Mental health informal leave guidance
Lack of robust criteria and clear guidance for staff making decisions about informal ground leave for mental health patients.
115 items
6 sources
Source spread
Where this theme appears
Mental health informal leave guidance has been flagged across 6 independent accountability sources:
79 PFD reports
1 committee rec
1 CQC action
12 IMB recs
10 PHSO decisions
12 LGO/SPSO decisions
When the same issue appears across inquiries, coroner reports, and regulators independently, it indicates a recurring issue across the public record.
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
PFD Reports (79) — showing 50 strongest matches
Keward Guy Domonic Harding
Concerns: An urgent mental health assessment was significantly delayed for over two weeks, potentially preventing detection of a decline in physical health that could have been treated.
Overdue
Christopher James Morgan
Concerns: The Trust lacks clear policies for communicating risk level changes and leave access with family, and has no defined staff-to-patient ratio for escorted leave from psychiatric wards.
Overdue
Linda Hudson
Concerns: Hospital discharge of a high-risk patient without family notification, inadequate communication regarding medication protocols, and a delayed nurse follow-up visit created significant safety risks.
Overdue
Yousef Shokri-Gharab
Concerns: An outdated and unreviewed policy for informal patient leave failed to reflect current practice, risking patient safety due to lack of multidisciplinary consensus and proper documentation.
Response (Mersey Care NHS Foundation Trust): • The Corporate Governance Team have been tasked with ensuring that all policies are received and updated to ensure that reflect national best practice. • Of the 120 Corporate Policies …
Responded
Maureen Leaver
Concerns: Inadequate medical supervision and ineffective systems for investigating acutely ill elderly patients in a psychiatric ward were identified, alongside a lack of understanding of legal duties for patient transfers.
Overdue
Andrew Hall
Concerns: Inadequate communication and documentation of mental health risks, failure to administer prescribed medication, and insufficient patient observation within the prison healthcare unit were identified. Training gaps for staff in risk assessment and ACCT procedures also contributed to concerns.
Response (HM Prison and Probation Service): Cameras have been removed from cells in the healthcare centre and any prisoner assessed as requiring high levels of observation is located in a constant observation cell. A system is …
Overdue
Danuta Corbett
Concerns: The hospital's leave policy for informal patients was not followed, and inadequate risk assessment for escorted leave, using an untrained agency worker, resulted in critical safety failures.
Response (Sussex Partnership NHS Trust): The consultant psychiatrist now carefully reviews notes taken during ward review. The Trust has reinforced with staff that should extraordinary circumstances arise again, a retrospective note must be completed, and …
Responded
Alexander Holt
Concerns: Failures included not challenging minimised suicidal intent, providing intended treatment, ensuring continuity of care, and maintaining information flow, leading to inadequate risk assessment and a broken referral process.
Overdue
Leah Levine
Concerns: Lack of clearly written conditions for temporary hospital leave, including supervision levels and observation regimes, led to conflicting staff understanding and poor communication with caregivers.
Response (Greater Manchester West NHS): The Salford Directorate developed a procedure for granting leave to informal patients with family and friends, outlining considerations for the multidisciplinary team. This procedure will be implemented by May 31st, …
Responded
Tommy Faisali
Concerns: Psychiatric GP referrals are handled by unqualified staff, and risk assessments are not consistently completed or documented, leading to uncommunicated patient risks and a lack of care continuity within mental health teams.
Overdue
Charlotte Bevan and Zaani Malbrouck
Concerns: There was no mandatory multi-disciplinary team meeting or widely circulated care plan for pregnant women with known mental health conditions, risking fragmented and uncoordinated care.
Response: A consultant perinatal psychiatrist has been tasked to review individual pathway arrangements against NICE guidelines, aiming to agree and implement a Trust-wide pathway. The Trust also plans to prepare and …
Responded
Brian Shillinglaw
Concerns: The provided text is incomplete and does not contain specific concerns.
Overdue
Helen England
Concerns: No protocol or guidance exists for Mental Health Nurses regarding doctor referral decisions when discharging self-harm patients, particularly those on a Community Treatment Order, creating a significant risk.
Response (Helen England): The Trust has amended its Community Treatment Order Procedure in light of the coroner's concerns and is communicating this to staff.
Responded
Tracey Lynch
Concerns: No specific concerns are provided in the truncated text.
Overdue
Lee Grimes
Concerns: Home health care failed to act on overdose disclosures and ensure follow-up with mental health services, compounded by inadequate staff training in managing overdose reports.
Responded
Leslie Morrison
Concerns: No formal mental capacity assessment or consideration of a DoLS authorisation was undertaken in the community, and details of the patient's mental health condition did not accompany him to the hospital; the coroner suggests policies to ensure up-to-date information is provided upon admission or discharge.
Response (MORRISON Leslie): The Trust will discuss the coroner's letter at the Clinical Effectiveness Committee to consider how to address the concerns raised regarding information transfer and mental capacity assessments. They are also …
Overdue
Danny Sweet
Concerns: The coroner questioned whether it was appropriate to presume the best-case scenario for patients presenting inconsistently and whether there should be a check to ensure consistency in treatment decisions; the Serious Incident Report was also incomplete.
Response (Cornwall NHS Trust): The Trust will launch a review of clinical risk assessments for people presenting with suicidal thoughts or acts, particularly focusing on the use of the STORM risk assessment tool. They …
Responded
Pamela Gressman
Concerns: There was insufficient consideration of physical effects from reported foreign body ingestion, leading to an absence of a clear treatment and observation plan for physical symptoms.
Responded
Rohan Fitzsimons
Concerns: Insufficient inpatient mental health beds, influenced by funding, led to significant delays in Mental Health Act assessments, posing a risk of individuals taking their own lives while awaiting necessary detention.
Response (Avon and Wiltshire NHS Trust): The Trust has reviewed and simplified its joint protocol for the Management of Missing Persons and Absent Without Leave, consulting with clinicians and police. A standard template to record relevant …
Overdue
Anthony Preston
Concerns: The discharge system lacked robustness, with no documentary proof of a telephone call to the Crisis Team, and no immediate follow-up notification of discharge; the coroner noted this left a high-risk patient without support.
Overdue
Oliver Ford
Concerns: The telephone triage process lacked a robust risk assessment, and any assessments were often undocumented. Insufficient PCLS weekend cover led to crucial follow-up delays for patients triaged on Fridays.
Response (Avon and Wiltshire NHS Trust): The telephone triage process now includes the access trigger tool, which assesses risk. There are now two clinicians on duty at PCLS until 8pm Monday to Friday, and the clinicians …
Responded
Micael McMonigle
Concerns: Staff showed a lack of knowledge and failure to follow policy regarding leave for informal patients, risk assessments were not updated, and the response to the patient's absence was delayed and did not conform with procedures; staff knowledge of leave policy was inadequate.
Overdue
Margaret Richardson
Concerns: A robust, comprehensive Action Plan with timescales needs to be put in place, following the findings of the Serious Incident Investigation and the evidence heard during the inquest.
Overdue
John Jones
Concerns: The hospital failed to ensure an unwell patient engaged with crucial group therapy, despite it being the reason for admission, leading to isolation and a suboptimal therapeutic environment.
Overdue
John Jones
Concerns: A significant delay in notifying the GP of patient discharge from the Crisis Team left the patient without community support. Crisis Team training lacked clear communication protocols for such handovers.
Overdue
Peter Usher
Concerns: Inadequate mental health assessments failed to gather comprehensive patient information from various sources, lacked proper staffing support, and indicated a lack of clinical insight from the duty doctor.
Response (North East London NHS Foundation Trust): North East London NHS Foundation Trust is undertaking a series of actions including sending FOI requests to other trusts, reviewing and updating S136 guidance and policy, creating a secure NHS …
Response (Borough Mental Team): The Borough Mental Team has identified four areas for improvement: handover of patients between the police and 136 suite staff; filing and storage of 136 paperwork; supporting officers dealing with …
Responded
Wendy Telfer
Concerns: Inadequate training for physical healthcare staff on mental health needs and Mental Health Act application is a concern. A severe national shortage of psychiatric beds also caused critical delays in patient transfer, contributing to preventable deaths.
Response (Northern Eastern and Western Devon NHS Trust): The CCG is monitoring timely discharge performance data, the DPT contract review meeting also monitors the rates of delayed discharges from mental health wards through data reported to NEW Devon …
Response (Royal Devon and Exeter NHS Trust): The Trust describes mental health training delivered, including specific programmes with Devon Partnership Trust (DPT). It argues that in this case, staff sought and followed specialist advice from the DPT …
Response (Devon Partnership NHS Trust): The Trust undertook a Root Cause Analysis investigation with the Royal Devon and Exeter NHS Foundation Trust (RD&E), the actions from which are completed and part of regular management supervision. …
Responded
Jonathan Zucker
Concerns: A lack of a lead clinician or systemic coordination between private and NHS mental health services resulted in fragmented patient care oversight.
Response (PSYCH): The Royal College of Psychiatrists will discuss consultant accountability, ownership during transitions, and care involving multiple teams at its Professional Practice and Ethics Committee meeting on November 2, 2017, to …
Response (Department of Health): The Department of Health acknowledges the concerns raised and highlights existing guidance on care planning and continuity of care, including GMC guidance and consensus statements. It notes that the Royal …
Responded
Janet Muller
Concerns: Deficient nursing records, risk assessments, and care plans, coupled with inadequate staffing and persistent issues allowing Mental Health Act patients to abscond, increased patient risk.
Response (Janet Muller): NHS England is implementing enhanced governance arrangements to monitor QVH's action plan, engaging with the Trust to promote networking with BSUH, and assessing the suitability of QVH for specialized services. …
Responded
Sabrina Walsh
Concerns: The absence of CCTV in corridors and communal areas at the acute care facility delayed locating vulnerable patients, risking timely intervention.
Response (NHS England): NHS England provides context regarding the use of CCTV in mental health units, referencing relevant guidance and the Sussex Partnership NHS Foundation Trust's consultation with patients and staff. They note …
Response (Sussex NHS Trust): The Trust is implementing the installation of CCTV in the entrance areas of all 12 of its acute inpatient/PICU wards, including Woodlands.
Responded
Khuong Lam
Concerns: Mental health guidance lacks provisions for reviewing Section 17 leave upon ward transfer, and there's a need for better communication to clinicians and consideration of two escorts for patient safety.
Overdue
Andrew Codling
Concerns: A community health team's voicemail to a patient missed an opportunity to reinforce crisis support numbers, potentially contributing to a missed chance to prevent self-harm over a weekend.
Response (East London NHS Trust): East London NHS Trust has developed and implemented a new protocol within CMHTs regarding the use of mobile phones in communication with service users, including an explanatory letter with contact …
Responded
Rastislav Petrisko
Concerns: Inconsistent risk assessment and classification of a patient, combined with a delayed police notification policy for absconding low-risk patients, led to an unacceptable delay in emergency response.
Overdue
Keith Heatley
Concerns: There was a lack of documented multidisciplinary decision-making and policy guidance regarding leave for informal patients, coupled with inconsistent recording of MDT meetings and no clinical review before high-risk patient leave.
Response (Swansea Bay Health Board): The health board implemented a checklist to ensure multidisciplinary team members, including the Community Mental Health Team and family, can express their views on patient leave. They also appointed a …
Responded
Patricia Chambers
Concerns: Concerns were identified regarding practices at West London Mental Health Trust, indicating a risk of future deaths if appropriate action is not taken.
Overdue
David Squire
Concerns: Smoke-free hospital guidance forces detained mental health patients who smoke into unescorted 'off-grounds' leave without staged assessment, significantly increasing risks of absconding, self-harm, and harm to others.
Response (NHS England): NHS England is working with Public Health England to reduce smoking rates in people with severe mental illness and is committed to smoke-free mental health inpatient units. NHS England will …
Responded
John Richardson
Concerns: Confusion among staff regarding voluntary patients' leave status highlighted the absence of a specific leave policy for voluntary patients, unlike those sectioned under the Mental Health Act.
Response (Sussex Partnership NHS Trust): Guidance regarding voluntary patients leaving the wards has been included in the new Acute Care Operational Policy.
Responded
Thomas Wedrychowski
Concerns: Annual monitoring for diabetes in patients on antipsychotics may be insufficient for high-risk individuals, and there is a critical lack of physical healthcare information sharing between primary and secondary care providers.
Overdue
David Fowler
Concerns: The patient's family was not informed or invited to an MDT meeting before his Mental Health Act section was lifted. Staff lacked clarity on who was responsible for family communication, and no formal policy was in place.
Response (Transitional Rehabilitation Unit): The TRU revised policies and procedures for critical decision-making, multidisciplinary team communications, mental capacity assessments, care coordination, communication with family and statutory services, and aftercare/discharge planning. The Responsible Clinician made …
Responded
Lewis Francis
Concerns: A lack of mechanisms for transferring serious crime suspects in police custody to mental health facilities and insufficient understanding of autistic prisoners' needs pose significant risks.
Response (Wiltshire Police): Wiltshire Police is working with other forces and the South West Provider Collaborative to develop a Memorandum of Understanding regarding mental health pathways.
Response (Avon and Somerset Police): Avon and Somerset Police, on behalf of the South West Provider Collaborative, has clarified out-of-hours admission processes and confirmed with providers that services are commissioned to admit patients out of …
Responded
Kimberley Smith
Concerns: The Trust lacks clear written policies for managing informal patients' leave requests, including risk assessments and monitoring. A vital recommendation for a comprehensive alcohol detoxification protocol also remains unimplemented.
Response (Surrey and Borders Partnership NHS Foundation Trust): The Trust has developed guidance regarding alcohol detoxification for people admitted to inpatient wards and are developing new guidelines for managing people with Alcohol Use Disorders (AuDs). They have also …
Responded
Katy Samuels
Concerns: The Section 17 Leave Policy lacked clear guidance on escorted leave and escort identity verification, enabling a detained patient to leave unobserved, return intoxicated, and subsequently self-harm.
Response (Coventry and Warwickshire Partnership NHS Trust): Coventry and Warwickshire Partnership NHS Trust has amended its Section 17 Leave Policy to ensure patients are collected from and returned to the ward by identified individuals. The Trust is …
Responded
Antony Schofield
Concerns: Inadequate risk assessments, poor communication during patient transfer, and a lack of professional curiosity by community mental health staff led to missed opportunities to address escalating suicidal risk, compounded by poor audit and flawed investigation.
Response (Greater Manchester Mental Health NHS Foundation Trust): Greater Manchester Mental Health NHS Foundation Trust has updated its process for obtaining staff statements following a Serious Incident, and has addressed factual inaccuracies with the RCA investigation author. They …
Responded
Jude Lloyd
Concerns: Inadequate care planning and communication between inpatient, CMHT, and GP services led to unmanaged diabetes and missed mental capacity assessments. The Trust's internal investigation was also flawed and incomplete.
Response (Greater Manchester Mental Health NHS Foundation Trust): Following a Root Cause Analysis Investigation, recommendations were made and implemented to address concerns regarding diabetes monitoring and management. An eLearning training package is in place for CMHT staff regarding …
Responded
Alexandra Tolley
Concerns: The care plan's instruction not to restrain or follow a high-risk patient absconding under Section 2 was incompatible with safety duties. Informal decisions for ground leave lacked criteria and proper risk assessment.
Response (Leeds and York Partnership NHS Foundation Trust): The Trust will update its procedure for patients who go missing, including external feedback, aiming for ratification by January 2022; it will also communicate clear timescales to external organizations for …
Responded
Marshall Metcalfe and Jane Ireland
Concerns: Children's Social Care disengages during mental health admissions, leading to a lack of social worker input in discharge planning and continuity of care, which increases patient risk upon leaving the facility.
Overdue
James Forryan
Concerns: Easily accessible websites openly promote and provide guidance on suicide methods, contributing to deaths. There is a lack of sufficient regulation and enforcement against such harmful online content.
Response (Department of Health and Social Care): The Department of Health and Social Care is taking steps to protect users online with the Online Safety Bill, working with stakeholders to remove harmful suicide and self-harm content. They …
Responded
Mena Terefi
Concerns: Mental health services face demand far exceeding capacity following a transformation, with referrals over 100% above anticipated levels and insufficient resources, risking future deaths.
Overdue
William Savory
Concerns: There was a significant two-hour delay in initiating the missing persons protocol for an informal patient, as staff were unaware of the requirement to act immediately. This lack of awareness poses a risk of future delays and deaths.
Overdue
Thomas Smith
Concerns: Mental health staff lacked critical knowledge and training on "Spice" dangers. Flawed Section 17 leave risk assessments meant escorts were unaware of recent drug-related risks or patient care plans, compromising safety.
Response (Responses from NHS England): ELFT has refreshed staff training on risks associated with spice and reiterated the need for robust pre-leave risk assessments, communicated and agreed by the nurse in charge, prior to a …
Overdue
IMB Recommendations (12)
Heathrow Immigration Removal Centre (2021)
The policy which results in people with severe mental health issues being held in IRCs should be reviewed. Despite the introduction of a new Detention Service Order (DSO) published in June 2020 on ‘mental vulnerability and immigration detention’, the Board feels that further action is necessary as the problem remains.
Ministry of Justice
Gatwick IRC/RSTHF (2022)
Increase the Detention Gatekeeper’s threshold(s) for bringing men with mental health issues into detention and improve facilities and support to enhance the prospect of release from detention for men exhibiting deterioration of their mental health in detention (section 4.4).
Home Office
Isle of Wight (2020)
In 2020 there have been a number of remand prisoners requiring immediate admission to inpatient healthcare facilities in the prison and urgent referral to secure units. Are there any actions planned with HM Courts and Tribunals Service to provide appropriate psychiatric assessment in the court setting, to ensure prisoners who are significantly mentally unwell are diverted to psychiatric hospital rather …
Ministry of Justice
Isle of Wight (2020)
Again the issue of prisoners experiencing significant mental health issues has been overlooked. The HMIP recommendation to Her Majesty’s Prison and Probation Service (HMPPS) to ensure that mentally ill prisoners are transferred to appropriate facilities, in line with national guidance, was rejected. What plans are in place to ensure that mentally ill prisoners are managed in line with HMIP recommendations …
Ministry of Justice
Swaleside (2021)
The Board has concerns regarding the mental health of residents who have suffered long-term lock-down. (see sections 5 and 6.2)
HMPPS
Bronzefield (2024)
The Board remains concerned about the number of prisoners coming into the prison, having been identified as acutely mentally unwell (including some prolific self-harmers), either requiring section under the Mental Health Act or admission to a secure hospital. How does the Prison Service plan to provide support to manage these prisoners, who cannot be easily moved to secure psychiatric hospitals …
HMPPS
Bronzefield (2024)
The number of women sent to Bronzefield under a ‘Place of Safety’ warrant has nearly doubled this year. What are the Minister’s plans to address this issue? (6.3)
Ministry of Justice
Norwich (2022)
The Board requests again that the Prison Service looks at the care of prisoners who are located in the segregation unit for long periods of time.
HMPPS
Heathrow Immigration Removal Centre (2022)
The Home Office needs to consider different ways of dealing with detainees who, for physical or mental reasons, feel incapable of sharing a room and should avoid using the CSU as a punishment for detainees who resist a request to share.
Home Office
Swaleside (2025)
Again, the length of time spent in the care, separation and reintegration unit (CSRU) by a number of prisoners remains too long and far exceeds regular recommendations. The Board notes the response last year about exit strategies, but there has been no improvement. What actions and strategies have been implemented to reduce the time prisoners spend in the CSRU, why …
HMPPS
Lindholme (2025)
The Board asks that the Governor considers monitoring the population of the CSU as currently many prisoners are being held there in excess of 42 days.
Governor / Director
Humber (2020)
The Board has grave concerns about the potential for long-term damage to the prisoners. We are keen to hear from the minister about the proposals he has to address this, as restrictions are removed.
Ministry of Justice
PHSO Casework Decisions (10)
P-003684 — An independent provider in the Hammersmith and Fulham …
Mrs D complains staff allowed Mr E to leave his mental health facility. Mrs D also complains staff did not take the action they should have to find Mr E when he did not return from his leave.
NHS in England
Partly Upheld
Jul 2025
P-001067 — Essex Partnership University NHS Foundation Trust
Mr and Mrs A complain that Essex Partnership University NHS Foundation Trust (the Trust) did not communicate with or invite Mr A to any review meetings including the discharge meeting and discharged Mrs A from Hospital too soon. They also complain that when Mrs A went back into the mental …
NHS in England
Partly Upheld
Apr 2021
P-003805 — Berkshire Healthcare NHS Foundation Trust
Mr R complains the Trust requested his mother be put under a Deprivation of Liberty Safeguards instead of a Section 3 and did not communicate effectively with him and his sister, who both have Lasting Power of Attorney.
NHS in England
Aug 2025
P-004375 — Hampshire and Isle of Wight Healthcare NHS Foundation …
Mr E complains about the service Buckinghamshire Healthcare NHS Trust provided to him and his daughter while she was detained in June 2023
NHS in England
Upheld
Nov 2025
P-004702 — Central and North West London NHS Foundation Trust
Ms S complains about care and treatment provided by the Trust in 2022. She also complains staff breached her confidentiality and did not give her reasons for detaining her under the Mental Health Act 1983.
NHS in England
Jan 2026
P-003249 — West London NHS Trust
Ms K complains about the care and treatment she received from the West London NHS Trust whilst she was detained under Section 2 of the Mental Health Act.
NHS in England
Dec 2024
P-002030 — Somerset NHS Foundation Trust
Mrs E complains the Trust should have admitted her father under Section 3 of the Mental Health Act. She also complains the Trust put her under pressure to find a private care home and to pay for the care.
NHS in England
Jun 2023
P-002520 — South London and Maudsley NHS Foundation Trust
Ms H complains the Trust deliberately moved her to a block of flats and wrongly sectioned her under the Mental Health Act.
NHS in England
Mar 2024
P-002901 — West London NHS Trust
Ms L complains the Trust medicated her against her will while she was detained under Section 2 of the Mental Health Act. She also says the Trust's staff accused her of medical fraud and being violent.
NHS in England
Aug 2024
P-004426 — South West Yorkshire Partnership NHS Foundation Trust
Mrs Whyman complains about care and treatment from the Trust in relation to her outpatient mental health care. We understand this was a very difficult experience for Mrs Whyman. We have not found any indications of failings on behalf of the Trust.
NHS in England
Nov 2025
LGO / SPSO Decisions (12)
23-009-939b — Barts Health NHS Trust (23 009 939b)
Summary: We will not investigate this complaint about the decision to detain a patient under the Mental Health Act, because of concerns they were refusing treatment for their physical health. This is because there was a right to appeal the assessment outcome through a tribunal and it would have been …
LGO (Local Government & …
Health
Apr 2024
23-014-778a — Lewisham & Greenwich NHS Trust (23 014 778a)
Summary: We consider London Borough of Lewisham and Lewisham and Greenwich NHS Trust did not appropriately seek the views of Mrs Y’s supported accommodation before deciding she could not return there from hospital. Also, the Council did not carry out a Mental Capacity Act assessment and best interest decision in …
LGO (Local Government & …
Health
Upheld
Sep 2024
19-018-519c — Brighton & Hove Clinical Commissioning Group (19 018 …
Summary: The complainant, Ms B, said she learnt in 2020 the Council, the Trust and two Clinical Commissioning Groups did not properly consider her daughter’s, Miss G’s, entitlement to free aftercare following her detainment under the Mental Health Act 1983. She also complained about the care and support provided to …
LGO (Local Government & …
Health
Upheld
Mar 2022
19-018-519b — NHS East Sussex Clinical Commissioning Group (19 018 …
Summary: The complainant, Ms B, said she learnt in 2020 the Council, the Trust and two Clinical Commissioning Groups did not properly consider her daughter’s, Miss G’s, entitlement to free aftercare following her detainment under the Mental Health Act 1983. She also complained about the care and support provided to …
LGO (Local Government & …
Health
Not Upheld
Mar 2022
22-002-419 — Staffordshire County Council
Summary: We will not investigate this complaint about a refund of care home fees and the person’s eligibility for free care under s117 of the Mental Health Act 1983, as the issue has now been resolved.
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2022
22-002-185 — Leeds City Council
Summary: We will not investigate this complaint about the Council’s decision to detain him under the Mental Health Act 1983. This is because there is insufficient evidence of fault to justify an investigation.
LGO (Local Government & …
Adult Care Services
Jul 2022
22-006-560 — Bristol City Council
Summary: We will not investigate this complaint about information provided by the Council about voting rights for people who are detained in hospital under the Mental Health Act. This is because there is insufficient evidence of injustice.
LGO (Local Government & …
Other Categories
Sep 2022
23-012-217 — Kent County Council
Summary: There was delay in revising Mr Y’s care and support plan after a review in April 2023 and a change of placement in August and a failure to complete a mental capacity assessment in line with the Code of Practice to the Mental Capacity Act. This caused avoidable confusion. …
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2024
25-000-113 — Liverpool City Council
Summary: Ms X complains the Council, Trust and ICB are not providing her with section 117 aftercare support which she is entitled to after being detained under Section 3 of the Mental Health Act 1983. We will not investigate this complaint because we have seen evidence all the organisations have …
LGO (Local Government & …
Adult Care Services
Jul 2025
24-021-630 — Bath and North East Somerset Council
Summary: We will not investigate Ms X’s complaint about the Council’s involvement in her detention under the Mental Health Act. There is not enough evidence of fault to justify our involvement. Some of Ms X’s concerns are matters for other bodies to consider.
LGO (Local Government & …
Adult Care Services
Jun 2025
201104524 — Mental Welfare Commission for Scotland
Mrs C complained that the Mental Welfare Commission for Scotland (the Commission) failed to respond appropriately to a letter sent to them by her son. The letter contained her son's concerns about his detention and treatment under Mental Health legislation. In addition, Mrs C complained that the Commission failed to …
SPSO (Scottish Public Se…
Scottish Government and Devolved Administration
Partly Upheld
Jul 2012
23-011-009 — Cornwall Council
Summary: We investigated a complaint about the section 117 aftercare provided to Ms A by the Council, the Trust and the ICB after she was detained under section 3 of the Mental Health Act 1983. We found no fault by any of the organisations.
LGO (Local Government & …
Adult Care Services
Not Upheld
Jun 2024