Recurring concern

Unsafe self-discharge decision-making

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First reported 9 May 2014•Latest report 25 Sep 2023

Definition

What this concern includes

Includes failures in the self-discharge decision process, including consideration of admission circumstances and current risks, establishment of current patient circumstances and relevant agency input, appropriate clinical responsibility and senior review, documentation of the rationale, and reconsideration when the patient's presentation or circumstances materially change.

Not included

Excludes ordinary planned discharge, discharge timing and post-discharge follow-up concerns where self-discharge or a decision about permitting self-discharge is not the material condition.
Excludes generic mental-health risk-assessment failures that are not connected to a self-discharge decision.
Excludes failures to provide care or support after a safe self-discharge decision has been made.
Excludes generic documentation, staffing or communication deficiencies unless they directly make a self-discharge decision unsafe.
Excludes the substantive clinical quality of treatment or admission decisions where no self-discharge decision is involved.

Reports: 3
Individual concerns: 6
Date range: 2014–2023
Stated actions: 4

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Greater Manchester Mental Health NHS Foundation Trust2

King'S College Hospital NHS Foundation Trust1

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.

25 Sep2023
Manchester West
Concerns raised2
1. Lack of a checklist for junior Doctors managing self-discharge against medical advice patients
2. Failure to refer self-discharge patients to a Consultant or Senior Doctor for Mental Health Act detention consideration
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 3
1. Action
  Complete a Trust-wide review of self-discharge against medical advice policies and procedures.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated completed
2. Action
  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.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated in progress
3. Action
  Disseminate the ratified procedure to Care Groups and staff through the intranet and junior-doctor induction.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated planned
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
Lack of a checklist for junior Doctors managing self-discharge against medical advice patients
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 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
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, 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
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 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
15 Jan2020
Manchester West
Concerns raised3
1. Failure to consider admission circumstances and current risks in self-discharge decisions
2. Failure to keep contemporaneous documentation of self-discharge and detention decision-making rationale
3. Failure to recognise when to seek senior opinions about Mental Health Act section 5(2) detention criteria
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.
AI-generated summary

Daniel Jeffrey Moran · 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 Jeffrey Moran was pronounced dead at home on 14 July 2019 after using a rope as a ligature to partially suspend himself from a window. He had a history of depression, alcohol misuse and multiple recent suicide attempts, and had self-discharged from hospital after being assessed as not meeting the criteria for detention under the Mental Health Act. Concerns included staff understanding of confidentiality, patient-flow prioritisation, roles and responsibilities in managing risk, documentation, and decisions about self-discharge and detention.

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 consider admission circumstances and current risks in self-discharge decisions
Wider context from the report
“4. Doctors and ward staff involved in making decisions about self-discharge should consider the circumstances of admission as well as current risks when making decisions around discharge. They also need a greater understanding of the circumstances when it is appropriate to seek more senior opinions in regards to whether the patients meets the criteria to be detained under the Mental Health Act, section 5 (2) and ensuring contemporaneous documentation are kept in relation to their decision making rationale. ”
Source location
Daniel Jeffrey Moran · 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
Failure to keep contemporaneous documentation of self-discharge and detention decision-making rationale
Wider context from the report
“4. Doctors and ward staff involved in making decisions about self-discharge should consider the circumstances of admission as well as current risks when making decisions around discharge. They also need a greater understanding of the circumstances when it is appropriate to seek more senior opinions in regards to whether the patients meets the criteria to be detained under the Mental Health Act, section 5 (2) and ensuring contemporaneous documentation are kept in relation to their decision making rationale. ”
Source location
Daniel Jeffrey Moran · 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
Failure to recognise when to seek senior opinions about Mental Health Act section 5(2) detention criteria
Wider context from the report
“4. Doctors and ward staff involved in making decisions about self-discharge should consider the circumstances of admission as well as current risks when making decisions around discharge. They also need a greater understanding of the circumstances when it is appropriate to seek more senior opinions in regards to whether the patients meets the criteria to be detained under the Mental Health Act, section 5 (2) and ensuring contemporaneous documentation are kept in relation to their decision making rationale. ”
Source location
Daniel Jeffrey Moran · Prevention of Future Deaths report
Page 2 · concerns
Open source report
9 May2014
Inner South London
Concerns raised1
1. Failure to inform the consultant of the patient and imminent self-discharge before discharge
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 1
1. Action
  Notify consultants within 12 hours when their patient self-discharges from hospital.
  Stated by The TrustStated completed
AI-generated summary

Miss Abiola Dosunmu · 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

Abiola Dosunmu developed abnormal blood tests, proteinuria and symptoms that were treated as cellulitis, before rapidly deteriorating and being found dead at home on 24 August 2012. The report identified concerns about failures to communicate the proteinuria and abnormal results, inadequate follow-up and monitoring, and a missed opportunity to diagnose and treat SLE earlier.

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 inform the consultant of the patient and imminent self-discharge before discharge
Wider context from the report
“(5) Before discharge neither the patient nor the imminent self discharge were not known to the consultant, who would have wished to be informed and would have sought further investigations and communications. ”
Source location
Miss Abiola Dosunmu · 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
Notify consultants within 12 hours when their patient self-discharges from hospital.

Verbatim wording from the response
“The medical records (in particular the clinical noted dated 09.03.12 at 13.25 hours) suggest that the Trust communicated the significance of Abiola’s illness as it was understood at the time and did its best to dissuade her from leaving hospital. The Trust is satisfied that it acted appropriately by warning Abiola and her mother of the serious consequences of self-discharging. Nonetheless, with immediate effect consultants will be notified within 12 hours that their patient has discharged themselves from hospital to minimise the potential risk to the patient or others (see also paragraph 5 below).”

Source location
2014-0209-Response-by-Kings-College-Hospital
Page 1 · response
Published 5 May 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Lack of a checklist for junior Doctors managing self-discharge against medical advice patients

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

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

Concerns raised3

Failure to consider admission circumstances and current risks in self-discharge decisions

Failure to keep contemporaneous documentation of self-discharge and detention decision-making rationale

Failure to recognise when to seek senior opinions about Mental Health Act section 5(2) detention criteria

Concerns raised1

Failure to inform the consultant of the patient and imminent self-discharge before discharge

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

Actions described in response 3

Actions described in response 1