First reported 14 Nov 2016•Latest report 18 Oct 2024
Definition
What this concern includes
Includes failures of the end-to-end out-of-area mental health placement process that materially undermine continuity of care or support, including placement distance, community follow-up, home-team coordination, discharge, transfer or repatriation where these are specifically tied to the out-of-area placement.
Not included
Excludes generic mental health staffing, funding, communication or information-sharing deficiencies that are not specifically tied to managing an out-of-area placement.
Excludes deficiencies in local or in-area mental health care where out-of-area placement is not materially involved.
Excludes isolated family, visitor or pet-involvement difficulties unless they form part of the broader failure of continuity of care in an out-of-area placement.
Excludes unrelated delays in emergency treatment, diagnosis, discharge or transfer outside the out-of-area mental health placement process.
Reports
10
Distinct published reports
Individual concerns
13
A report can raise multiple concerns
Date range
2016–2024
First to latest report issue date
Stated actions
33
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
NHS England5
Avon and Wiltshire Mental Health Partnership NHS Trust1
Berkshire Healthcare NHS Foundation Trust1
Betsi Cadwaladr University LHB1
Cygnet Hospital Harrow1
Dorset Healthcare University NHS Foundation Trust1
Elmbridge Borough Council1
Elysium Healthcare Limited1
NHS Birmingham and Solihull Integrated Care Board1
Reading Borough Council1
Recipient name withheld1
Surrey and Borders Partnership NHS Foundation Trust1
Executive non-departmental public body5
Ministerial department5
NHS trust3
English district council1
English unitary authority1
Healthcare site1
Integrated care board1
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.
Northamptonshire
Concerns raised1
Excessive distance of out-of-area acute beds from patients’ home addresses
This report raised 5 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.
Manchester South
Concerns raised1
Delays in transferring patients from out-of-area independent-provider hospitals
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.4
Action
Run the Mental Health, Learning Disability and Autism Inpatient Quality Transformation Programme to localise and realign inpatient care.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 25 June 2024.
Action
Publish the Commissioning Framework for Mental Health Inpatient Services.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 25 June 2024.
Action
Require each Integrated Care Board to develop and publish a three-year plan to localise and realign mental health inpatient care.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 25 June 2024.
Action
Continue working with the NHS to maximise mental health service capacity.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 25 June 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Individual trusts and local health systems are responsible for assessing and managing bed capacity, patient flow and specialist rehabilitation-unit availability.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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 raised2
Failure of out-of-area and private providers to coordinate effectively with local discharge arrangements
Use of out-of-area mental health placements limiting family contact
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.2
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.
Action
Make funding available to support discharge from mental health inpatient settings and reduce out-of-area placements.
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.
Manchester South
Concerns raised2
Lack of consistent adoption and awareness of delayed-discharge protocols across independent providers
Out-of-Area patients remaining away from home because of delayed discharge or repatriation
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.10
Action
Develop and publish statutory guidance for discharge from 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 13 November 2023.
Action
Provide additional funding to support adult social care and NHS discharges, including from 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 13 November 2023.
Action
Work with NHS England to ensure systems prioritise eliminating inappropriate out-of-area placements, focusing on discharge and patient flow.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 13 November 2023.
Action
Work towards eliminating adult acute out-of-area placements across the NHS.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 13 November 2023.
Action
Publish guidance supporting timely, local, high-quality therapeutic inpatient care and timely discharge.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 13 November 2023.
Action
Support health and care systems to operationalise inpatient mental health care localisation plans through regional and national assistance.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 13 November 2023.
Action
Add a dedicated Hospital Overview section identifying out-of-area patients requiring repatriation to support daily bed-allocation decisions.
Stated by Dorset Healthcare University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 November 2023.
Action
Appoint a dedicated clinical Out of Area Coordinator.
Stated by Dorset Healthcare University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 November 2023.
Action
Implement an out-of-area inpatient-care procedure requiring regular contact and documentation with patients, families, carers and treating clinicians.
Stated by Dorset Healthcare University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 November 2023.
Action
Conduct monthly audits of out-of-area patient records against procedure standards, including coordinator input, care coordination, contacts, reviews and repatriation planning.
Stated by Dorset Healthcare University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 November 2023.
Surrey
Concerns raised1
Difficulty accessing community treatment and support after out-of-area placement
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
Update the CMHRS policy to require ongoing contact during transfers between Trusts, based on SBAR/RAG-rated need, until transfer completion.
Stated by Surrey and Borders Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 23 April 2021.
Action
Provide local team visits when transitioning patients are nearby and accessible, where necessary.
Stated by Surrey and Borders Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 23 April 2021.
Action
Refer patients with urgent needs to their local HTT or crisis service for immediate care and risk assessment.
Stated by Surrey and Borders Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 23 April 2021.
Birmingham and Solihull
Concerns raised1
Out-of-area mental health beds disrupting patient support and continuity of care
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
Update the system-wide mental-health commissioning strategy, including plans to reduce service fragmentation.
Stated by NHS Birmingham and Solihull Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 4 October 2018.
Action
Commission independent system modelling to identify solutions and investment priorities for mental-health demand and capacity.
Stated by NHS Birmingham and Solihull Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 4 October 2018.
Action
Provide additional investment to expand commissioned mental-health service capacity and provision.
Stated by NHS Birmingham and Solihull Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 4 October 2018.
Avon
Concerns raised2
Lack of guidance for managing children returning to their local area after out-of-area psychiatric inpatient care
Lack of guidance for managing children receiving out-of-area psychiatric inpatient care
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Cornwall and Isles of Scilly
Concerns raised1
Difficulty for nearest relatives and Responsible Medical Officers to carry out statutory functions during distant placements
This report raised 5 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.4
Action
Eliminate clinically unnecessary out-of-area placements for adult acute mental health care by 2020/21.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 19 February 2017.
Action
Develop an evidence-based adult acute mental health treatment pathway and accompanying commissioning support tools with the NCCMH and stakeholder group.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 19 February 2017.
Action
Publish a national definition of acute out-of-area placements following consultation.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.
Action
Monitor progress toward eliminating inappropriate non-specialist adult acute out-of-area placements and provide targeted support to local areas.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 19 February 2017.
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Includes failures of the end-to-end out-of-area mental health placement process that materially undermine continuity of care or support, including placement distance, community follow-up, home-team coordination, discharge, transfer or repatriation where these are specifically tied to the out-of-area placement.
