The safety of mental health patients is being put at risk when they are discharged from inpatient services, the Parliamentary and Health Service Ombudsman has warned.
A report called on the Government to take urgent action after finding patients are stuck in a ‘continuous revolving door’ of care and discharge.
An analysis of more than a 100 people with a mental health condition who had experienced failures in care, found poor record keeping, a lack of communication and joint working were all leading to poorer outcomes for patients.
Failure to properly plan when patients are being transferred from inpatient or emergency departments back into the community was also a factor identified by Ombudsman Rob Behrens in the report.
He urged the Government to take action by strengthening the bill for a Mental Health Act and prioritise pushing it through Parliament.
Several other recommendations include requiring a follow-up check within 72 hours for people discharged from emergency departments and consulting with and listening to patients and their families and carers when planning transitions of care.
Written care plans that are missing or not shared with the wider multidisciplinary team including the GP and carers can also impact patient safety, the report found.
Mr 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.
‘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.’
Lucy Schonegevel, director of policy and practice at 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.’
Saffron Cordery, deputy chief executive at NHS Providers, said clearly there was more trusts could do to improve how people with mental health conditions are discharged from hospital and supported in the community.
‘To get to the root of the problem, however, we need to ensure mental health services—and wider services that people with mental health conditions rely on—are adequately funded and supported over the long term.’
This is not a mental health problem and does not need a mental health Act; it is a problem throughout health, and needs a Health Act, along with appropriate funding. Far too much is being wasted on private health care when it could resource a lot more care in total if given to the NHS, and especially primary care.