Recurring concern

Unreliable Section 117 mental health aftercare arrangements

First to latest report 25 Feb 2022 — 21 Nov 2025

Reports that mention this concern
6
Times this concern has been raised
7
Stated actions linked to this concern
9

What this concern includes

Includes failures of the Section 117 Mental Health Act aftercare process, including eligibility and entitlement decisions, interpretation of criteria, national or local guidance, policies and procedures, aftercare-plan content and depth, professional understanding, planning and coordination of aftercare.

What is not included
  • Excludes general mental-health discharge or community-care failures that do not explicitly concern Section 117 aftercare.
  • Excludes failures limited to the delivery or quality of an aftercare service after an adequate Section 117 decision and plan have been established, unless the assertion also identifies a failure of the Section 117 aftercare arrangement itself.
  • Excludes generic training, communication or care-coordination deficiencies unless they are directly tied to Section 117 aftercare eligibility, planning or provision.
  • Excludes other statutory aftercare, housing, placement or social-care entitlement processes without an explicit Section 117 connection.

Reports and published responses 6 reports

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

  1. Worcestershire

    AI-generated summary

    Timothy Thomas Reading · 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

    Timothy Thomas Reading died on 9 January 2025. He had a history of mental illness and had been discharged from inpatient care into the community under a community treatment order. The report identified the absence of a formal documented section 117 support plan, slow and disjointed transition arrangements, and no handover between responsible clinicians; the inquest concluded that he died by suicide, with hanging recorded as the medical cause of death.

    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

    Lack of guidance defining the component elements and required depth of s.117 plans

    Wider context from the report

    “(2) I was informed by the Representative of BSMHFT that there is no national guidance from the NHS or other source that explains what a s.117 plan should address. If so, this represents a lacuna which gives rise to concern that mental health providers are unclear as to the component elements for a s.117 plan and the degree or depth of planning required for individual patients. ”

    Source location

    Timothy Thomas Reading · Prevention of Future Deaths report
    Page 2 · 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

    Absence of formal documented s.117 discharge plans agreed by all responsible care and treatment providers

    Wider context from the report

    “(1) The absence of a formal documented s.117 plan agreed by all those responsible for a patient’s care and treatment upon discharge into the Community from a lengthy inpatient stay creates a risk of disjointed, disorganized and inadequate support for vulnerable people suffering serious mental health conditions. This, in turn, may cause them to feel unsupported and helpless. BSMHFT did not provide a Plan despite requests to do so. S.117 is intended to ensure that patients receive planned and structured support tailored to their requirements. Such planning was absent in this case. ”

    Source location

    Timothy Thomas Reading · 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

    Use a standardized Rio form covering all relevant s.117 meeting areas and remind acute-care staff to complete it.

    Verbatim wording from the response

    “The Trust has now looked at the inpatient care and CMHT care around the s.117 plan on the back of your concerns. Section 117 of the Mental Health Act 1983 places a joint duty on the NHS Integrated Care Board and local authority to provide aftercare services for individuals detained under certain sections of the Act following discharge.”

    Source location

    Response from Birmingham and Solihull MH NHS Foundation Trust
    Page 1 · response
    Published 23 February 2026

    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 national guidance sufficiently addresses the required content and planning of Section 117 aftercare plans.

    Verbatim wording from the response

    “NHS England Mental Health colleagues have advised that there is clear guidance set out in the Mental Health Act Code of Practice on Section 117 aftercare which includes planning based on the person’s individual needs. It includes examples such as ensuring the person’s wider social, cultural and spiritual needs are met and specifies that after care should aim to support people in regaining or enhancing their skills, or learning new skills, in order to cope with life outside of hospital. Before deciding to discharge or grant more than a very short-term leave of absence to a patient, or to place a patient onto a Community Treatment Order (CTO), the responsible clinician should ensure that the patient’s needs for after-care have been fully assessed, discussed with the patient (and their carers, where appropriate) and addressed in their care plan.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 23 February 2026

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    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 Trust is better placed to respond to concerns about the absence of a requested Section 117 plan.

    Verbatim wording from the response

    “We note that your report has also been addressed to the Trust who will be better placed to respond to the concerns raised around the absence of Section 117 plan provided by the Trust despite it being requested.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 23 February 2026

    Open published response

  2. East Riding and Hull

    AI-generated summary

    Chloe Louise Barber · 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

    Chloe Louise Barber, who had a history of self-harm and multiple overdoses and had been detained under the Mental Health Act, was found at home on 3 November 2021 and was confirmed dead at 17:05. The report identified concerns about transition pathways between CAMHS and adult psychiatric services, guidance on administering depot antipsychotic preparations, and understanding of section 117 aftercare responsibilities.

    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

    Insufficient knowledge among healthcare and social workers about provision of s117 Mental Health Act 1983 aftercare

    Wider context from the report

    “3. There was considerable uncertainty and ignorance about the provision of aftercare pursuant to s117 of the Mental Health Act 1983 amongst some healthcare workers and social workers, who should in any event be closely liaising with each other as well as with other allied professionals. ”

    Source location

    Chloe Louise Barber · 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

    Issue national guidance explaining section 117 aftercare obligations and when they apply.

    Verbatim wording from the response

    “National guidance has been issued by NHS England and the Department of Health and Social Care (DHSC) providing staff with clear information about s117 and when this applies, including the following:”

    Source location

    Response from NHS England
    Page 3 · response
    Published 13 August 2025

    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

    Publish statutory guidance clarifying joint discharge planning and section 117 aftercare funding responsibilities.

    Verbatim wording from the response

    “We are aware that there can sometimes be disagreements between organisations as to which one should be responsible for aftercare under section 117, which can delay access to aftercare. To address this, statutory guidance on discharges from mental health inpatient settings² was published in January 2024 which provides clarity in relation to how organisations across the health system work together to ensure effective discharge planning and the best outcomes for people who are discharged from hospital. It includes additional guidance on how budgets and responsibilities are shared to pay for aftercare under section 117. Integrated care boards, as commissioners of health services in their areas, should ensure that all providers of mental health services are aware of this guidance.”

    Source location

    Response from Department for Health and Social Care
    Page 2 · response
    Published 13 August 2025

    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

    The concerns about aftercare and discharge arrangements relate to locally commissioned services rather than NHS England specialised services.

    Verbatim wording from the response

    “Colleagues from NHS England’s North East and Yorkshire region have advised that the concerns raised in your Report relate to locally commissioned services rather than specialised services. During Chloe’s admission to the Cygnet Hospital in Sheffield, oversight was provided by the Regional NHS England Mental Health, Learning Disability and Autism (MHLDA) Specialised Commissioning Team. Case management was in place to support the commissioning process and ensure the quality of care, including regular engagement with the provider and monitoring of Chloe’s care and pathway. Prior to discharge, multi-agency planning meetings were held, including a section 117 Mental Health Act discharge planning meeting. These meetings involved the multidisciplinary team (MDT), local CAMHS, adult mental health services, the local authority children’s social worker, as well as Chloe and her parents.”

    Source location

    Response from NHS England
    Page 3 · response
    Published 13 August 2025

    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

    Local authorities and integrated care boards are jointly responsible for arranging section 117 aftercare and ensuring providers know the relevant guidance.

    Verbatim wording from the response

    “With regard to your concerns around a lack of knowledge amongst some healthcare staff and social workers about section 117 aftercare, it is vital that organisations across the health system work together to ensure effective discharge planning and the best outcomes for people who are discharged from hospital. Section 117 of the Mental Health Act places a joint duty on local authorities and integrated care boards, in co-operation with voluntary agencies, to provide or arrange for the provision of aftercare to patients detained in hospital for treatment under section 3 (and some other sections) who then cease to be detained.”

    Source location

    Response from Department for Health and Social Care
    Page 2 · response
    Published 13 August 2025

    Open published response

  3. Inner North London

    AI-generated summary

    Joanita Nalubowa · 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

    Joanita Nalubowa died after suspending herself with a ligature shortly after being told she would be discharged to Stockton, away from her family support network and against her wishes. The report raises concern that rigid accommodation criteria and the lack of discretion may create a risk of future deaths where a person's historical area of residence is inappropriate or dangerous and section 117 aftercare does not apply.

    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

    Rigidity and lack of flexibility in criteria for aftercare outside section 117

    Wider context from the report

    “Please see Box 4, above. The evidence at the Inquest was that this situation is not uncommon, with those detained under the MHA not infrequently having social circumstances such that their historical place of residency is, for whatever reason, deeply inappropriate (or even dangerous). It should be noted that section 117 Mental Health Act 1983 did not apply. I am concerned that the rigidity and lack of flexibility in the criteria, coupled with the evidence this is a not uncommon phenomenon, gives rise to a risk of future deaths in cases which do not meet the threshold for aftercare under s.117. ”

    Source location

    Joanita Nalubowa · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  4. Essex

    AI-generated summary

    Molly Ann Sergeant · 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

    Molly Ann Sergeant, aged 17, was found deceased on 16 October 2020 after hanging, having left a note. The report identifies concerns about delayed autism diagnosis, insufficient assessment and discharge planning, failures in social-care assessments and coordination, and a lack of understanding of her aftercare rights and chronic suicide 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

    Lack of understanding of section 117 Mental Health Act rights and entitlements

    Wider context from the report

    “(6) A lack of understanding of section 117 Mental Health Act rights and potential for consideration for entitlements to meet Molly’s needs related to her mental health disorder, by Essex County Council: a. compelling Molly to choose between family members as part of her discharge planning and then as a consequence changing Molly’s status during her detention from homeless. b. Lack of assessment for any s117 needs to facilitate discharge c. Lack of appreciation of the impact of Molly’s autism diagnosis in a background of chronic suicide risk on decision-making and Molly’s potential to understand the decisions being made. ”

    Source location

    Molly Ann Sergeant · 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

    Maintain the pan-Essex Section 117 protocol setting out multi-agency care planning processes, including accommodation responsibilities.

    Verbatim wording from the response

    “There is a pan-Essex SET Section 117 Protocol which was published in April 2022. This highlights the primary purposes of Section 117 and is intended to articulate a clear process by which multi-agency care planning in the context of Section 117 should be undertaken. It makes clear reference to the provision of accommodation issues within the Section 117 arrangements. It is currently a 26-page document.”

    Source location

    Response from Essex County Council
    Page 4 · response
    Published 10 March 2023

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    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 and publish internal Section 117 guidance covering duties, processes and the Section 117 Panel.

    Verbatim wording from the response

    “There is also an internal Section 117 guidance working group which has been developed by the Leads for Mental Health within ECC. This is due to be published in Spring 2023. This will cover Section 117 duties and responsibilities, the Section 117 process, the Section 117 Panel.”

    Source location

    Response from Essex County Council
    Page 4 · response
    Published 10 March 2023

    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

    Deliver Section 117, Section 85, mental health and autism awareness training and awareness-raising for Children and Families staff.

    Verbatim wording from the response

    “In relation to training and awareness-raising sessions across Children and Families in respect of Section 117, Section 85 and autism awareness, there has been extensive mental health training that has taken place throughout 2021 and 2022 and the dates of this training were previously submitted to the Coroner. Further Section 117 training sessions took place in January 2023 and further courses are due to take place in May and July 2023. The Essex Social Care Academy is currently working on additional commissioning options in relation to further mental health training and autism awareness”

    Source location

    Response from Essex County Council
    Page 4 · response
    Published 10 March 2023

    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

    Complete the draft Section 117 practice guidance and produce a Thinking Practice Tool to support Section 117 planning.

    Verbatim wording from the response

    “The draft Section 117 practice guidance will be completed in the Spring 2023, and a “Thinking Practice Tool “will be produced to assist staff in relation to the issues involved in Section 117 planning.”

    Source location

    Response from Essex County Council
    Page 4 · response
    Published 10 March 2023

    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

    The acknowledged shortcomings were not causation or contributory factors in Molly’s death.

    Verbatim wording from the response

    “It is not our view that these shortcomings, which we have fully acknowledged and have taken significant steps to ensure do not happen again, were causation factors or contributory factors which led to Molly’s very sad death.”

    Source location

    Response from Essex County Council
    Page 2 · response
    Published 10 March 2023

    Open published response

  5. Lancashire and Blackburn with Darwen

    AI-generated summary

    Daniel Robert Nelson · 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

    Daniel Robert Nelson had a history of schizophrenia, drug dependency, homelessness and imprisonment. After discharge from mental health care with inadequate planning and without required section 117 support, he was placed in unsuitable emergency accommodation with access to drugs and died from an accidental heroin overdose; concerns included the absence of Trust protocols, policies or adequate procedures for section 117 discharges.

    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

    Lack of adequate governance procedures for section 117 discharges

    Wider context from the report

    “Within the Trust there was no protocol, policy or adequate standard operating procedures governing section 117 discharges ”

    Source location

    Daniel Robert Nelson · 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

    Ratify the Section 117 Aftercare Policy governing service responsibilities for people subject to Section 117.

    Verbatim wording from the response

    “The Trust has a Section 117 Project Group that has developed a Section 117 Aftercare Policy that addresses responsibilities of services to someone who is subject to Section 117 of the Mental Health Act 1983 (MHA). The policy has been widely consulted upon and is due to be ratified at the Trust Mental Health Act and Mental Capacity Act Compliance Committee on 24th November 2022. Following ratification the policy will be shared with staff through the Social Care Leads in each division of the Trust. The policy will be uploaded to the Trust intranet and will be shared with staff through the Trust’s weekly communication briefing and the Trust Patient Safety Newsletter.”

    Source location

    Response from Greater Manchester Mental Health
    Page 1 · response
    Published 5 October 2022

    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

    Disseminate the ratified Section 117 Aftercare Policy to staff through divisional leads, the intranet, weekly briefings and the Patient Safety Newsletter.

    Verbatim wording from the response

    “The Trust has a Section 117 Project Group that has developed a Section 117 Aftercare Policy that addresses responsibilities of services to someone who is subject to Section 117 of the Mental Health Act 1983 (MHA). The policy has been widely consulted upon and is due to be ratified at the Trust Mental Health Act and Mental Capacity Act Compliance Committee on 24th November 2022. Following ratification the policy will be shared with staff through the Social Care Leads in each division of the Trust. The policy will be uploaded to the Trust intranet and will be shared with staff through the Trust’s weekly communication briefing and the Trust Patient Safety Newsletter.”

    Source location

    Response from Greater Manchester Mental Health
    Page 1 · response
    Published 5 October 2022

    Open published response

  6. Essex

    AI-generated summary

    Stephanie Moyce · 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

    Stephanie Moyce, who had a history of mental health issues and repeated suicide attempts, took her own life on 30 July 2021 and was discovered by her partner. The report identified concerns about unclear responsibility for care and oversight after psychotherapy discharge, inadequate discharge planning and safety-netting, the lack of routine multidisciplinary discussion, and insufficient involvement of her carer in Section 117 after-care reviews.

    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 involve patients’ carers as equal partners in the development and review of Section 117 after-care plans

    Wider context from the report

    “4. The evidence in this case indicated that, contrary to EPUT’s own established Protocol, a patient’s carer (in this case her long-term partner who no confidentiality issue were identified) are not in practice always “seen as equal partners in the development and review of Section 117 after-care plans” and involved directly in such reviews. ”

    Source location

    Stephanie Moyce · Prevention of Future Deaths report
    Page 3 · 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