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Maintaining momentum: driving improvements in mental health care

The complaints we see: inappropriate discharge and provision of aftercare

We have previously reported on the problem of unsafe discharge from hospital in physical healthcare. We see similar issues in mental health services.

Being discharged from hospital, particularly after having been detained under the Mental Health Act 1983, can be the most vulnerable time for patients. Moving from intense, round the clock supervision and support back into the community, with more limited options can be very challenging.

There is a heightened risk of suicide in the first three months after discharge. Often people require support from a number of services, such as community mental health teams, GPs, and social services. Discharge planning is crucial to ensure the safety of patients during the transition.

The aim in the Five Year Forward View for Mental Health is to ensure people have the right care at the right time and the support to lead active and independent lives. NHS England’s implementation plan identifies the need to improve and promote the use of personalised, recovery-focused care planning in secure inpatient services. This is in line with the requirements of section 117 of the Mental Health Act 1983, making sure discharge planning starts while the patient is still in hospital and engaging with other services early.

Evidence from complaints to us shows a huge disconnect between the ambitions set out in the Five Year Forward View for Mental Health and the reality of discharge. The complaint below is typical of the failings we see in discharge planning: it can be rushed, with the patient and their family not involved and little thought given to the support needed in the period after leaving hospital.

Mr C

What happened

Mr C had a complex history of mental health problems, including bipolar disorder and emotionally unstable personality disorder.

As a child, he had special educational needs, including attention deficit hyperactivity disorder, dyslexia and dyspraxia. Mr C had difficulty engaging with mental health services, had been sectioned under the Mental Health Act 1983 several times, and had been a voluntary inpatient. He had been put on the waiting list for a care co-ordinator several times, though one was never allocated.

Mr C had been detained under the Mental Health Act 1983, before being discharged with support from the Community Treatment Team (CTT). He was discharged from the CTT having missed an appointment. Mr C died shortly after from a drug overdose.

The Trust instigated a Critical Incident Review following Mr C’s death. Mr C’s father, Mr F, then brought a complaint to the Ombudsman covering many issues over a long period of time.

What we found

Immediately before his death, Mr C was discharged from the CTT because he missed a single appointment. At the time he was not registered with a GP, but there was no discharge plan and no offer of access to a crisis service if Mr C needed to re-engage with support.
 
Mr C was not told of the decision to discharge him. That decision contravened the Trust’s own policy, which states discharge should be discussed with the multi-disciplinary team (MDT) in order to mitigate risk, and also went against good practice for people with Mr C’s difficulties.

Throughout his time engaging with the Trust, Mr C had not been allocated a care co-ordinator. When discharged from the CTT, his psychiatrist felt a care co-ordinator would not have been helpful because of Mr C’s history of not engaging with services.

We found that Mr C’s complex needs meant he did require a care co-ordinator and that not having someone to address his mental health, substance misuse and housing needs contributed to his death.

Mr C was detained under the Mental Health Act 1983 before being discharged to the CTT. Mr C’s responsible clinician did not initiate an aftercare assessment as required under section 117 of the Act, which would have triggered involvement from the Clinical Commissioning Group and social services. There was little formal planning and there was poor communication between the inpatient and community services. Mr C’s responsible clinician did not ensure his aftercare needs had been assessed or covered in his care plan, and nor was this discussed with Mr C.

While Mr C had many complex issues, the Trust and mental health professionals should have done more to support and treat him. As a result, opportunities were missed to treat his illness and limit his deterioration.

The Trust also failed to investigate all the concerns raised by his father, Mr F, as part of his complaint. And, despite commissioning an independent review of Mr C’s care, the Trust failed to explain the inconsistencies between their own conclusions and those in the independent review. This added to Mr F’s distress and uncertainty about what happened to his son.

Our recommendations

We recommended the Trust write to Mr F to acknowledge and apologise for the failings we found and pay £2,500 for the injustice suffered. We also recommended the Trust produce an action plan to prevent a repeat of the failings, and explain how improvements in its service and complaint handling are being monitored.

This action plan showed the Trust had:

  • Arranged learning meetings with staff and Mr F to ensure the experience of Mr F and his son is shared and learned from.
  • Developed a new procedure to review all deaths and share learning across the Trust.
  • Added section 117 aftercare needs to the MDT paperwork.
  • Fully reviewed and updated serious incident procedures, with director-led quality assurance.
  • Fully reviewed complaints procedures and established a working group, comprising staff and members of the public, to implement the recommendations.

Section 117 aftercare

Section 117 of the Mental Health Act 1983 imposes a duty on health and social services to provide aftercare to patients who have been detained for treatment under section 3 of the Mental Health Act 1983. The services provided must meet the person’s needs as a result of their mental illness and reduce the chances of them having to go back to hospital.

The planning for aftercare should begin while a patient is still in hospital. Before deciding to discharge, the responsible clinician should ensure that the patient’s needs have been fully assessed, discussed with the patient and addressed in their care plan.

Aftercare can include almost anything arising from or related to the person’s mental health disorder that helps someone live in the community. It may include, for example, help with specialised accommodation, social care support, day centre facilities or recreational activities.