Patients at risk of suicide and harm over unsafe hospital discharges

Mental health services are failing to keep patients safe from suicide and harm after leaving hospital, the health ombudsman has warned.

It also identified failings around planning and communication when patients are discharged, and has urged the Government to strengthen the Mental Health Act.

The warning comes after the Department for Health and Social Care was forced to announce a Care Quality Commission (CQC) rapid review into mental health services in Nottingham following the killings of students Grace O’Malley-Kumar and Barnaby Webber, both 19, and school caretaker Ian Coates, 65, in June last year, by Valdo Calocane

Knifeman Calocane had paranoid schizophrenia and had been a regular patient of Highbury Hospital with mental health problems. In a report last week, The Independent revealed separate investigations into Highbury Hospital which have led to the suspension of more than 30 staff over allegations of falsifying records and harming patients.

The latest report by the Parliamentary and Health Service Ombudsman (PHSO), following a report in 2018, looked at more than 100 complaints between 2020 and 2023 where it had identified failings in mental health care.

Shortcomings included patient’s families not being told about their discharge from the hospital, a lack of communication between the multiple teams caring for patients, failings in the assessment of requests to leave hospital, and poor record keeping.

The findings come as an inquiry by the Health Services Safety Investigation Bureau has been launched, following reports by The Independent, which will probe failures which have led to patient deaths following discharge from hospital.

Health 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, he added: “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.”

One case highlighted by the PHSO is that of Tyler Robertson, 22, from Hebburn, who took his own life in July 2020.

After expressing suicidal thoughts to his family and the police, he was taken to A&E, but was discharged later the same day.

His family was not involved in the decision, but the ombudsman found clinicians should have approached the family as the level of risk may have been different if they had been consulted.

Mr Robertson was given information about support organisations but the contact details were out of date for most of them. He died in July 2020, less than six weeks after leaving the hospital.

Mr Robertson’s mother Nicola, 43, described her son as “the class clown in school” who was “always laughing”.

“But it was just a mask,” she said. “At home, we saw his struggles.

“He had never been diagnosed with a mental illness, but he had problems with his mental health from a very young age where he was either very happy or very down.”

She has since set up the support group Suicide Affects Families and Friends Everywhere (SAFFE).

A PHSO report from 2018 first highlighted issues around inappropriate transfers and aftercare. Six years on, the ombudsman is now calling for a “holistic, joined-up, person-centred approach” to care.

The PHSO has made a number of recommendations, including that NHS England introduces 72-hour follow-up checks for mental health patients discharged from emergency departments.

People discharged from mental health centres should also be able to select a nominated person to discuss decisions in transitions of care, the PHSO said, while patients and their carers should feel “empowered to give feedback, including through complaints”.

Lucy Schonegevel, director of policy and practice at the charity Rethink Mental Illness, said: “Someone being discharged from a mental health service, potentially into unsafe housing, financial insecurity or distanced from family and friends, is likely to face the prospect with anxiety and a sense of dread rather than positivity.

“Mistakes or oversights during this process can have devastating consequences.

“This report puts a welcome spotlight on how services can improve the support they offer people going through the transition back into the community, by improving communication and the ways in which different teams work together to provide essential care.”

DHSC and NHS England have been approached for comment.

If you are experiencing feelings of distress, or are struggling to cope, you can speak to the Samaritans, in confidence, on 116 123 (UK and ROI), email jo@samaritans.org, or visit the Samaritans website to find details of your nearest branch.

If you are based in the USA, and you or someone you know needs mental health assistance right now, call the National Suicide Prevention Helpline on 1-800-273-TALK (8255). This is a free, confidential crisis hotline that is available to everyone 24 hours a day, seven days a week.

If you are in another country, you can go to www.befrienders.org to find a helpline near you.