Systemic Investigation
Partially Accepted
Partially Complied
Discharge from mental health care: making it safe and patient-centred
Systemic investigation into unsafe discharge from mental health settings. Based on PHSO casework showing patients being discharged without adequate follow-up, safety planning or family involvement. Makes 5 recommendations covering statutory guidance implementation, 72-hour follow-up extension, nominated person involvement, and the Mental Health Bill.
5 recommendations
3 with response
Recommendations
Department of Health and Social Care / NHS England
Rec 1
Partially Accepted
We note the Department of Health and Social Care's (DHSC) national statutory guidance on discharge from mental health settings. As it is implemented, DHSC and NHS England must engage with people and services to assess the impact the guidance has on them. In particular, they must make sure that Integrated Care Systems account for the different professionals that should be involved in the discharge multi-disciplinary team (MDT).
Partially accepted:
DHSC published statutory guidance on discharge from mental health inpatient settings on 26 January 2024, days before this report. Implementation monitoring is ongoing but no formal per-recommendation response has been published.
26 January 2024
NHS England
Rec 2
Pending
NHS England should extend the requirement for a follow-up check within 72 hours of discharge for people from inpatient mental health settings to include people discharged from emergency departments.
NHS England / Integrated Care Boards
Rec 3
Partially Accepted
NHS England and Integrated Care Boards should make sure that people who are being discharged from mental health settings can choose a nominated person to be involved in discussions and decision-making around transitions of care.
Partially accepted:
The Mental Health Act 2025 (Royal Assent 18 December 2025) introduces a statutory 'nominated person' role replacing the nearest relative concept, which aligns with this recommendation.
18 December 2025
NHS England
Rec 4
Pending
NHS England should make sure that patients and their support network are active and valued partners in planning transitions of care and are empowered to give feedback, including through complaints.
HM Government
Rec 5
Accepted
The Government must show its commitment to transforming and improving mental health care by introducing the Mental Health Bill to Parliament as a priority.
Government accepted:
The Mental Health Bill was introduced in the House of Lords on 6 November 2024 and received Royal Assent on 18 December 2025 as the Mental Health Act 2025.
18 December 2025