Recurring concern

Inadequate psychiatrist review of mental health admission and discharge decisions

First to latest report 9 Mar 2015 — 1 Aug 2025

Reports that mention this concern
5
Times this concern has been raised
7
Stated actions linked to this concern
6

What this concern includes

Includes failures of psychiatrist or appropriately senior psychiatric review, discussion or escalation that is dedicated to deciding or reconsidering whether a mental health patient should be admitted, discharged or remain under care.

What is not included
  • Excludes generic failures of documentation, training, staffing or communication unless they directly concern the required psychiatric review of an admission or discharge decision.
  • Excludes failures concerning ongoing psychiatric review that are not tied to an admission, discharge or continued-care decision.
  • Excludes non-psychiatric clinical review and specialist access problems unrelated to mental health admission or discharge decisions.

Reports and published responses 5 reports

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

  1. North London

    AI-generated summary

    Sidi Chax Bojang · 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

    On 19 July 2024, Sidi Chax Bojang left the platform at Oakleigh Park Railway Station and was struck by a fast train. He had recently attended hospital after reporting self-harm and experiencing a “wooshing” sound and flashes of light, and had called an ambulance on the morning of his death after cutting himself. The concerns included that possible serious mental illness and hallucinations were not recognised, that a psychiatrist did not review him before discharge, and that discharge was left to a senior psychiatric nurse.

    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 obtain psychiatrist review before discharge

    Wider context from the report

    “Where there is a significant change in presentation when assessed suggesting that the patient is now well, when either the same day, or a short time before presentation, acts of self harm, suicidal behaviour or thoughts were present. That a psychiatrist did not review the person presenting before discharge. The discharge of the person in these circumstances fell to a senior psychiatric nurse. ”

    Source location

    Sidi Chax Bojang · Prevention of Future Deaths report
    Page 2 · concerns

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    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 decisions falling to a senior psychiatric nurse

    Wider context from the report

    “Where there is a significant change in presentation when assessed suggesting that the patient is now well, when either the same day, or a short time before presentation, acts of self harm, suicidal behaviour or thoughts were present. That a psychiatrist did not review the person presenting before discharge. The discharge of the person in these circumstances fell to a senior psychiatric nurse. ”

    Source location

    Sidi Chax Bojang · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Manchester West

    AI-generated summary

    Shaun Daniel Houghton · 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

    Shaun Daniel Houghton was found dead in a rural area on 1 December 2022 after self-discharging from Atherleigh Park Hospital against medical advice the previous day. During the inquest, concerns were raised about self-discharge procedures, including the absence of routine referral to a Consultant or Senior Doctor, the lack of a checklist for junior doctors, and medication not being prescribed or dispensed at discharge.

    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 refer self-discharge patients to a Consultant or Senior Doctor for Mental Health Act detention consideration

    Wider context from the report

    “1. During the Inquest evidence was heard that: - i. There are 5 separate units at Atherleigh Park Hospital and the current self-discharge against medical advice procedures or policies are uniform across all 5 units and do not involve a referral to a Consultant or Senior Doctor before the patient leaves the Hospital to check whether the patient should be considered for detention under the Mental health Act 1983. ii. There is no check list in relation to self-discharge against medical advice patients for junior Doctors to refer to before the patient leaves the Hospital. iii. No medication was prescribed or dispensed to the Deceased at the time of self-discharge. 2. I request that the Greater Manchester Mental Health NHS Foundation Trust reviews the procedures and policies to cover all 5 units at the Atherleigh Park Hospital in relation to self-discharge against medical advice patients, with a review to there being a written policy, including a check list to assist junior Doctors. 3. I further request that the Trust reviews the procedures and policies in relation a referral to a Consultant or Senior Doctor before a self-discharge against medical advice patient leaves the Hospital to check whether the patient should be considered for detention under the Mental health Act 1983. 4. I further request that the Trust reviews the procedures and policies in relation to the prescription and dispensing of medication before a self-discharge against medical advice patient leaves the Hospital. ”

    Source location

    Shaun Daniel Houghton · Prevention of Future Deaths report
    Page 3 · 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

    Complete a Trust-wide review of self-discharge against medical advice policies and procedures.

    Verbatim wording from the response

    “The Trust took the decision to review policies and procedures Trust wide in relation to self-discharge against medical advice. A small cohort of senior clinicians undertook this review. Following this review it was highlighted that there were variations in practice occurring across the Trust.”

    Source location

    Response from Greater Manchester Mental Health NHS Foundation Trust
    Page 2 · response
    Published 26 September 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, ratify and implement a single Trust-wide self-discharge procedure with a checklist, senior clinical review, capacity and risk assessments, detention consideration, documentation and medication supply requirements.

    Verbatim wording from the response

    “Once the review was completed, it was agreed that a single Trust wide Standard Operating Procedure (SOP) would be written and implemented to ensure that all areas of the Trust follow a standardised, good practice process (which includes a checklist) in relation to self-discharge against medical advice.”

    Source location

    Response from Greater Manchester Mental Health NHS Foundation Trust
    Page 2 · response
    Published 26 September 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

    Disseminate the ratified procedure to Care Groups and staff through the intranet and junior-doctor induction.

    Verbatim wording from the response

    “The SOP will be submitted for ratification in January 2024 to the oversight committee and once approved, will be issued to all Care Groups to be disseminated to staff. This is expected to be”

    Source location

    Response from Greater Manchester Mental Health NHS Foundation Trust
    Page 2 · response
    Published 26 September 2023

    Open published response

  3. Inner West London

    AI-generated summary

    Mr Oleg Khala · 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

    Mr Oleg Khala, who had complex mental and neurodevelopmental illnesses and was vulnerable, died by hanging after being discharged twice from hospital despite requesting admission because of suicidality and sleeplessness. The principal concerns included generic CATT assessments, discharge without consultant discussion, failure to provide a care coordinator, and insufficient access to neurodevelopmental expertise.

    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 resolve differing psychiatric team assessments before discharge

    Wider context from the report

    “5. That where psychiatric teams differ in their assessments such as CATT and psychiatric liaison, as occurred here, patients are not discharged until opinion is soft from the on-call consultant and re-discussion taken place between those with differing views. ”

    Source location

    Mr Oleg Khala · Prevention of Future Deaths report
    Page 4 · 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

    Failure to discuss CATT discharge and admission patients with the on-call psychiatrist

    Wider context from the report

    “4. That patients to be discharged by CATT, as well as patients to be admitted are discussed with the on-call psychiatrist so that plans may be reviewed, and thus the risk of not admitting patients who would benefit from and/ or require admission such as Mr Khala, are less likely to be discharged inappropriately. ”

    Source location

    Mr Oleg Khala · Prevention of Future Deaths report
    Page 4 · 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

    Remind crisis-assessment staff that they may request senior consultant discussion regardless of the proposed disposition.

    Verbatim wording from the response

    “CATT team members (and other non-medical and trainee medical staff undertaking assessments of patients in crisis) have been reminded that they can request senior discussion with On-call Consultants irrespective of decision to admit, to offer an admission to a home-based care pathway or to discharge.”

    Source location

    Response from West London NHS Trust
    Page 4 · response
    Published 10 July 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

    Embed trusted-assessment working between CATT and Psychiatric Liaison teams for joint admission and home-treatment decisions.

    Verbatim wording from the response

    “The Clinical Directors, Service Managers, Clinical Leads and Team Managers responsible for CATT and Psychiatric Liaison are in regular discussion about interface matters between their services and cases of concern are reviewed regularly. All are in agreement that it is best practice for assessments to take place and decisions to be made jointly wherever possible, and work is ongoing to embed a culture of ‘trusted assessment’ between the teams in respect of decisions to admit to beds or home-based treatment pathways under CATT.”

    Source location

    Response from West London NHS Trust
    Page 6 · response
    Published 10 July 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

    Work with North West London partners to implement clinical escalation protocols for clinical disagreement.

    Verbatim wording from the response

    “Where a joint assessment and decision is not possible, the person(s) completing the assessment will communicate and discuss and agree the findings with the referrer, service user and within the multi-disciplinary team (MDT) handover, which involves consultants. The availability of in-hours and on-call psychiatric registrar (approved under section 12 of the Mental Health Act) and consultant) to provide guidance or supplementary assessment in the event of clinical disagreement has been re-communicated to teams, and will be incorporated into work we are doing with partners across North West London to implement clinical escalation protocols.”

    Source location

    Response from West London NHS Trust
    Page 6 · response
    Published 10 July 2023

    Open published response

  4. Milton Keynes

    AI-generated summary

    Colette Denise Vivienne Jean DUNN · 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

    Colette Denise Vivienne Jean Dunn was taken to hospital by ambulance with police officers after threatening to kill herself, but was discharged without a formal Mental Health Act assessment. Later that day, she doused herself with petrol and set fire to herself, sustaining severe burns, and died the following morning. Concerns included the absence of a full mental health assessment before discharge, lack of a clear discharge protocol between relevant agencies, and inadequate facilities in Milton Keynes for people experiencing a mental health crisis.

    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 complete a full Mental Health Act assessment by a psychiatrist before discharge

    Wider context from the report

    “1. During the course of the evidence it was clear that prior to discharge from the hospital a full Mental Health Act assessment by a psychiatrist should have been carried out before the decision was taken to discharge Ms Dunn, particularly as the police officers were expressing their concerns to the staff that Ms Dunn had indicated that once she had left the hospital it was her intention to kill herself and indicated that she would tell the staff what they wanted to hear in order to secure her discharge. ”

    Source location

    Colette Denise Vivienne Jean DUNN · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  5. Manchester City

    AI-generated summary

    Craig Douglas Bell · 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

    Craig Douglas Bell was found dead in his cell at HMP Manchester on 13 December 2012 after taking his own life by hanging using a self-constructed ligature. He had a history of self-harm and suicidal ideation and was subject to ACCT procedures. The principal concerns included inadequate sharing of risk information, insufficient senior psychiatric involvement in discharge planning, the lack of a graduated risk-management plan, and limited availability of safer or CCTV-monitored cells for prisoners at risk of suicide.

    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 suitably senior psychiatric clinician attendance at discharge case reviews

    Wider context from the report

    “3. I am concerned at the lack of attendance of the Consultant Psychiatrist or a suitably qualified and experienced junior colleague at the discharge case review/meeting. In a case of patient still on an ACCT and being discharged to an ordinary wing location without as senior clinician being able to attend and participate in the discharge case review , risk assessment at that stage and risk planning. In this case there was no attendance on the 6 December 2012 and no clinician had seen him since 27 November 2012. This would allow a more sophisticated and timely assessment of risk at that time. Measures to try and reduce or mitigate the risks could then be discussed and put in place in a graduated manner. It is appreciated that such case reviews may have to be rearranged so as to facilitate full attendance. The court has previously identified the concern arising from that fact that no senior clinician took the opportunity at the appropriate time to stand back and take an overall view of the entire circumstances and the risks presented. ”

    Source location

    Craig Douglas Bell · Prevention of Future Deaths report
    Page 5 · 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