The issue of unsafe discharge from hospital is nothing new. The year before I took up post as the national health Ombudsman, my predecessor had seen patients not being assessed or consulted properly before discharge, carers not being informed and people being kept in hospital due to poor coordination across services.
Any health or social care environment can develop a ‘closed culture’ where poor working culture or practices risk causing harm to patients and affect a service’s ability to respond when things do go wrong. Settings that care for people who may be less able to advocate for themselves, such as inpatient mental health wards, are at even greater risk. During my tenure as Ombudsman, I have repeatedly called for urgent action to address patient safety and cultural issues in mental health services. This has included my demands for a statutory inquiry into the deaths of people being cared for in Essex inpatient settings and the need for a radical transformation of eating disorders services.
When we think about transfers of care between mental health settings, it is clear that decisions are always a balance of considering what is in a person and their carer’s best interests, resources and safety. The cases highlighted in this report show what happens when transfers of mental health care go tragically wrong. They demonstrate why collaboration between health and care professionals, families, carers, and individuals is key, and why allowing the time for clear and honest communication around decision-making and care planning is vital. Everyone involved should be guided by the principle of ‘progress’ over ‘process’: that we should be thinking about transitions in care as steps on a path to recovery rather than just administrative procedure.
It is right that we recognise and pay tribute to the overwhelming majority of hard-working professionals who are committed to delivering care for those who most need it on a daily basis in spite of huge pressures. The failings we see in my Office’s mental health casework are symptomatic of services that have lacked the necessary political prioritisation and real will for radical change. The lack of traction in bringing about reform to the Mental Health Act is a testament to this. It is something the Government must address as a priority if it wants to prove it is committed to making vast improvements for people using mental health services.
Although we have seen valuable steps to change access and attitudes towards mental health conditions and care, reaching the point where mental health is given equal priority to physical health in terms of access and outcomes of care still remains a long way off. But we must remain determined to see radical improvements. We cannot fall victim to the same revolving door of short-term policies and planning of mental health pathways.
Rob Behrens CBE
Parliamentary and Health Service Ombudsman