developing a personality disorder pathway and ineffective communication with families of mental health patients.
Response (NHS England): • NHS England has provided funding since 2021/22 to develop and implement new models of integrated primary and community mental health care, including a dedicated offer for individuals with personality … (AI summary)
Response (Hampshire and Isle of Wight): • The ICB endorsed the recommendation for a new all-age community and mental health Trust, which is planned to go-live on 1 April 2024. • The ICB is re-commissioning ASC … (AI summary)
Response (Southern Health NHS Foundation Trust): • The Trust is progressing with Project Fusion to establish a new, single community and mental health provider by April 2024, and has established a Neurodiversity Clinical Delivery Group. • … (AI summary)
Responded
Sobhia Khan
Concerns: Concerns were raised regarding the Ministry of Justice's discharge of a high-risk patient without adequate Mental Health Tribunal scrutiny, the absence of forensic pathways for s.41 restricted patients in the locality, and gaps in police powers to arrest individuals posing a serious risk in relationships.
Response (Derby City Council): • Derby City Council has introduced regular, jointly funded training for social supervisors, including an introductory course and annual refreshers. • The council is finalising a Memorandum of Understanding with … (AI summary)
Response (Derbyshire Healthcare NHS Foundation Trust): • The Trust invested £2.7 million to establish a Forensic Community Mental Health Team (FCMHT) to provide care and supervision for s.41 restricted patients. • The FCMHT has received training … (AI summary)
Response (Derbyshire Constabulary): • The Constabulary sent a letter to the national policing lead for the Management of Sexual Offenders and Violent Offenders (MOSOVO) for consideration regarding police powers of arrest. • The … (AI summary)
Response (Cygnet): • Cygnet reviewed the PFD action plan at Clinical Governance meetings and scheduled it as a monthly agenda item until September 2024. • Spousal Assault Risk Assessment documents are provided … (AI summary)
Responded
Timothy Clayton
Concerns: Concerns were raised regarding Epsom General Hospital's discharge planning policy, which remains under review, and a clinician's misunderstanding of capacity in relation to an unsafe discharge. Additionally, pressure to vacate hospital beds was noted to impact clinicians' ability to prepare properly considered discharge plans, leading to rushed decisions.
Response (NHS England): • NHS England met the target for 5,000 additional core general and acute beds and established Care Transfer Hubs in all hospitals. • The 2024/25 operational planning guidance asks systems … (AI summary)
Response (St Georges Epsom and St Helier): • The Hospital Discharge and Criteria to Reside Policy has been reviewed, updated, and approved, clarifying the identification of vulnerable patients and the involvement of families in discharge planning. • … (AI summary)
Responded
Louise Crane
Concerns: The coroner identified inaccurate record keeping practices, including staff using other's ID cards, and a widespread lack of understanding regarding therapeutic engagement among ward staff. Additionally, the trust's systems for safe patient transition from intensive to acute care were inadequate, failing to facilitate identified risks.
Response (North London NHS Foundation Trust): • The Trust implemented an Enhanced Mandated Support (EMS) programme across its Hospital Division to address immediate safety risks and embed quality improvements. • A new staffing model was approved … (AI summary)
Responded
Sidi Bojang
Concerns: The report identifies an issue with discharging individuals who quickly appear well after recent self-harm or suicidal thoughts, noting that a psychiatrist did not review them before discharge and a senior psychiatric nurse made the decision.
Response (Department for Health and Social Care): • NHS England has strengthened mental health expertise within urgent and emergency care, ensuring all Type 1 Emergency Departments have access to 24/7 mental health liaison services. • NHS England … (AI summary)
Responded
Charlotte Tetley
Concerns: Patients risk being removed from inpatient bed lists prior to a mental health professional conducting an appropriate review on the same day, despite prior recommendations for admission or daily review.
Response (Cheshire and Wirral Partnership NHS Foundation Trust): • The Trust has embedded administrative support within First Response to ensure that outcomes of Clinical Prioritisation Meetings are directly documented in SystmOne. • A new Standard Operating Procedure for … (AI summary)
Responded
Sarah Heaver
Concerns: The report identified a lack of appropriate neurological investigation and structured observations, unreliable medical records, and delays in psychiatric input for discharged patients, particularly over bank holidays.
Response (Kent and Medway Mental Health NHS Trust): • The Trust implemented a three-week rolling rota for independent prescribers to ensure cross-cover for weekends, bank holidays, annual leave, and sickness. • Responsibility for booking annual leave for prescribers … (AI summary)
Response (East Kent Hospitals University NHS Foundation Trust): • The Trust updated its Vital Signs Policy in November 2025 to incorporate specific requirements for neurological assessment, including for patients receiving Naloxone infusions, and embedded these standards into training … (AI summary)
Responded
Mark Vidler
Concerns: The coroner identified that staff sometimes prioritised process over patient-centred care, noted a lack of clear clinical decision-making in rapid response referrals, and raised concerns about insufficient inclusion of receiving teams in discharge planning.
Response (Kent and Medway NHS Mental Health Trust): • The Trust is revising its Rapid Response and Home Treatment Team Standard Operating Procedures to ensure senior clinical oversight for referral decisions and to include receiving teams in discharge … (AI summary)
Responded
Michaela Finch
Concerns: The coroner noted that the full nature of the deceased's mental health deterioration and irrational behaviour was not appreciated as significant, leading to discharge with a conservative community-based care plan and no escalated home-based treatment.
Response (Greater Manchester Integrated Care): • Greater Manchester Integrated Care (NHS GM) strengthened oversight and responsiveness within existing services, including improving identification and review of individuals at risk of deterioration. • NHS GM reviewed all … (AI summary)
Response (Greater Manchester Mental Health NHS Foundation Trust): • The Trust has appointed a Strategic Lead for Co-Occurring Conditions and established a working group to develop a trust-wide strategy and staff training. • The Trust updated its Standard … (AI summary)
Responded
Select committee recommendations(3)
#18 —
Recommendation: We recommend that the Ministry of Justice and Welsh Government redesign the Female Offending Blueprint for Wales to take account of the policy changes since it was published in 2019, drawing on the recommendations contained within the Women’s Justice Board’s …
Response status not verified
#17 —
Recommendation: The number of Welsh women receiving custodial sentences in Wales is rising, as is the number of those offenders receiving short sentences. This is despite longstanding and ever-increasing evidence that prison—and short sentences—pose particular harm to women and do little …
Response status not verified
#9 — Government fails to halve detentions of autistic people; numbers in mental health settings rise.
Recommendation: The Government has fallen short on its commitment to halve the number of people with a learning disability and autistic people inappropriately detained in mental health hospitals. Promises to bring forward a new Mental Health Bill to help address this …
Response status not verified
PPO death in custody recommendations(1)
PHSO ombudsman recommendations(1)
IMB individual recommendations(26)
Wymott (2020)
Too many prisoners with severe mental health problems get stuck in prisons, often in segregation units, because there are not enough place in secure psychiatric units (see paragraph 5.2.2). There is a desperate need for more of these places.
NHS / Healthcare Provider
In Progress
Downview (2020)
As was highlighted in our previous report, segregation is not suitable as a long-term rehabilitation environment for the prisoner mentioned in our report who has suffered significant brain trauma leading to specific medical needs. For such prisoners, national-level attention and coordination are required to identify and facilitate transfers to a more suitable location, where the individual can receive appropriate rehabilitative …
Ministry of Justice
In Progress
Bedford (2022)
We have also seen many prisoners at HMP Bedford with such severe mental health issues that effective treatment by the local mental health team has not been possible. These men do not belong in prison: they get no better and take up an enormous amount of officer time. Transfer to an appropriate mental health facility is hugely difficult and the …
Ministry of Justice
Hewell (2025)
What is being done to ensure that the 28-day limit for transfer of prisoners to a mental health hospital is enforceable?
Ministry of Justice
In Progress
Chelmsford (2025)
Many prisoners entering prison have mental health problems - some of them severe - and they urgently need care in a specialist unit. However, there are not enough secure places to meet the needs of the prison population, creating a ‘log-jam’ in local healthcare units, where facilities are taken up by prisoners who should be elsewhere. This obviously impacts on …
Ministry of Justice
Rejected
Woodhill (2020)
To ask the minister to work with ministerial colleagues in the Department of Health to ensure that delays in transferring prisoners to secure mental health facilities are reduced.
Ministry of Justice
In Progress
Whatton (2020)
The Board has had to report that a prisoner was held for a long time in secure conditions with deteriorating mental health while waiting for secure hospital accommodation (see paragraph 5.2.3). Despite regular assurances from the National Health Service (NHS) commissioners that this area of concern was being addressed nationally, there have been no improvements to the speedy resolution of …
Ministry of Justice
In Progress
Wandsworth (2020)
Delays in transfers to secure psychiatric accommodation, reported by the Board each year since 2009, remained a problem. The Minister responded to the Board in 2019 that the 14-day target had not been agreed with NHS England, Her Majesty’s Prison and Probation Service’s (HMPPS) primary partner. Has it now been agreed?
Ministry of Justice
In Progress
Stoke Heath (2020)
The Board has registered its concern about unacceptably long waiting times for assessment for transfer to prisons with inpatient beds. The Board supports the prison’s proposal to create a crisis unit within the prison’s decommissioned inpatient unit, to enable care to be provided appropriately on site while waiting for assessment and transfer under the Mental Health Act. The Board hopes …
Governor / Director
Woodhill (2021)
Again, we ask the minister to work with ministerial colleagues in the Department of Health to ensure that delays in transferring prisoners to secure mental health facilities are reduced.
Other
In Progress
Leicester (2022)
Does the minister agree that allowing them to make progress to safe discharge should have a higher priority?
Ministry of Justice
Brinsford (2022)
The amount of time taken to transfer the more vulnerable prisoners with mental health problems is another concern raised regularly. Officers within the inpatient health care are very supportive and compassionate to their patients, however they are not specialist-trained in mental health. Some inpatients have been based in the unit for months before being transferred to more specialist accommodation.
Ministry of Justice
In Progress
Yarl’s Wood IRC (2023)
The Board is concerned with the length of time between identification of need and the sourcing of mental health beds and/or secure mental health beds for vulnerable persons. The Board does not consider the CSU to be an appropriate place for a detained person who is having a mental health crisis.
NHS / Healthcare Provider
Whatton (2023)
Can the Minister commit to a date when the statutory limit of 28 days for transfers of prisoners needing secure psychiatric care, which was referred to in the previous Minister’s response to our report last year, will be passed into law?
Ministry of Justice
In Progress
Swinfen Hall (2023)
Will the Minister explain how provision can be increased to ensure that waiting times for approved transfers to secure hospitals are reduced?
Ministry of Justice
Erlestoke (2025)
What solutions are being sought to provide more suitable accommodation and support for those with the most complex needs? Last year, the Board asked about long term plans to establish more appropriate mental health provision within the secure estate. This issue remains despite local improvements.
Ministry of Justice
In Progress
Doncaster (2025)
The Board remains extremely concerned about the prolonged delays transferring mentally ill patients to secure hospitals. What steps will the Minister take to urgently review and address this issue?
Other
In Progress
Northumberland (2020)
Following on from our previous concern, voiced in our 2019 report, regarding a lack of sufficient places within specialised facilities for men with severe mental health (MH) needs in the North East, the Board feels that this is still a pertinent concern. This concern was illustrated by one prisoner’s period in segregations, extending over 100 days due to no available …
Ministry of Justice
In Progress
Leicester (2020)
Although the numbers are small, and the Gatekeeping process has improved, the Board has still had to report that two prisoners were held for a long time in inhumane conditions with deteriorating mental health while waiting for secure hospital accommodation (see section 6.2.1). In his reply to the Board’s previous report, the minister stated that ‘NHS England and NHS Improvement …
Ministry of Justice
In Progress
Cookham Wood (2020)
There is a chronic lack of secure mental health hospital beds for children nationally, and the time taken to transfer boys with significant mental health issues to hospital from a YOI is inhumane. What urgent steps will be taken to work with ministerial colleagues in the Department of Health to provide more secure mental health services for children?
Ministry of Justice
In Progress
High Down (2022)
What steps does the minister intend to take to ensure that prisoners who require transfer to an outside secure mental health unit are assessed and transferred without delay? (see section 5.2.)
Ministry of Justice
Portland (2024)
There continues to be national concern (raised in the draft Mental Health Bill) about the increase in residents with poor mental health and the way they are treated in law. Will the Minister undertake to work with other Ministers to ensure an integrated system to allow the humane treatment of such residents and provide facilities to transfer prisoners to more …
Ministry of Justice
In Progress
New Hall (2024)
The Board feels that prison is not an appropriate environment for women with severe mental health issues and those women requiring assessment and admission to secure mental health establishments were not assessed and transferred promptly enough.
HMPPS
In Progress
Isle of Wight (2024)
Can the Minister work with the Minister for Health and Social Care to provide sufficient beds in secure hospital facilities to ensure that the increasing number of mentally ill prisoners in the prison estate can be transferred to an appropriate care setting within the 28-day transfer target?
Ministry of Justice
In Progress
Thameside (2025)
NHS England should outline what is being done to increase capacity for mental health transfers from prison to hospital, particularly in light of the proposed statutory 28-day time limit.
NHS / Healthcare Provider
In Progress
Hewell (2025)
When will the transfer of men with severe or complex mental health conditions be consistently achieved within the 28-day limit?
Governor / Director
In Progress
Health investigations(27)
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec B
The House of Lords' decision in Secretary of State for the Home Department v. Oxford Regional Mental Health Review Tribunal [1988] A.C. 120 should be reversed by law so as to allow a tribunal to adjourn an application in order to give time for a further examination of the patient's …
east_of_england
Independent investigation: Ivy Newman, Tower Hamlets (1998) — Rec 27
Apatient referred to a CMHTwho presents a risk to his own health or to others should not be discharged from the CMHTon the basis of non-engagement alone.
london
Independent investigation: Ivy Newman, Tower Hamlets (1998) — Rec 15
There should be no discharge from in-patient care without an aftercare plan in place.
london
Independent investigation: Ivy Newman, Tower Hamlets (1998) — Rec 11
No patient should be discharged by an SHO (other than as part of an existing plan) without consultation with a senior colleague.
london
Independent investigation: Gwen Poole, Llanbradach, Caerphilly (2009) — Rec 3.23
Aneurin Bevan Health Board and Cygnet Hospital must undertake a thorough review of the rationale for the clinical decisions made at the time of Mr H’s discharge from Cygnet Hospital and his subsequent care by the CMHT and non-admission to Tŷ Sirhowy.
wales
Independent investigation: Stephen O’Brien, Crewe (2016) — Rec 5
The Trust should develop a policy and guidance on the discharge of patients who are failing to engage but are actively psychotic and have a moderate risk of violence exacerbated by substance misuse.
north_west
Independent investigation: Mary Skerrit (81)Keith Fernandez, Stoke NewingtonPalmers Green — Rec R5
Mental health NHS trusts should be particularly careful when they discharge patients with serious risk indicators whose assessments are incomplete. They should try to actively re-engage such patients when appropriate.
london
Independent investigation: Brian Dodd, Prestatyn (2003) — Rec a)
That Bro Morgannwg NHS Trust and Cardiff and Vale NHS Trust give careful consideration to whether patients conditionally discharged into the community can be adequately managed in full-time independent living or whether they should remain in supervised hostel accommodation. This is particularly the case where the required relapse indicators and …
wales
An independent investigation into the care and treatment of MN: … — Rec Recommendation 5
The Trust should develop a policy and guidance on the discharge of patients who are failing to engage but are actively psychotic and have a moderate risk of violence exacerbated by substance misuse.
MN. MN was convicted of manslaughter in August 2017. At the time of the homicide MN was receiving care and treatment from Cheshire and Wirral Partnership NHS Foundation Trust
north_west
An independent investigation into the care and treatment of mental … — Rec 3
The Trust AWOL policy should be amended to ensure that any decision to discharge an AWOL patient in their absence is explicitly risk assessed, supported by a detailed decision making tool, and reported on centrally to ensure practice is monitored.
Greater Manchester Mental Health NHS Foundation Trust
north_west
Accepted
An assessment of a mental health trust’s internal investigation of … — Rec R2
The trust to ensure Responsible Clinicians (RCs), responsibly exercise their power under the Mental Health Act when discharging a patient from their CTO because the criteria for making it no longer apply. A formal multi-disciplinary team (MDT) meeting should be held with colleagues to discuss the patient and agree an …
north_east_yorkshire
Independent investigation: Ivy Newman, Tower Hamlets (1998) — Rec 32
No-one referred by a GPor CMHTshould be discharged from the drug service without a risk assessment being carried out.
london
Independent investigation: Ivy Newman, Tower Hamlets (1998) — Rec 13
When someone with a severe and enduring mental illness re-presents to medical services after absconding from compulsory in-patient care, the patient should be re-assessed by the psychiatric services (ideally the one from which he/she absconded) irrespective of whether the MHAsection has expired.
london
Independent investigation: Anthony Rigby, Blackburn (2002) — Rec 15
More frequent use should be made of s.25 when high risk patients who have enduring mental illness are discharged.
north_west
Independent investigation: Peter Greenfield (PG), Croydon (2003) — Rec 5
The trust should review its policy on hospital discharge for patients with borderline personality disorder and related personality difficulties to consider a better system for patients who are drunk and therefore in breach of conditions for remaining in hospital. (II/AA)
london
Independent investigation: John Curran, Highbury & Islington (2006) — Rec R22
The trust should ensure that the home treatment team is adequately resourced and able to operate to reduce or abolish over-occupancy, to provide a safer and more appropriate alternative to the use of unescorted leave and to provide a gate-keeping service for admissions to inpatient facilities.
london
Independent investigation: Gwendoline SmithDavid Smith, Sandiacre (1995) — Rec 13
Where an intended discharge is delayed for further consideration, a full review meeting should be held prior to discharge being granted.
midlands
Independent investigation: Colin Anderson, Newcastle (2006) — Rec 18
In circumstances where a patient proposes to discharge himself or herself (or has done so) against medical advice, a risk assessment covering the potential risks to the patient and any other person should always be carried out and documented.
north_east_yorkshire
An independent inquiry into the care and treatment of Ms … — Rec 5
The review recommends that consideration be given to the development of a generic risk assessment specifically for patients who have either unexpectedly discharged themselves or who have left when under a legal duty to remain.
south_east
*Independent investigation into the care and treatment of Mr H: … — Rec 1
The Independent Team has been provided with a copy of the proposed new policy document, “Policy on the Transfer of Clients From Low Secure Services”. Detailed constructive commentary has been provided to the authors of the document via The Trust’s Head of Serious Incidents. Because of the increased risks associated …
South Essex Partnership University NHS Foundation Trust
east_of_england
An independent investigation into the care and treatment of Christie … — Rec 9
Health and social care agencies must provide appropriate challenge where there are concerns about unsafe discharge arrangements from Tier 4 inpatient care, including appropriate escalation up to chief officers where concerns for children’s safety are high.
An independent investigation into the care and treatment of Christie at Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
Independent investigation: Brian Cherry, Walthamstow (2004) — Rec R1
As has been stated by (Forensic Social Worker 1) and (JHC Psychiatrist 1), it seems appropriate for Mr Bryan to be transferred to an environment of lower security. Mr Bryan needs to move to a more challenging setting to further his rehabilitation.
london
Independent investigation: Maurice Hilton, Peterlee (2006) — Rec 24
Trusts should review all policies, formal or informal, that prescribe general rules for discharge from services, and ensure that they are not applied in a formulaic way. Discharge should be dictated not by non attendance per se, or by self evaluation, or by rigidly applying service criteria, but by clinical …
north_east_yorkshire
Independent investigation: Maurice Hilton, Peterlee (2006) — Rec 15
The panel recognises the pressure that may force psychiatrists to rapidly admit a patient to hospital where there is an urgent need for treatment. However the appropriateness of the placement should be kept under close review, and the trust should ensure that the responsible psychiatrist is supported in finding an …
north_east_yorkshire
Independent investigation: Asiya Khatun, Newham (2000) — Rec 14
East London and The City Mental Health NHS Trust and the North East London Strategic Health Authority should review capacity in secure inpatient mental health facilities to permit direct access to a secure bed when appropriate on clinical and risk grounds, without the necessity for access through the criminal justice …
london
Independent investigation into the care and treatment of Mr S — Rec 2
West London Mental Health Trust must ensure that prior to discharging a detained patient from inpatient services, a section 117 aftercare meeting is held and that appropriate mental health aftercare plans are identified and put into place.
Mr S who committed a homicide in November 2012. Mr S had previously received treatment from Central and North West London NHS Foundation Trust
london
Accepted
An independent investigation into the care and treatment of Christie … — Rec 11
CNTW must ensure there is a written protocol that details the pathway for discharge from Ferndene Psychiatric Intensive Care Unit (PICU), including timescales for informing and involving families and the young person in arrangements so that, wherever possible, a young person is not suddenly transferred without adequate preparation.
An independent investigation into the care and treatment of Christie at Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
Independent reviews(2)
Mental Health Taskforce 2016 — Rec 22
In 2016, NHS England and relevant partners should set out how they will ensure that standards are introduced for acute mental health care, with the expectation that care is provided in the least restrictive way and as close to home as possible. These plans should include specific actions to substantially …
Health & Social Care
Wessely Review — Rec 120
Health and social care commissioners should have a duty to collaborate to ensure provision of community based support and treatment for people with a learning disability, autism, or both to avoid admission into hospital and support a timely discharge back into the community.
Health & Social Care
Accepted
PHSO casework decisions(10)
P-001556 — Wrightington, Wigan and Leigh NHS Foundation Trust
Mr A complained the Trust provided improper mental health treatment, discharged him while psychotic, and failed to send him copies of his medical records.
NHS in England
Jul 2022
P-002871 — Central and North West London NHS Foundation Trust
Miss E complained the Trust provided inadequate mental health care, including inappropriate discharge, insufficient therapy, poor facilities, and isolation during a complaint, causing mental deterioration.
NHS in England
Jul 2024
P-001701 — University Hospitals Birmingham NHS Foundation Trust
Mr P complained the Trust prematurely discharged his wife, leading to a brain bleed, stroke, and life-changing injuries, asserting care fell below expected standards.
NHS in England
Jan 2023
P-003585 — Nottinghamshire Healthcare NHS Foundation Trust
Mrs R complained Nottinghamshire Healthcare NHS Foundation Trust failed to provide effective mental health support to her father, Mr Y, leading to his accidental death, by discharging him while suicidal and mismanaging appointments.
NHS in England
Upheld
Jun 2025
P-004242 — University Hospital Southampton NHS Foundation Trust
Mr I complained the Trust prematurely discharged his wife, suffering from depression and psychosis, leading to her being found wandering and developing a severe foot infection.
NHS in England
Oct 2025
P-002557 — Lancashire and South Cumbria NHS Foundation Trust
The Trust failed to support her mother, discharged her too early without a care plan, and did not communicate with the family, leading to her premature death.
NHS in England
Apr 2024
P-003346 — Leeds Teaching Hospitals NHS Trust
The Trust allegedly rushed an operation instead of offering radium treatment for cancer, and discharged Mrs A prematurely without a care package, leading to her death.
NHS in England
Feb 2025
P-004340 — Greater Manchester Mental Health NHS Foundation Trust
Mrs E complained the Trust wrongly discharged her, refused medication changes, made incorrect referrals, ignored bullying, and delayed complaint handling, impacting her mental health.
NHS in England
Nov 2025
P-002028 — Southern Health NHS Foundation Trust
Her sister was inappropriately discharged, given unsuitable medication, and missed opportunities for readmission, which she believes led to her death.
NHS in England
Jun 2023
P-003458 — University Hospitals Bristol and Weston NHS Foundation Trust
Mr R complained the Trust failed to properly investigate and treat his son Y's condition, discharged him when unwell, and did not act on his deterioration, leading to his premature death.
NHS in England
Mar 2025
LGO / SPSO decisions(6)
NIPSO-17755 — Southern Health and Social Care Trust
Investigation concludes that observations should have been carried out and discharge delayed until patient was well enough to tolerate fluids and food.
NIPSO (NI Public Service…
Health & Social Care
Nov 2018
23-008-538 — Oxfordshire County Council
Summary: Ms X complained about Oxfordshire County Council, Oxford Health NHS Foundation Trust, and NHS Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board. She complained about faults relating to aftercare under section 117 of the Mental Health Act 1983. We have upheld Ms X’s complaints about discharge, assessment, care planning …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2024
24-007-618b — North London NHS Foundation Trust (24 007 618b)
on the lessons that can be learnt from our complaints about end of life care given in care homes and in the home.
LGO (Local Government & …
Health
Upheld
Feb 2026
24-007-618a — NHS North Central London ICB (24 007 618a)
on the lessons that can be learnt from our complaints about end of life care given in care homes and in the home.
LGO (Local Government & …
Health
Upheld
Feb 2026
202302960 — Fife NHS Board
C complained that the board had unreasonably failed to follow the care plan put in place to support them with their mental health. In particular, C complained that the board had failed to arrange their admission to hospital during an episode of crisis. The board’s response to C’s complaint advised …
SPSO (Scottish Public Se…
Health
Not Upheld
Feb 2024
202204453 — Forth Valley NHS Board
C complained that the board failed to carry out a reasonable assessment of their late parent (A) when they were admitted to hospital. They were also unhappy with the decision to discharge A and said that the board failed to communicate adequately with them and their family during the time …
SPSO (Scottish Public Se…
Health
Upheld
Apr 2024
Domestic Homicide Reviews(5)
Kent — recommendation 1
KMPT should review existing policies relating to inpatient discharge in order to ensure that in every case, whether by self-discharge or not, the responsibility for further care is decided within 24 hours of the unexpected absence of a patient from a ward. This should apply whether a patient is unexpectedly …
KMPT
Kent and Medway NHS …
Tower Hamlets — recommendation 5
No patient should be considered for discharge from THCfMH within 24 hours of admission without the agreement of a senior member of staff. Senior members of staff include the following: the borough lead nurse and deputy borough lead nurse, the responsible clinician or duty consultant and the modern matron or …
East London Foundation Trust
East London NHS Foundation …
Chorley and South Ribble — recommendation 3
Consider retention and discharge processes especially where service users are living in unsuitable accommodation.
Discover Drug and Alcohol Recovery Service
Kirklees — recommendation 23
Where the patient has been the victim of an assault or sexual abuse, to ensure that safety risks and social support needs are assessed and that safety and support arrangements are in place prior to discharge from both accident and emergency and inpatient hospital wards
Calderdale and Huddersfield NHS Foundation Trust
Calderdale and Huddersfield NHS …
Central Bedfordshire — recommendation 20
ELFT to review the ongoing support services for those discharged from hospital following multiple attempts to die by suicide. ELFT state that changes in service provisions and offers that differ from patient to patient may prove difficult to change as it will mainly be based on budget and capacity but …
ELFT
East London NHS Foundation …