Mental Health Patients Are Being Failed As They Leave Care, Warns Ombudsman
The safety of mental health patients is being put at risk when they leave inpatient services, leading to a continuous revolving door of care and discharge, England’s Health Ombudsman has warned.
In a new report that examines issues in transferring people with poor mental health out of inpatient and emergency care, the Ombudsman has called on the Government to take urgent action, including strengthening and bringing forward reforms to the Mental Health Act.
The Ombudsman found a range of issues such as
- families not being updated or informed about a patient’s discharge from hospital care
- poor record keeping
- lack of communication and joint working between the multiple teams caring for a patient
- failings in assessing requests to leave hospital.
This can lead to poorer outcomes for that patient, including increased risk of suicide. Without proper support in the community, people can become stuck in a revolving door in and out of inpatient services.
The report comes after the Parliamentary and Health Service Ombudsman (PHSO) analysed over 100 cases involving people with a mental health condition and failures in their care.
It highlights six cases involving failures in the planning, communication, or care of a person with a mental health condition being transferred from inpatient services or emergency departments back into the community.
In 2018, PHSO published Maintaining Momentum: driving improvements in mental health care, which highlighted a range of issues around mental health care including inappropriate transfers and aftercare. Six years on, and the same failings around transfers and aftercare are still happening, putting patients at risk.
Ombudsman Rob Behrens said:
“The overwhelming majority of professionals in mental health services are hard-working and demonstrate their commitment and care on a daily basis. However, the stories in our report show the human tragedies that happen when mistakes are made and how important it is for people to speak up and make complaints so that they don’t happen again.
“Delaying the transfer of someone out of hospital can cause harm, but so can inappropriately discharging people too soon. Too often, the focus is on transferring patients out of inpatient services quickly. No doubt this is at least partly due to the huge strain the NHS and mental health services are under. But the priority must always be patient safety. We know that unsafe transfers can have devastating consequences, such as patients being stuck in a re-admission cycle and, tragically, suicide.
“We need to see a holistic, joined-up, person-centred approach. Crucially, patients, their families and carers must be listened to and involved with decision-making.
“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. The lack of progress on the Mental Health Act is deeply disappointing, we must see that strengthened and prioritised.”
