First reported 31 Oct 2014•Latest report 27 May 2026
Definition
What this concern includes
Includes deficiencies in the end-to-end discharge planning process for inpatient mental health admissions, including failures of social care involvement, practitioner preparedness, coordination and management of issues arising during discharge or out-of-area admissions.
Not included
Excludes generic mental health bed-capacity shortages or delays in obtaining admission.
Excludes general communication or information-sharing failures not specifically tied to inpatient mental health discharge planning.
Excludes failures in Mental Health Act assessment, admission notification or ongoing inpatient care unless they directly concern discharge planning.
Excludes isolated clinical treatment failures that do not concern the discharge process.
Reports
17
Distinct published reports
Individual concerns
19
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
43
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.
Department of Health and Social Care5
Essex Partnership University NHS Foundation Trust3
NHS England2
Berkshire Healthcare NHS Foundation Trust1
Betsi Cadwaladr University LHB1
Birmingham and Solihull Mental Health NHS Foundation Trust1
Care Quality Commission1
Central and North West London NHS Foundation Trust1
Cygnet Hospital Harrow1
Elysium Healthcare Limited1
Essex County Council1
Lancashire & South Cumbria NHS Foundation Trust1
Lewisham and Greenwich NHS Trust1
London Borough of Lewisham1
Midlands Partnership University NHS Foundation Trust1
NHS trust14
Ministerial department5
Executive non-departmental public body2
Healthcare site2
London borough council2
Clinical commissioning group1
Coronial office1
English county council1
English unitary authority1
Health and social care service regulator1
Local health board1
Private limited company1
Type not available1
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.
Essex
Concerns raised1
Failure to resolve unmet discharge conditions and escalated self-harm concerns before discharge
This report raised 18 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
Recruit a Community and Inpatient Liaison Practitioner CPN to coordinate inpatient communication and safer discharge planning.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 August 2026.
Action
Hold weekly ward discharge-planning meetings with key care workers and community leads, documenting complex-discharge actions.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 August 2026.
Action
Ensure Home First Home Team staff attend inpatient MDT meetings and ward reviews to coordinate discharge interventions.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 August 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Discharge to community mental health services was considered appropriate and proportionate based on multidisciplinary risk assessment and the patient’s clinical presentation.
Stated by Essex Partnership University NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Discharge planning meetings may proceed without a community team member because records and multidisciplinary notes remain accessible to all relevant staff.
Stated by Essex Partnership University NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Worcestershire
Concerns raised1
Absence of formal documented s.117 discharge plans agreed by all responsible care and treatment providers
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
Use a standardized Rio form covering all relevant s.117 meeting areas and remind acute-care staff to complete it.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 February 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Trust is better placed to respond to concerns about the absence of a requested Section 117 plan.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Oxfordshire
Concerns raised2
Discharge policy failing to specifically address Tribunal discharge directly from PICU to the community
Failure to rapidly coordinate complex discharge arrangements
This report raised 6 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
Produce and circulate additional discharge guidance for staff through the discharge checklist.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 17 June 2025.
Action
Review the Discharge Policy and recommend amendments, including a new section on unplanned discharge.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 17 June 2025.
Action
Obtain approval and publish the revised Discharge Policy, then brief ward teams on its requirements.
Stated by The TrustStated plannedThe respondent said that this action was planned when they made their response on 17 June 2025.
Inner South London
Concerns raised1
Failure to provide an out-of-hours social worker welfare check on the day of discharge
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.
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.2
Action
Provide same-day Enablement Care Officer visits after discharge to assess care suitability and escalate changes.
Stated by Lewisham and Greenwich NHS Trust and London Borough of LewishamStated completedThe respondent said that this action was complete when they made their response on 29 January 2025.
Action
Provide next-day out-of-hours welfare calls by a therapist or social worker for patients discharged between 5pm and 8pm.
Stated by Lewisham and Greenwich NHS Trust and London Borough of LewishamStated completedThe respondent said that this action was complete when they made their response on 29 January 2025.
East London
Concerns raised1
Lack of safety planning 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.7
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
Improve discharge and care-planning documentation with discharge prompts, carer involvement, and service-user review of correspondence.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 1 August 2024.
Action
Provide Trust-wide community mental-health-team training on enhanced transition care planning.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 1 August 2024.
Action
Roll out STORM risk-management training to frontline staff, targeting 60% of registered urgent-care practitioners by the end of 2024.
Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 1 August 2024.
Action
Re-share the clinical risk policy and provide ward posters on safe discharge steps.
Stated by The TrustStated completedThe respondent said that this action was complete 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.
Berkshire
Concerns raised1
Lack of training for practitioners in the discharge process, including issues arising from out of area admissions
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.4
Action
Deliver face-to-face care planning and risk assessment training to the multidisciplinary team.
Stated by Cygnet Health Care LimitedStated completedThe respondent said that this action was complete when they made their response on 3 April 2024.
Action
Update risk e-learning guidance to address risk assessment around discharge.
Stated by Cygnet Health Care LimitedStated plannedThe respondent said that this action was planned when they made their response on 3 April 2024.
Action
Develop and deploy discharge-policy induction slides covering checklists, risks, documentation and communication with community teams.
Stated by Cygnet Health Care LimitedStated in progressThe respondent said that this action was in progress when they made their response on 3 April 2024.
Action
Implement revised Clinical Risk training with increased focus on high-risk discharge situations.
Stated by Berkshire Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 3 April 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The existing discharge SOP applies regardless of admission location, and Adult Social Care practitioners are required to follow it.
Stated by Reading Borough CouncilExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
North Wales (East and Central)
Concerns raised1
Lack of joint discharge planning between the Health Board and out-of-area psychiatric facilities
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.
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 formal weekly multidisciplinary out-of-area monitoring meetings with documented actions, escalation and oversight of repatriation, clinical activity and discharge planning.
Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 12 February 2024.
Action
Develop a standard operating procedure governing information sharing, repatriation and discharge planning, and key documentation for out-of-area acute placements.
Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 12 February 2024.
Action
Launch and implement the fully ratified standard operating procedure for out-of-area acute placements.
Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 12 February 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The described processes did not create a future-death risk for Elysium because information was provided and Betsi had time to intervene.
Stated by Elysium Healthcare LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Lawful constraints prevented delaying discharge or requiring a joint discharge meeting for an informal patient who wished to leave.
Stated by Elysium Healthcare LimitedUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Manchester South
Concerns raised1
Failure of out-of-area and private providers to coordinate effectively with local discharge arrangements
This report raised 7 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.1
Action
Publish statutory guidance for discharge from all mental health inpatient settings.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 12 February 2024.
Essex
Concerns raised1
Discharge planning that compels a choice between family members and changes homelessness status
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.
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.2
Action
Operate weekly multi-agency oversight meetings for autistic and learning-disabled young people in Tier 4 inpatient beds and coordinate safe discharge responsibilities.
Stated by Essex County CouncilStated completedThe respondent said that this action was complete when they made their response on 10 March 2023.
Action
Maintain the pan-Essex Section 117 protocol setting out multi-agency care planning processes, including accommodation responsibilities.
Stated by Essex County CouncilStated completedThe respondent said that this action was complete when they made their response on 10 March 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The acknowledged shortcomings were not causation or contributory factors in Molly’s death.
Stated by Essex County CouncilDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Molly was not made to choose between family members during discharge planning; independent supported living was the only feasible alternative.
Stated by Essex County CouncilDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Blackpool and the Fylde
Concerns raised1
Failure of social care to remain involved throughout mental health admissions
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.
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Includes deficiencies in the end-to-end discharge planning process for inpatient mental health admissions, including failures of social care involvement, practitioner preparedness, coordination and management of issues arising during discharge or out-of-area admissions.
