Recurring concern

Unsafe discharge, closure or withdrawal of mental health services

First to latest report 16 Jan 2015 — 11 Jan 2026

Reports that mention this concern
17
Times this concern has been raised
19
Stated actions linked to this concern
22

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.

What is 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 and published responses 17 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Surrey

    AI-generated summary

    MARY NABILIA GWANYAMA · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mary Nabila Gwanyama, who was suffering from severe depression, died on 26 May 2018 after stepping in front of an oncoming train at Weybridge Station. The principal concerns included discharge without adequate housing and risk planning, lack of formal risk assessments and medical review, ineffective medication, failures in discharge coordination, and difficulties in providing community support after she was housed out of area.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide coherent community-care planning and care-coordinator involvement at discharge

    Wider context from the report

    “6. Mary was discharged from the Home Treatment team on ineffective medication and without any coherent plan for her care in the community. Her care coordinator was not involved in the discharge planning. The CPA was not followed. ”

    Source location

    MARY NABILIA GWANYAMA · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Premature discharge before the effectiveness of prescribed medication is adequately observed

    Wider context from the report

    “5. Mary was prematurely discharged from the Abraham Cowley Unit suffering from severe depression and before sufficient time had been taken to observe the effectiveness of her prescribed medication. This appears in part to have been because the imperative to discharge patients took precedence over adequate discharge planning and assessment. The CPA (“Care Programme Approach”) was not followed. ”

    Source location

    MARY NABILIA GWANYAMA · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Update CPA and Acute Care Services policies to require a pre-discharge CPA meeting for every homeless inpatient.

    Verbatim wording from the response

    “The Trust accepts that a discharge CPA meeting was not held prior to Ms Gwanyama being discharged from the Abraham Cowley Unit and, given she was homeless at the time and her housing situation was uncertain, such a meeting should have taken place. Accordingly, the Trust’s CPA policy and Acute Care Services Operational Protocol will be updated to reflect that anyone who is homeless must have a CPA discharge meeting on the inpatient ward prior to discharge.”

    Source location

    2021-0117-Response-from-Surrey-and-Borders-Partnership-NHS-Foundation-Trust-Redacted
    Page 1 · response
    Published 23 April 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement SBAR in Home Treatment Team practice and update its operational policy to strengthen multidisciplinary medical-review documentation and decision-making.

    Verbatim wording from the response

    “As explained in ████████ letter dated 24th March 2021, consideration is given at the daily HTT handover meetings, where there is a doctor present, as to how to best meet people’s needs within their overall care plan. It should also be noted that in addition to the handover meetings, each HTT holds weekly clinical reviews attended by the full multi-disciplinary team. During this review, each person on the HTT caseload is systematically reviewed to determine the appropriateness of the existing care plan, risk management plans including medical review and discharge plans.”

    Source location

    2021-0117-Response-from-Surrey-and-Borders-Partnership-NHS-Foundation-Trust-Redacted
    Page 2 · response
    Published 23 April 2021

    Open published response

  2. Nottinghamshire

    AI-generated summary

    Sean Daniel FEGAN · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Sean Daniel Fegan, who had autism, complex mental health conditions and drug misuse, died from toxicity after taking a combination of prescribed and illicit substances on or before 26 April 2020. The report raised concerns about decisions regarding secondary mental health care, access to treatment, dual diagnosis services, liaison with family members, implementation of care plans and autism awareness.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to establish informed agreement before withdrawing mental health services

    Wider context from the report

    “5. Implementation of care plans – a care plan was devised by the liaison nurse and psychiatrist, only to be overruled by persons who had not themselves assessed Mr Fegan, on an incorrect basis, and without a review of the risk assessment justifying that decision. Mr Fegan was called and invited to agree to the withdrawal of services. Such a practice runs the significant risk that patients who are less assertive or who have poor insight into their mental health needs will be said to have ‘agreed’ that a service is no longer required. ”

    Source location

    Sean Daniel FEGAN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Emphasise accurate documentation of changed care plans, discussion, rationale and risk review in staff feedback.

    Verbatim wording from the response

    “The Trust will always aim to work with patients to decide the most appropriate level of care. This process is a dynamic one, and we will always seek to include the patient in the decision making. The decision making to discharge from CRHT at that point was based on immediate needs and in the knowledge that Mr Fegan did have psychiatic diagnoses and he had an open referral for assessment with the LMHT and could re refer to CRHT if his situation changed. It will be emphasised to staff that if a care plan is changed, there needs to be clear, accurate documentation relating to the discussion and rationale for this change, including review of risk. This will be captured in feedback to the team, including reflections on the decision making to discharge at that point and the evidence behind it.”

    Source location

    2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
    Page 4 · response
    Published 30 March 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review crisis-team step-down guidance in the Standard Operating Procedure.

    Verbatim wording from the response

    “We are reviewing guidance to staff in the Standard Operating Procedure for the crisis teams to ensure accurate decision making when stepping down from crisis team care, and an audit will be developed to provide ongoing assurance. Findings will be shared through our internal lessons learned bulletin, and the Trust’s regular Quality & Risk Meetings.”

    Source location

    2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
    Page 4 · response
    Published 30 March 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop an audit providing ongoing assurance about crisis-team step-down decision making.

    Verbatim wording from the response

    “We are reviewing guidance to staff in the Standard Operating Procedure for the crisis teams to ensure accurate decision making when stepping down from crisis team care, and an audit will be developed to provide ongoing assurance. Findings will be shared through our internal lessons learned bulletin, and the Trust’s regular Quality & Risk Meetings.”

    Source location

    2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
    Page 4 · response
    Published 30 March 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Share audit findings through the internal lessons-learned bulletin and regular Quality and Risk Meetings.

    Verbatim wording from the response

    “We are reviewing guidance to staff in the Standard Operating Procedure for the crisis teams to ensure accurate decision making when stepping down from crisis team care, and an audit will be developed to provide ongoing assurance. Findings will be shared through our internal lessons learned bulletin, and the Trust’s regular Quality & Risk Meetings.”

    Source location

    2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
    Page 4 · response
    Published 30 March 2021

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Discharge from crisis care was based on immediate needs, an open mental health referral, and the option to re-refer if circumstances changed.

    Verbatim wording from the response

    “The CHRT Teams provide services for those with immediate needs and aim to prevent admissions to hospital. If there are no immediate risks, the patient can be discharged from the CRHT caseload, with the option to self-refer if risks were to increase.”

    Source location

    2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
    Page 4 · response
    Published 30 March 2021

    Open published response

  3. Staffordshire South

    AI-generated summary

    Dean Mark Rowland · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Dean Mark Rowland, who had a history of two recent self-harm attempts and depression, was found hanging from a bannister on 21 March 2017, and the inquest concluded that his death was suicide. Concerns included his inability to obtain a GP appointment or telephone consultation for nine days when he wished to discuss increasing his antidepressant medication, and his discharge from the community mental health team after one consultation without a follow-up plan beyond returning to primary care.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide follow-up after community mental health assessment

    Wider context from the report

    “(2) He was referred to a community mental health team having made two serious previous suicide attempts. He was discharged after only one consultation with no follow up plan other than for him to refer back to primary care. The family perceived he would have benefitted from a further appointment. He was very willing to engage with services. ”

    Source location

    Dean Mark Rowland · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The assessment found low suicide risk and sufficiently detailed needs assessment, so discharge after one consultation was considered the right decision.

    Verbatim wording from the response

    “When seen on 19th August 2016, Mr Rowland had moved to Birmingham in order to reside with his mother, and reported improvements in his mental health due to this change of environment and a now amicable relationship with his ex-wife and access to his children. Mr Rowland described his wellbeing “feel like I have my life back and am like my old self” and reported various self-help methods such as exercise and making time for himself. Importantly he expressed no further ideas of suicide. A Patient Health Questionnaire 9 (PHQ-9) was completed as part of the assessment; this is a 9-item questionnaire to explore current symptoms of depression, yielding a score of between 0 and 27. Mr Rowland scored 8, which is indicative of mild depression that would not usually require treatment; scores of 15 and above are usually seen in individuals requiring the input of a CMHT.”

    Source location

    2017-0208-Response-by-South-Staffordshire-and-Shropshire-Healthcare
    Page 2 · response
    Published 12 September 2017

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing self-help resources, GP referral routes and CMHT re-referral contacts were considered sufficient without ongoing CMHT follow-up.

    Verbatim wording from the response

    “Mr Rowland engaged fully in his assessment and coproduced the plan which was later communicated to him by letter. He felt that the difficulties in his mental health had improved and that he did not require input from the CMHT, but was aware that he could be re-referred at any time should this situation change. The letter validated his efforts to be well and detailed online self-help resources to support these efforts, and also recommended that he register with a GP in Birmingham if he wished to continue to reside there, so that he could be referred quickly to his local mental health services in future should the need arise. If the assessment had highlighted the need for ongoing input from the CMHT, this would have been transferred to the service in Birmingham local to Mr Rowland’s new residence, but as described it was not required.”

    Source location

    2017-0208-Response-by-South-Staffordshire-and-Shropshire-Healthcare
    Page 2 · response
    Published 12 September 2017

    Open published response

  4. Rutland and North Leicestershire

    AI-generated summary

    Anthony John Preston · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Anthony John Preston was admitted to The Priory Hospital in October 2013, discharged home on 11 November 2013, and was admitted to The Bradgate Unit four days later after becoming extremely anxious and depressed. He hanged himself in May 2014. Concerns included the lack of robust documentary evidence that his discharge had been communicated to the Leicestershire Crisis Team, the absence of immediate follow-up, and the resulting lack of support for him and his main carer when he was considered at high risk; the report states that no causal connection was suggested between his death and the discharge arrangements.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide immediate written discharge and high-risk notification to the crisis team

    Wider context from the report

    “(3) There was no immediate follow up by email or fax to the Crisis Team to notify the discharge, and the fact that Mr Preston was at high risk because of the anxiety created when he was living at home. ”

    Source location

    Anthony John Preston · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Central Hampshire

    AI-generated summary

    Louise Dawn Locke · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Louise Dawn Locke, a vulnerable adult with undiagnosed mental problems associated with alcohol dependency, died by suicide after hanging herself at her home in Winchester on 27 May 2015. The concerns included her premature discharge from mental health services without a proper risk assessment or adequate support, and inadequate systems for collating information across agencies to identify and support people at high risk.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to offer adequate support at discharge

    Wider context from the report

    “(1) The Community Mental Health Service discharged Louise Locke prematurely and without carrying out a proper risk assessment or offering her adequate support ”

    Source location

    Louise Dawn Locke · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Premature discharge from community mental health services

    Wider context from the report

    “(1) The Community Mental Health Service discharged Louise Locke prematurely and without carrying out a proper risk assessment or offering her adequate support ”

    Source location

    Louise Dawn Locke · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Formulate and obtain approval for standard arrangements ensuring patients seeking second opinions are not prematurely discharged and can access suitable appointments.

    Verbatim wording from the response

    “The Adult Mental Health Management Team have discussed this and an action has been assigned to the Clinical Service Directors in each area to formulate a standard plan to ensure that patients requesting second opinions have access to these, and are not prematurely discharged if they advise that they are unable to attend their appointment. There is agreement across all areas that a second opinion offer should be individually negotiated to the needs of the service user, and that if someone alerts us that they cannot attend the appointment then other arrangements will be made to facilitate the appointment either through a different venue or through the consultant travelling to another area. The standard process will depend on the geography of each area and consultants working arrangements.”

    Source location

    2016-0026-Response-by-Southern-Health-NHS-Trust
    Page 1 · response
    Published 29 January 2016

    Open published response

  6. Cumbria

    AI-generated summary

    Alice Anne McMeekin · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Alice Anne McMeekin was fatally attacked with a hatchet at an address in Newton Street, Millom, Cumbria, on 8 June 2013, sustaining fatal head injuries. The report raises concerns about police information not being fully shared with the ambulance and psychiatric teams, and about the assessment and discharge of the attacker despite information indicating significant risks and possible mental disorder.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Discharge without timely and adequate follow-up care for a person remaining at risk

    Wider context from the report

    “2.The Partnership Trust The Coroner concluded that the evidence at the inquest showed that the perpetrator was suffering from a mental disorder when he tried to kill himself on the 6th June 2013. Whilst the psychiatric nurse that day did not have all the information which was available at the inquest he had information to show that perpetrator had a history of self-harm, unemployment, family stressors, multiple and complex drug misuse, quasi-incestuous sexual feelings, past sex abuse, hopelessness, low mood and serious suicide attempt that day. 3.Not withstanding the above the nurse decided that the perpetrator was of zero risk and was not suffering from a mental disorder. He was discharged with the only potential follow up being talking therapy which would not commence, if it ever did, some weeks hence. The evidence at inquest shows that this was a very disturbed young man having intended to kill himself 6 hours earlier and who remained a risk to himself. Whilst the information known to the nurse at the time the tragic outcome could not have been anticipated, there was an opportunity to render care, which could, as a consequence have made a difference. It is a concern that the two assessments after the killings also concluded the perpetrator was not suffering from a mental disorder. ”

    Source location

    Alice Anne McMeekin · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  7. Norfolk

    AI-generated summary

    Mark Robert Anstice · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mark Robert Anstice, who had a history of mental health and social problems and previous self-harm, was found hanged on 27 September 2014. Concerns included that recommended support-worker or care-coordinator provision was not actioned, uncertainty about a carer’s assessment referral, gaps in team awareness of appointments, and difficulties supporting his attendance at group sessions due to lack of transport or means.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to establish contact and review non-attendance before discharge from mental health team

    Wider context from the report

    “(1) On 12 August 2014 Psychiatrist recommended Mr Anstice would benefit from a Support Worker and/or Care Co-ordinator – this was not actioned. The reason for this is not known – it was indicated this may be due to an administrative problem; (2) It was recommended a referral be made for a Carer’s Assessment on 1 September 2014. It is not clear this referral was made. Even if it had been made there would be difficulties with assessment and provision of the service in view of the fact Mr Anstice resided in Norfolk and the service would be provided by Suffolk MH Team (3) The appointment arranged with the Psychiatrist for 12 November 2014 was not known by other members of the Team, despite Team Meetings being in place to discuss Mr Anstice’s care. (4) It was recommended to Mr Anstice he attend Group sessions to help overcome feelings of social isolation, whilst being unaware as to whether Mr Anstice was physically able to attend those Group sessions. He did not have the transport or means to attend such groups. (5) When it became known to the IDT that Mr Anstice did not have the transport or means to attend the Groups, consideration was given as to how to help him overcome those practical difficulties but Mr Anstice was not informed that help was being considered. (6) Mr Anstice was discharged from Bury North IDT on 17 September 2014, being invited to attend Groups and having attended one on the 5 September 2014. However IDT were unable to speak with Mr Anstice by telephone on 5 September 2014, 8 September 2014 (tried 3 times) and he did not attend Group session on 12 September 2014. (7) At the time of Mr Anstice’s discharge from Bury North IDT, IDT were unaware Mr Anstice had an appointment with a Psychiatrist on 12 November 2014. ”

    Source location

    Mark Robert Anstice · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026