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 8 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
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: Inadequate medical supervision and ineffective systems for investigating acutely ill elderly patients in a psychiatric ward were identified, alongside a lack of understanding of legal duties for patient transfers.
Overdue
Michael Worrall
Concerns: The limited availability of psychological therapy at Avesbury House risks adverse outcomes for patients, particularly upon discharge to the community if prior therapy is discontinued.
Overdue
Rebecca Overy
Concerns: An immediate transfer, mandated by law, was detrimental to a young adult's mental health. This highlighted a critical service gap for secure mental health care for 18-24 year olds with complex needs.
Overdue
Robert Anstice
Concerns: Critical recommendations for support and care coordination were not actioned, and communication breakdowns meant team members were unaware of appointments. The patient was discharged despite difficulties in engagement and unmet practical needs.
Overdue
Simon Alliston
Concerns: A patient with a long mental health history was discharged without a formal handover or recorded reason, despite the community team believing ongoing support was needed. No serious incident investigation followed his death.
Response (SEPT): The trust has made changes to its Serious Incident reporting process, ensuring clinical information is made available, decisions are taken by Executive Directors, and the process no longer requires confirmation …
Responded
Katherine Bonaventura
Concerns: The system for assessing detained patients returning from leave is flawed, lacking thorough family/carer consultation and adequate mental state assessment documentation.
Overdue
George Taylor
Concerns: A significant number of patients are being sent out of county monthly due to an ongoing lack of acute psychiatric beds, posing a clear risk of future deaths.
Response (Department of Health): The Department of Health acknowledges the concerns, highlights the Crisis Care Concordat, and states that NHS England is aware of the report. They note that the local CCG is reviewing …
Response (NHS Kernow Clinical Commissioning Group): NHS Kernow is working with partners to develop alternatives to hospital admission and ensure early assessment and intervention, including a budget for community care to prevent admissions, reviewed in 2015. …
Responded
Louise Locke
Concerns: Premature discharge from mental health services occurred without adequate risk assessment or support, compounded by a lack of systems to collate multi-agency information and inconsistent suicide prevention approaches.
Response (Southern Health NHS Foundation Trust): The Adult Mental Health Management Team has assigned an action to Clinical Service Directors to formulate a standard plan to ensure that patients requesting second opinions have access to these …
Responded
Freda Weston
Concerns: Premature discharge, critical delays in antibiotic administration due to severe staff shortages, and staff unfamiliarity with escalation guidelines were identified. Handover sheets were also destroyed.
Response (Weston): Stockport NHS Foundation Trust will supply Patient Information Leaflets with monitored dosage systems, including a generic medicine patient information leaflet. All wards in the Medicine Business Group have access to …
Responded
Dorota Kijowska
Concerns: The outcome of a critical review meeting was not formally signed off by attendees nor clearly communicated to the patient, leading to a lack of clarity.
Overdue
Dean Rowland
Concerns: Delays in accessing GP appointments for antidepressant review and premature discharge from community mental health services, despite previous serious suicide attempts, posed significant risks.
Response (South Staffordshire and Shropshire Healthcare): The Trust states that the CMHT conducted a sufficiently detailed assessment of Mr. Rowland's needs and appropriately discharged him, providing resources for future support and contact information.
Response (Peel Medical Practice): Peel Medical Practice has instituted a duty doctor and telephone triage system to improve access for patients needing appointments or telephone consultations sooner than routine appointments.
Responded
Ryan Vout
Concerns: There was a lack of coordinated psychiatric discharge, failing to involve professionals and family. Also, ambulances could not be pre-arranged for Mental Health Act warrants, and pre-entry risk assessments lacked formality.
Response (Nottinghamshire County Council): Nottinghamshire County Council has developed a more robust process for communicating demographics and essential risk information in relation to s135(1) warrants between AMHPs and the Police, including a typewritten document …
Response (East Midlands Ambulance Service NHS Trust): EMAS acknowledges its responsibility to provide timely ambulance service for patients with mental health needs. EMAS plans to adapt its operating model with an urgent care tier, which will go …
Response (Department of Health): The Department of Health acknowledges the concerns raised, focusing on discharge planning and transport for patients sectioned under the Mental Health Act. They state that these matters are operational and …
Responded
Miriam Roach
Concerns: There are concerns regarding the aftercare or transition arrangements for those discharged from hospital to home with a moderate to high risk of self-harm and/or suicide, and specifically the obligations for putting in place contact arrangements for such patients.
Overdue
Marcus Hance
Concerns: The dual diagnosis policy, requiring substance misuse treatment before mental health support, and discharge from services after missed appointments, prevented access to crucial mental health care.
Response (Cornwall NHS Trust): The Trust endorses the response provided by NHS Kernow, confirming they will work in partnership with them on the outlined actions regarding the Dual Diagnosis strategy and reviews of interdependencies …
Overdue
William Edge
Concerns: A suicidal patient was discharged without adequate follow-up from the Home Treatment Team, who could not revisit despite an urgent family request, due to critical bed shortages and underfunding.
Response (NHS England): NHS England acknowledges concerns about mental health service demands and funding. They state that providers will make more robust plans to contact patients who do not attend appointments, and will …
Response (NHS Birmingham and Solihull ICB): Birmingham and Solihull CCG has already invested in various mental health services, including a new pathway for personality disorders, increased community provision, and staffing for 'step up step down' services.
Responded
Eileen Cooke
Concerns: A frail elderly patient was prematurely discharged with unresolved medical issues, inadequate care planning, and without a 'best interests' meeting or family involvement, highlighting a systemic problem with hasty discharges.
Response (Response Mid Yorkshire Hospitals): The Trust describes its processes for safe discharge of elderly patients, including defining frailty, use of ACE units, care home liaison, and gathering patient feedback, but doesn't outline specific changes …
Responded
Colette Dunn
Concerns: A full Mental Health Act assessment was omitted before discharge despite police concerns. A lack of clear discharge protocols between agencies and inadequate facilities for mental health crisis intervention were identified.
Overdue
Matthew Craven
Concerns: A patient died from pregabalin toxicity after consuming excess prescribed medication post-discharge, raising concerns about managing medication risks for individuals with a history of misuse.
Response (Pennine Care NHS Trust): The Trust will develop an escalation process for rejected referrals in Stockport, clarify and communicate target timescales for routine appointments, implement an escalation protocol for disagreements on face-to-face appointments, and …
Responded
Stephen Kennedy
Concerns: A patient couldn't access recommended psychological therapy due to internal service barriers and long waiting lists. Additionally, a severe lack of acute inpatient mental health beds led to further self-harm and suicide attempts.
Response (Department of Health and Social Care): The Department of Health and Social Care highlights national initiatives to improve mental health services, including expanding CRHTTs, integrating primary and secondary care, and establishing a national single point of …
Response (Birmingham and Solihull Mental Health NHS Trust): The Trust is developing training and guidance for staff on Personality Disorder and patients with Personality Disorder, to be mandated for all staff working within our Home Treatment Teams during …
Response (NHS Birmingham and Solihull ICB): The CCG acknowledges the coroner's concerns and is unable to identify any correlation between funding and this death, but has recognised the need to continually improve its quality monitoring function …
Responded
Sasha Forster
Concerns: Staff lacked resources to collect a patient when leave was revoked, placing an unfair burden on the family and contributing to the patient taking a fatal overdose.
Overdue
Denton Duhaney
Concerns: Hospital failed to assess or treat a patient with psychiatric issues, did not follow discharge protocols for self-discharge, and neglected to inform external mental health teams, leading to a dangerous gap in care.
Response (Fieldhead Hospital): Fieldhead Hospital updated their Standard Operational Policy to ensure consistency across Psychiatric Liaison Teams and disseminated guidance to community services for maintaining contact with service users awaiting discharge and the …
Responded
Sky Rollings
Concerns: The absence of dedicated in-patient mental health provision for young people aged 14-25, and the immediate application of adult services at 18, poses risks by not acknowledging developmental needs.
Response (NHS England): NHS England acknowledges concerns about transitioning young people from CAMHS to adult mental health services, explains the current policy, and notes work has commenced regarding community transformation and development of …
Response (North Staffordshire Combined Healthcare NHS Trust): North Staffordshire Combined Healthcare NHS Trust will review the Transition of Young People to Adult Mental Health Service Policy, and explore options for a designated in-patient service or unit for …
Responded
Neil Bastock
Concerns: The decision to rescind the section was made by a responsible clinician who had only been in the role for two weeks.
Response (Leeds and York Partnership NHS Foundation Trust): Leeds and York Partnership NHS Foundation Trust will formalize support and supervision arrangements for locum medics, review their clinical handover process, and ensure families are involved in decisions about rescinding …
Responded
Theo Brennan-Hulme
Concerns: A persistent culture of bullying and lack of compassion within the Crisis Resolution Home Treatment Team led to a dangerous belief that some suicides are "inevitable," compounded by unchecked patient discharge decisions.
Response (Hellesdon Hospital): Hellesdon Hospital has updated its discharge policy to include a documented discussion and MDT review prior to discharge, particularly for young people. They are also working with service users to …
Responded
Ian Darwin
Concerns: Tees Esk and Wear Valleys NHS Foundation Trust routinely fails to conduct timely serious incident investigations, allowing hazards to persist and compromising learning, despite past assurances and national guidelines for 60-day completion.
Response (TeesEsk and Wear Valleys NHS Foundation Trust): The Trust has contracted additional expert capacity for incident reviews, implemented weekly sitrep meetings, modified documentation and report templates, and is introducing more flexibility to Serious Incident Review Panels, and …
Response (Tees Esk & Wear Valley NHS Foundation Trust): The Trust has contracted additional expert capacity for incident reviews, implemented weekly sitrep meetings, modified documentation and report templates, and is introducing more flexibility to Serious Incident Review Panels, and …
Responded
Lauren Bridges
Concerns: Underfunding for local mental health beds and reliance on independent providers caused delayed discharges for out-of-area patients. Fragmented IT systems and inconsistent processes created significant communication failures.
Response (NHS England): NHS England reports on actions taken by Dorset Healthcare University NHS Foundation Trust: improvement to data and oversight, appointment of an out of area co-ordinator and a programme of quality …
Response (Dorset Healthcare University NHS Foundation Trust): Dorset HealthCare has made changes to the Hospital Overview document, enhanced the daily Hospital Overview situation report, improved communication between Clinical Site Managers and introduced monthly audits to ensure standards …
Response (Department of Health and Social Care): The Department of Health and Social Care notes actions taken by NHS England and Dorset Healthcare University NHS Foundation Trust. They are investing in community mental health care and have …
Responded
Kirsty Taylor
Concerns: Fragmented mental and physical health services lack seamless connectivity for neurodivergent patients, particularly those with ADHD. Additionally, communication with families of mental health patients remains ineffective, and the Personality Disorder Pathway development is too slow.
Response (NHS England): NHS England is working to develop new models of integrated primary and community mental health care, including a dedicated community mental health offer for those with diagnoses of ‘personality disorder’ …
Response (Hampshire and Isle of Wight): The ICB has endorsed the creation of a new all-age Trust to oversee community and mental health services across Hampshire and Isle of Wight, expected to go live on 1 …
Response (Southern Health NHS Foundation Trust): Southern Health NHS Foundation Trust, along with other trusts, is working towards establishing a new, single community and mental health provider by 1 April 2024 (Project Fusion). They are continuing …
Responded
Sobhia Khan
Concerns: Inadequate Ministry of Justice scrutiny of discharge reports and a lack of forensic pathways for high-risk Mental Health Act patients, compounded by insufficient police powers to intervene for public safety.
Response (Derby City Council): Derby City Council has made changes to manage mentally disordered offenders, including working alongside the Forensic Community Mental Health Team and finalizing a Memorandum of Understanding to employ a Senior …
Response (Derbyshire Healthcare NHS Foundation Trust): Derbyshire Healthcare NHS Foundation Trust has invested in a Forensic Community Mental Health Team, which has undertaken shared cultural awareness training with the police and probation. The Trust has adopted …
Response (Derbyshire Constabulary): Derbyshire Constabulary has strengthened the protection offered to vulnerable people via civil orders and Stalking Protection Orders. The force has a comprehensive programme of activity to raise standards and improve …
Response (Cygnet): Cygnet has reviewed the PFD action plan at Clinical Governance meetings and shared it with relevant teams; all staff complete a report writing and record keeping Skill workbook, and Cygnet …
Response (Ministry of Justice): Response is a placeholder document.
Responded
Timothy Clayton
Concerns: Hospital discharge planning policy is inadequate, with clinicians erroneously relying on patient capacity to justify unsafe discharges without proper informed consent, exacerbated by bed pressures.
Response (NHS England): NHS England highlights the meeting of the target of 5,000 additional core general and acute beds in January 2024. NHS England also notes that Epsom and St Helier University Hospitals …
Response (St Georges Epsom and St Helier): Epsom and St Helier University Hospitals NHS Trust has updated its Hospital Discharge and Criteria to Reside Policy, emphasised the importance of family involvement in decision-making, and is providing additional …
Responded
Louise Crane
Concerns: Inaccurate record-keeping, a widespread lack of therapeutic engagement understanding among staff, and systemic failures during step-down from PICU hindered safe patient transition and risk mitigation.
Response (North London NHS Foundation Trust): The Trust has implemented measures including mandatory training on record keeping, increased audit frequency and revised content, a new supervision policy, a 'ward buddy' system, and Quality Improvement programmes, with …
Responded
Sidi Bojang
Concerns: Patients exhibiting recent self-harm or suicidal thoughts were discharged by a senior psychiatric nurse without a psychiatrist review, despite significant changes in presentation, posing a risk of unsafe discharges.
Response (Department for Health and Social Care): NHS England has strengthened mental health expertise in urgent and emergency care, ensuring 24/7 access to mental health liaison services in Type 1 Emergency Departments. E-learning on suicide prevention is …
Responded
Charlotte Tetley
Concerns: A patient was prematurely removed from the inpatient bed list before an appropriate daily mental health review, despite documented need for admission, risking patient safety.
Response (Cheshire and Wirral Partnership NHS Foundation Trust): The Trust has implemented several system changes, including documenting Clinical Prioritisation Meeting outcomes in SystmOne, establishing a Patient Flow Meeting, inviting clinicians to the Clinical Prioritisation Meeting, developing an SOP …
Responded
Sarah Heaver
Concerns: Critical neurological investigations and structured observations were omitted for a low GCS patient, compounded by inconsistent medical records. Additionally, patients are discharged to inadequate psychiatric care.
Response (Kent and Medway Mental Health NHS Trust): • The Trust had already identified a lack of consistent prescribing cover over weekends in February 2025. • The lack of cover occurred because 2 of the 3 Independent prescribers …
Response (East Kent Hospitals University NHS Foundation Trust): • The Trust referenced NICE CG176 (Head Injury guidelines), Royal College of Emergency Medicine guidelines on self-harm, and 2022 NICE guidance (NG225) guidance on self-harm. • The Trust stated that …
Responded
Mark Vidler
Concerns: Mental health services suffered from process-driven care, unclear clinical decision-making in triaging referrals, and pre-determined discharge decisions lacking receiving team involvement. The CAMS program also lacked dedicated resources and IT integration.
Response (Kent and Medway NHS Mental Health Trust): The Trust is revising its Rapid Response Standard Operating Procedure to ensure senior clinical oversight of referrals, revising its CAMS policy, considering a dedicated CAMS workforce, and promoting the use …
Responded
Micheala Finch
Concerns: Hospital discharge decisions failed to adequately assess a patient's significant mental health deterioration and suicidal ideation, attributing issues solely to alcohol misuse and not deploying escalated home-based treatment.
Response (Greater Manchester Mental Health NHS Foundation Trust): • The Trust has recently recruited two Deputy Medical Directors for the Trust. • The Trust is currently reviewing and updating the Trust Co-Occurring Conditions Policy with a planned publication …
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 Pending
#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 Pending
#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 Pending
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
PHSO casework decisions(10)
P-001556 — Wrightington, Wigan and Leigh NHS Foundation Trust
Mr A complains that the Trust did not provide proper treatment on the Mental Health Ward and discharged him in a psychotic state of mind. He also complains the Trust has 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 complains the Trust should not have discharged her, failed to provide adequate psychiatric treatment, did not provide her with appropriate access to a shower during her inpatient stay and isolated her from her mental health team while it investigated her complaint.
NHS in England
Jul 2024
P-001701 — University Hospitals Birmingham NHS Foundation Trust
Mr P complains the Trust discharged his wife too soon after she collapsed suddenly at home. He says it was later found she had a bleed on the brain.
NHS in England
Jan 2023
P-003585 — Nottinghamshire Healthcare NHS Foundation Trust
Mrs R complains that in the months leading up to her father’s death in May 2022, the Trust discharged him despite him saying he was suicidal. She complains it did not allocate face to face appointments, it cancelled scheduled appointments and did not liaise with other services to ensure his …
NHS in England
Upheld
Jun 2025
P-004242 — University Hospital Southampton NHS Foundation Trust
Mr I complains about the Trust’s treatment of his wife after she was admitted to A&E on 29 February 2024 with depression and psychosis. He complains on 1 March she was discharged from hospital, despite not being well enough to leave.
NHS in England
Oct 2025
P-002557 — Lancashire and South Cumbria NHS Foundation Trust
Mrs E complains that between December 2021 and May 2022 the Trust did not give her mother enough medication or therapy, it prematurely discharged her without a suitable care plan in place and it did not communicate well with her family.
NHS in England
Apr 2024
P-003346 — Leeds Teaching Hospitals NHS Trust
Mr A complains the Trust rushed his wife for surgery instead of considering other surgery, discharged her when she was not well enough and did not put a care package in place to support her at home.
NHS in England
Feb 2025
P-004340 — Greater Manchester Mental Health NHS Foundation Trust
Mrs E complaints about aspects of care and treatment Greater Manchester Mental Health NHS Foundation Trust (the Trust) provided to her in 2024. She states the Trust incorrectly discharged her, did not change her medication and provided poor communication and complaint handling.
NHS in England
Nov 2025
P-002028 — Southern Health NHS Foundation Trust
Ms A complains about the Trust's care and treatment of her sister between 18 May and 6 August 2018. She complains the Trust discharged her sister from the mother and baby unit too soon, it did not look at her history properly, it prescribed medication that made her unwell and …
NHS in England
Jun 2023
P-003458 — University Hospitals Bristol and Weston NHS Foundation Trust
Mr R complains the Trust did not provide the correct assessment and treatment to his son meaning he was discharged prematurely.
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)
LGO (Local Government & …
Health
Upheld
24-007-618a — NHS North Central London ICB (24 007 618a)
LGO (Local Government & …
Health
Upheld
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