A report by the parliamentary health and service ombudsman (PHSO) highlights significant concerns over the early release of mental health patients in England, exposing them to an increased risk of suicide and harm. The investigation, covering 100 patient cases between 2020 and 2023, reveals various shortcomings in mental health care, urging a reform bill to modernize the system.
The PHSO report identifies failures such as inadequate record-keeping during patient discharge, lack of updates to family members about discharge plans, and incorrect decisions transferring individuals from inpatient services or emergency departments back into the community.
Notably, the report recommends the introduction of a mental health bill to reform the Mental Health Act 1983 urgently. The ombudsman expresses disappointment at the government’s sluggish progress in implementing necessary reforms, emphasizing the bill as an opportunity to revamp the mental health system for the 21st century.
Among the cases spotlighted is that of Tyler Robertson, who tragically took his own life six weeks after being discharged from an emergency department within the South Tyneside and Sunderland NHS foundation trust. The ombudsman concludes that the trust should have consulted Robertson’s family before discharging him.
Statistics from the National Confidential Inquiry into Suicide and Safety in Mental Health, spanning the decade up to 2020, reveal that 14% of mental health patient deaths by suicide occurred within three months of discharge from inpatient care.
This report follows a 2018 PHSO report addressing concerns about inappropriate transfers and aftercare. Rob Behrens, the parliamentary and health service ombudsman, urges the government to act on the recommendations, emphasizing the necessity of prioritizing patient safety over swift transfers.
Behrens states, “Mental health patients are among the most vulnerable in our society, and I urge the government to act on the recommendations in this report to keep them safe and prevent these same failures from happening again.”
Lucy Schonegevel, the director of policy and practice at Rethink Mental Illness, acknowledges the report’s importance in shedding light on areas where services can improve support for patients transitioning back into the community. She underscores the need for enhanced communication and collaboration among different teams to provide essential care.
An NHS spokesperson acknowledges the report’s recognition of ongoing efforts by NHS England to collaborate with patients and families on new inpatient care standards. Additionally, the NHS long-term plan commits to a yearly funding increase of £1bn to transform community mental health services and support patients in staying well after discharge.
