First reported 16 Jan 2015•Latest report 11 Jan 2026
Definition
What this concern includes
Includes premature or otherwise unsafe mental health discharge, case closure or service withdrawal involving inadequate assessment, review of risk, informed agreement, support, follow-up or receiving-service coordination.
Not included
Ordinary discharge or closure after adequate assessment, current risk review and safe continuity arrangements.
Missed appointments, referral delay or treatment deficiencies where service involvement was not ended unsafely.
Inpatient hospital discharge tracked by a more specific supported discharge process unless mental health case closure is also directly asserted.
Reports
17
Distinct published reports
Individual concerns
19
A report can raise multiple concerns
Date range
2015–2026
First to latest report issue date
Stated actions
22
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Norfolk and Suffolk NHS Foundation Trust3
Leicestershire Partnership NHS Trust2
Recipient name withheld2
All family members1
Berkshire Healthcare NHS Foundation Trust1
Change, Grow, Live1
Cumbria Constabulary1
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust1
Elmbridge Borough Council1
Essex Partnership University NHS Foundation Trust1
GP1
Hampshire and Isle of Wight Healthcare NHS Foundation Trust1
Hellesdon Hospital1
Kent and Medway Mental Health NHS Trust1
Leeds and York Partnership NHS Foundation Trust1
NHS trust16
Type not available4
Healthcare site2
Company limited by guarantee1
English county council1
English district council1
Executive non-departmental public body1
Independent healthcare provider1
Police force1
Sub-organisation1
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
Kent and Medway
Concerns raised1
Failure to include the receiving MHT+ team in HTT discharge decisions
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Hold twice-weekly clinical interface meetings with local MHT and MHT+ teams to discuss specific cases and support timely community treatment planning.
Stated by Kent and Medway Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 January 2026.
Action
Provide senior Rapid Response clinical input to interface forums for clinically considered decisions and agreed safe discharge plans.
Stated by Kent and Medway Mental Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 21 January 2026.
Action
Revise procedures to require invitations to MHT+ colleagues, including medics, and audit forum participation quarterly for quality and patient safety.
Stated by Kent and Medway Mental Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 21 January 2026.
East London
Concerns raised1
Lack of adequate risk formulation before discharge
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.8
Action
Implement discharge steps and multidisciplinary discharge planning meetings with managerial and matron oversight.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 1 August 2024.
Action
Review named-nurse processes and guidelines to clarify risk-assessment and discharge responsibilities across inpatient wards.
Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 1 August 2024.
Action
Provide clinical risk-assessment training and apply the clinical risk policy.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 1 August 2024.
Action
Operate a clinical dashboard identifying missing risk formulations and crisis summaries for managerial follow-up.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 1 August 2024.
Action
Review inpatient and community care plans and risk assessments during staff one-to-one supervision.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 1 August 2024.
Action
Conduct record, matron, and person-centred audits of risk formulation, crisis summaries, and care documentation, with feedback to staff.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 1 August 2024.
Action
Review care-coordinator roles and responsibilities and continue risk-assessment improvement through the Disengagement Safety Improvement Programme.
Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 1 August 2024.
Action
Implement the Safety Action Plan to document agreed discharge actions, relapse signatures, and multidisciplinary outcomes in patient records.
Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 1 August 2024.
Rutland and North Leicestershire
Concerns raised1
Lack of planned post-discharge support
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Discharge to primary care is considered appropriate for many patients when supported by a collaboratively formulated crisis and contingency plan with 24-hour access.
Stated by Leicestershire Partnership NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Berkshire
Concerns raised1
Insufficiently robust care coordination for patients discharged from mental health settings
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Roll out the new community mental-health care coordination and delivery model focused on planned, intervention-based care.
Stated by Berkshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 May 2024.
Action
Deliver five-day clinical-skills training covering named-worker responsibilities, targeted interventions, relapse prevention, discharge planning, 72-hour follow-up and evidence-based care.
Stated by Berkshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 May 2024.
Action
Update the transfer and discharge policy to require appropriate discharge correspondence with GPs and inclusion of 72-hour follow-up in care plans.
Stated by Berkshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 May 2024.
Suffolk
Concerns raised1
Failure to make adequate discharge decisions after failed engagement with mental health services
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
North Northumberland and South Northumberland
Concerns raised1
Insufficient in-person engagement before discharge from the Community Treatment Team
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
East London
Concerns raised1
Lack of multi-disciplinary team discussion to ensure a safe community plan following discharge
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Lincolnshire
Concerns raised1
Premature closure of the mental health assessment case
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Norfolk
Concerns raised1
Failure to conduct an immediate check or discussion before discharge from the Community Team following assessment
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Require young people to be seen or contacted before discharge through an implemented triage tool, including contact with referrers and significant others where appropriate.
Stated by Norfolk and Suffolk NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 February 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing discharge safeguards require contact, case-by-case decisions, multidisciplinary communication and follow-up to support safe discharge decisions.
Stated by Norfolk and Suffolk NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
West Yorkshire Eastern
Concerns raised1
Failure to establish alternative accommodation and transition arrangements before discharge consideration
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Rescinding detention was not premature discharge because the patient agreed to remain in hospital informally; discharge was not imminent.
Stated by Leeds and York Partnership NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Pin
Get email alerts
Request correction
Includes premature or otherwise unsafe mental health discharge, case closure or service withdrawal involving inadequate assessment, review of risk, informed agreement, support, follow-up or receiving-service coordination.
