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.”
The report shares the story of 22-year-old Tyler Robertson, an electrician from Hebburn.
Tyler was experiencing low mood and had expressed suicidal thoughts to his family. He later told the police about his suicidal thoughts and was taken to an emergency department within the South Tyneside and Sunderland NHS Foundation Trust.
Tyler was discharged that same day, but his family and carers were not involved in the discussion. A risk assessment was carried out by a team from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, but the Ombudsman found that the clinicians should have actively approached the family for information and the level of risk may have been different had the family been consulted.
Tyler was also asked by that team to self-refer and given information for support organisations, but the contact details were out of date and while he tried to call, he could not get in touch with most of them. Guidance says staff should have initiated contact with the support groups on his behalf.
Sadly, Tyler killed himself in July 2020, less than six weeks after leaving the hospital. The Ombudsman could not say that the failings directly led to his death, but the uncertainty around this is an injustice to his family.
Those involved in the care of Tyler have complied with the Ombudsman’s recommendations which included apologising to his family, acknowledging their failings and creating an action plan to prevent this from happening again.
Tyler’s mum Nicola, 43, described her son as outgoing and bubbly, a gym-enthusiast who loved going on holidays. Following his death, Nicola set up Suicide Affects Families and Friends Everywhere (SAFFE), a support group for people who have lost someone to suicide.
Nicola said:
“Tyler was the class clown at school and in public he was always laughing, but it was just a mask. 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.
“Losing Tyler was devastating. You just don’t expect to lose your kids. It feels as if we don’t live now, we’re just existing. If he had got the right help, he might still have taken his life, but he might not have, and the not-knowing is awful.
“People say time makes it easier, but I don’t think it does. The longer I don’t have him, the more I miss him. Nothing will bring Tyler back, but I would like to think that sharing his story could stop this from happening again or at least help another family in the same situation.”
The Ombudsman has urged the Government to take action by strengthening the bill for a Mental Health Act and prioritise pushing it through Parliament.
He also made several other recommendations including requiring a follow-up check within 72 hours for people discharged from emergency departments, and that the views of patients and their support network are listened to and actively taken into consideration when planning transitions of care.
Lucy Schonegevel, Director of Policy and Practice, 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.
“Learning from the lived experience of people severely affected by mental illness and their carers is key, but we also need Government to deliver on its commitment to bolster the workforce so staff are less stretched, and bring forward long-overdue reform of the Mental Health Act to improve the standard of care offered to people when they’re at their most unwell and vulnerable.”