Poor mental health step-down planning
Absence of detailed risk assessment and management plans during mental health care step-downs or medication weaning.
288 items
9 sources
Source spread
Where this theme appears
Poor mental health step-down planning has been flagged across 9 independent accountability sources:
64 PFD reports
6 committee recs
8 PPO recs
38 IMB reports
120 IMB recs
1 Article 2 learning point
2 detention investigation recs
28 PHSO decisions
21 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 (64) — showing 50 strongest matches
Peter Stanley
Concerns: A lack of formal 'step-down' policy exists for young people discharged from or failing to engage with Adult Mental Health Services. Additionally, there is insufficient encouragement for insurers to deny cover to establishments selling 'legal highs' linked to mental health issues.
Response (HM Prison and Probation Service): PECS has reviewed its contractors' operational policies to ensure staff understand and adhere to the requirement to share Prisoner Escort Records (PER) with relevant parties, including Youth Offending Services, and …
Overdue
John Andrews
Concerns: Inadequate discharge planning and communication for a vulnerable patient, leading to them returning home without necessary care arrangements, heating, or groceries.
Overdue
Janette Insley
Concerns: Inpatients lacked access to psychological treatment due to unavailable psychologists and resources, with an overemphasis on community services, leaving vulnerable patients without support post-discharge.
Response (Department of Health): The Department of Health acknowledges the concerns but states that the issues raised are most appropriately addressed at a local level, while also noting national investment in psychological therapies and …
Responded
Rebecca Overy
Concerns: An immediate transfer, mandated by law, was detrimental to a young adult's mental health. This highlighted a critical service gap for secure mental health care for 18-24 year olds with complex needs.
Overdue
Katherine Bonaventura
Concerns: The system for assessing detained patients returning from leave is flawed, lacking thorough family/carer consultation and adequate mental state assessment documentation.
Overdue
Michael McCrory
Concerns: The therapeutic observation policy was not consistently followed, with staff recording 'on ward' instead of precise patient whereabouts, and there was unclear training on minimising recurrence risks.
Overdue
Simon Tree
Concerns: The unit's new airlock system has security flaws, allowing patients to 'tailgate' visitors and leave, with inadequate monitoring by reception staff.
Response (Surrey Borders Partnership): The Trust has recruited a Security Manager, employs an out-of-hours receptionist, transferred administration support to the wards and improved camera coverage in the airlock. The Trust has also introduced cards …
Responded
Tanya Page
Concerns: Critical information about a patient's self-harm attempt was not shared between hospital wards due to staff reluctance driven by fear of perceived blame, hindering patient safety and learning.
Overdue
Robert Yarnell
Concerns: After the patient's discharge from a mental health unit, the Burnley and Pendle Complex Care and Treatment Team did not make sufficient attempts to contact him or his family, and care was not effectively transferred to the Trafford Crisis Resolution Home Treatment Team.
Overdue
Alice Mead
Concerns: Significant failings in mental health care involved the absence of a care coordinator, ignored patient requests for medication review, and an unacceptably delayed, "hands off" response to urgent concerns for a vulnerable patient.
Response (Sussex Partneraship NHS Trust): Sussex Partnership NHS Trust implemented an improved system for reviewing care coordinator caseloads, especially when a care coordinator leaves. Staff in East ATS and MHRRS have undergone Applied Suicide Intervention …
Responded
Laura McRory
Concerns: The Trust lacked a clear process for employees seeking mental health care, especially regarding confidentiality and external referrals. There was also an inadequate safety plan on discharge and deficiencies in the internal investigation.
Response (North East London NHS Foundation Trust): The Trust states it has carefully considered the report and is fully cognisant of the issues and committed to continuously review its service and has enclosed the Trust's action plan …
Responded
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
Christopher Jones
Concerns: Inadequate mental health care planning resulted in patients being without consultant review for extended periods post-discharge. Increased demand on services also created staff cover deficiencies.
Response: The Division produced a multi-agency document which became operational in August 2013 and has been reviewed regularly. MHM administrators send a report to managers of all CTPs due for review, …
Responded
Louise Turner
Concerns: Inadequate post-discharge mental health care, ineffective support systems, and inappropriate expectations for patients to initiate contact were identified. Devon also lacks female intensive psychiatric care beds.
Response (Northern Eastern and Western Devon Clinical Commissioning Group): The CCG outlines expected service responses from Devon Partnership NHS Trust related to safe service delivery and care planning. A proposal to build a local 10-bedded PICU facility at Wonford …
Responded
David Phillips
Concerns: An inappropriate healthcare professional conducted the mental health assessment for a vulnerable older person, and the assessing professional lacked critical access to the detainee's medical records.
Overdue
Victoria Halliday
Concerns: A lack of local female psychiatric intensive care beds, ineffective community psychiatric nursing, and inadequate community support for complex patients left individuals unsupported. Care Programme Approach and NICE guidelines were not followed.
Response (Leicestershire Partnership NHS Trust): Leicestershire Partnership NHS Trust is working with commissioners to procure a local, medium to long-term solution for female Psychiatric Intensive Care Unit (PICU) placements. They are also developing an integrated …
Response (East Leicestershire and Rutland Clinical Commissioning Group): East Leicestershire and Rutland CCG are in discussion with potential provider organisations and regional commissioning colleagues to provide a wider range of options for female PICU beds and are developing …
Response (Department of Health): The Department of Health acknowledges the concerns raised about the availability of psychiatric intensive care beds and the quality of care planning, noting that CCGs commission psychiatric intensive care beds …
Responded
David Knight
Concerns: National bed shortages led to out-of-county mental health placement, resulting in inadequate risk assessment for S17 leave, poor communication, and lack of family involvement.
Response (Department of Health): The Department of Health is working towards eliminating clinically unnecessary out of area placements for adult acute mental health care by 2020/21 and reducing significantly delayed transfers of care and …
Response (NHS England): NHS England's adult mental health programme is taking a whole system approach including developing access and quality standards for acute mental health care, reducing out of area placements and developing …
Responded
Debrata Sircar
Concerns: A significant delay in securing a mental health bed and conducting an MHA assessment, coupled with the absence of an interim care plan, compromised care for a patient at high risk of falls.
Response (Oxleas NHS Foundation Trust): Oxleas NHS Foundation Trust has changed its practice so that a referral for a MHA assessment triggers a review of zoning and risk management plan, and the client should be …
Overdue
Lester Stacey
Concerns: A patient with complex physical and mental health issues disengaged from community mental health services post-discharge following medication changes, contributing to low moods and his subsequent death.
Overdue
Terence Pimm
Concerns: Deficiencies in police call handling, record-keeping, and inter-agency information sharing hampered risk assessment for individuals with mental health issues. Insufficient training also affected police in identifying immediate risk and mental health assessors.
Response (Essex Partnership University NHS Trust): The Trust has directed all health-based place of safety calls through a new call centre where calls are recorded and documented. They have also reinforced to staff the importance of …
Response (Essex Police): Essex Police have instructed switchboard operators to refer public calls not concerning a person in custody to the Force Control Room, and advised custody suite staff on handling detainee-related calls. …
Responded
Sian Witheridge
Concerns: Mental health records were unavailable or unread, risk assessments were inadequate and unenforceable, and there was a misunderstanding of suicide risk coupled with disjointed care between services.
Response: The organisation plans to provide Highbury Grove Crisis House staff with access to their IT system in early 2018, following training and checks. It has also agreed to jointly investigate …
Overdue
Angela Byrne
Concerns: W-CDAS staff are not applying training, leading to inadequate risk assessment for vulnerable patients, and there are poor communications between inpatient and community services with inconsistent records.
Overdue
Michael Vukovic
Concerns: The patient was discharged from psychiatric admission without follow-up, as the Home Treatment Team never saw him and a referral to a drug and alcohol service was not followed up by the hospital.
Response (Michael Vukovic): Oxleas NHS Foundation Trust states that Mr. Vukovic was not referred to the Home Treatment Team and explains why. They note that Lifeline would not have been able to provide …
Responded
Martin Tilley
Concerns: A psychiatric patient with severe suicidal ideation and hallucinations was not followed up by the Homeless Healthcare Team after missing an appointment, and no emergency assessment referral was made.
Overdue
Miriam Roach
Concerns: There are concerns regarding the aftercare or transition arrangements for those discharged from hospital to home with a moderate to high risk of self-harm and/or suicide, and specifically the obligations for putting in place contact arrangements for such patients.
Overdue
Nigel Malloy
Concerns: There was a critical lack of information sharing and coordinated treatment planning between the Alcohol Liaison service and other support services for a patient with severe alcohol dependence and repeated admissions.
Response (Hampshire Hospitals NHS Trust): The Trust has a 24-hour referral service and pathway with Inclusion, leaflets about Inclusion Service, a weekly inreach service (now adhoc), regular telephone liaison, referrals to Mental Health Provider and …
Overdue
Agnes Lambert
Concerns: Senior staff failed to ensure a nurse's ward transfer despite patient fixation concerns, leading to an incident. The trust also caused distress by taking an unacceptably long four months for a disciplinary investigation.
Response (Camden and Islington NHS Trust): The Trust is rolling out 'vital conversations' training for managers and reviewing its disciplinary policy to include clearer criteria for investigations. A specially-trained staff member will review cases to challenge …
Responded
Daniel Collins
Concerns: A mental health service transferred a recently suicidal patient's care, requiring the patient to initiate contact with the new service, without proper handover or follow-up, risking loss of care during a crisis.
Overdue
Scott Carton
Concerns: Inadequate psychological support for prisoners with mental health and drug issues upon release, including unsuitable hostel placements without specialist input, compromises rehabilitation and increases re-offending risk.
Overdue
John Delahaye
Concerns: National risk assessment templates are unclear on medication, and unreliable electronic records impede identifying past medical conditions. Healthcare staff are also inconsistently present or informed of crucial ACCT reviews.
Response: NHS Digital began rolling out a new mandated coding system called SNOMED CT coding from April 2018 to replace all other coding systems; and SNOMED CT has been introduced as …
Overdue
Georgia Nelson
Concerns: There is a lack of suitable housing specifically for young patients with severe and enduring mental health issues.
Response (RBKC): RBKC and partner agencies are working together to identify ongoing needs and service developments arising from the closure of rehabilitation inpatient beds at Horton, including a potential local 'wrap around …
Response (CNWL NHS Trust): CNWL acknowledges the concerns raised and states that as discharge planning starts at admission, they will follow new NICE guidance on considering rehabilitation as appropriate. They offer a range of …
Responded
Michael Cox
Concerns: There is a critical shortage of suitable long-term placements for individuals with complex mental health histories, causing persistent difficulties for social workers in finding appropriate facilities.
Response (Cornwall Council): Cornwall Council is developing a multiagency strategy (2019-23) to improve support for people with complex needs, including mental health and substance use issues. A task and finish project will review …
Responded
Kim Morris
Concerns: A persistent lack of continuity in crisis mental health care, caused by under-resourcing and high demand, meant the patient repeatedly had to recount their story, causing distress and inadequate support prior to discharge.
Response (Leicestershire Partnership NHS Trust): The Trust acknowledges concerns about the Crisis team's service and states that it has received additional investment of £962k to enhance the service. An audit reviewing patients open to Crisis …
Responded
Sam Spooner
Concerns: A severe lack of multi-agency information sharing, communication, and co-operation led to fragmented care for a suicidal patient, with an over-reliance on the family and inadequate intervention by healthcare providers.
Response (British Association for Counselling and Psychotherapy): BACP acknowledges the challenges faced by private counsellors regarding information sharing and will pass the report to their Professional Standards Department to consider strengthening current guidance.
Response (Counsellor): The counsellor, via their legal representation, outlines the existing procedures for information sharing, including obtaining client consent, and emphasises the limitations faced by private practitioners.
Responded
Charlotte Grace
Concerns: The deceased was discharged without input from those to whose care she was being entrusted, and agencies/families were not routinely involved in the discharge process.
Response (Cumbria NHS Trust): Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust has implemented several actions: the policy for discharge planning has been updated; staff have been reminded of the importance of involving families; …
Responded
Samantha Savage-Greene
Concerns: A patient at high risk was repeatedly denied monitoring by the Home Based Treatment Team due to rigid protocol adherence, creating a significant gap in supervision for vulnerable individuals falling between service remits.
Overdue
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
Sean Owen
Concerns: Medication compliance was not monitored after discharge, care coordinator contact was insufficient, and there were significant delays in arranging a psychiatrist appointment despite the patient's deteriorating mental state.
Response (Pennine Care NHS Foundation Trust): The Clinical Director for the Borough has established a process that ensures that all new medical trainees receive a presentation regarding the standards expected and process of writing admission/discharge summaries …
Responded
Terence Tuttle
Concerns: Failures included inadequate dietician and mental health assessments, inaction on weight loss, poor mental capacity assessment, and insufficient care for mentally unwell patients refusing food, excluding family expertise.
Response (Hellesdon Hospital): NSFT expresses condolences and explains their limited involvement in Terrence Tuttle's care, stating they can only respond to one part of the coroner's concerns related to mental health liaison. They …
Overdue
Darrell Devlin
Concerns: Over-reliance on remote drug and alcohol service contacts without in-person assessments or drug testing led to inaccurate client assessment, risking harm from excessive dosage or polydrug exposure.
Response (Humankinds): Humankinds, the incoming provider of Addictions Services within Cumbria, describes actions already taken since taking over the service, including weekly provider meetings, clinical handover for high-risk cases, data transfer of …
Response (Greater Manchester Mental Health NHS Foundation Trust): Greater Manchester Mental Health (GMMH) acknowledges the concerns and apologizes, highlighting that the death occurred during the COVID-19 pandemic, and refers to a meeting with the new service provider, Humankind, …
Responded
Claire Copeland
Concerns: The prescription delivery system is unsafe, relying on physical documents without witnessed delivery or confirmation. It lacks effective mechanisms to detect or remedy failed deliveries, risking discontinuity of vital medical treatment.
Response (HumanKind): Humankind has implemented a standard operating procedure for prescription deliveries, including mandatory witnessed delivery and recording in the service user's notes. They have also established a contact procedure and contingency …
Response (Boots UK): Boots UK acknowledges the concerns raised and states the gravitas is duly noted.
Responded
Joshua Rennard
Concerns: Significant and systemic delays in actioning recommendations for Mental Health Act assessments place individuals with mental illness at risk of harm and death.
Overdue
Kieran Crimmins
Concerns: Crisis team actions were poorly monitored and falsely marked as complete, and significant procedures were communicated inappropriately. A lack of clear re-entry routes for vulnerable discharged patients revealed poor inter-service information sharing.
Overdue
Daniel Nelson
Concerns: The Trust lacked essential protocols, policies, or adequate standard operating procedures for governing Section 117 discharges, indicating a significant systemic gap in patient management.
Response (Greater Manchester Mental Health NHS Foundation Trust): The Trust has developed a Section 117 Aftercare Policy, updated training for staff on Section 117 responsibilities, and updated their clinical record system to automatically flag patients eligible for aftercare. …
Responded
Leroy Hamilton
Concerns: Critical shortages of inpatient mental health beds and PDU spaces leave acutely ill patients without specialist care. Police also failed to correctly classify and risk-assess mentally unwell individuals as high-risk missing persons.
Response (West Midlands Police): West Midlands Police have taken multiple steps including updating missing person investigation training, providing a toolkit for staff interactions with missing persons, upgrading the missing persons recording system, and developing …
Response (NHS Birmingham and Solihull ICB): Birmingham and Solihull ICB, with BSMHFT and UHBFT, are jointly reviewing pathways of care for acutely unwell people requiring mental health support, including the need for increased mental health beds …
Response (Department of Health and Social Care): The Department of Health is supporting the NHS to reduce waiting times in A&E by adding beds, speeding up discharge, and increasing transparency. West Midlands Police are setting up a …
Responded
Carol Robinson
Concerns: The patient was discharged from the Home Treatment Team without a medical review, comprehensive risk assessment, multi-disciplinary discussion, or communication with external agencies and family.
Response (North East London NHS Foundation Trust): The Trust has attached a detailed action plan to address concerns raised about a patient's discharge from the Home Treatment Team, including a lack of medical review, comprehensive risk assessment, …
Responded
Roger Stevenson
Concerns: A vulnerable adult with chronic mental ill health was "lost in the system" due to inadequate follow-up, delayed access to services, and lack of proactive support. Staffing shortages and poor family engagement further jeopardized care.
Response (Department of Health and Social Care): The Department of Health and Social Care outlines existing and planned initiatives to improve mental health support, including increased funding for community mental health services, expansion of NHS Talking Therapies, …
Overdue
Philip Malone
Concerns: A persistent and chronic lack of psychiatric bed capacity in Birmingham and Solihull continues to pose a significant risk, despite previous reports and insufficient remedial actions.
Response (Birmingham and Solihull Mental Health NHS Foundation Trust): The Trust acknowledges bed availability issues and highlights ongoing work with system partners and the ICB. Planned actions include continuing to work with system partners and developing a business case …
Response (NHS Birmingham and Solihull ICB): NHS Birmingham and Solihull ICB acknowledge BSMHFT's actions and state that they are working collaboratively to increase mental health inpatient bed capacity, with a business case for a new build …
Response (Department of Health and Social Care): The Department of Health and Social Care acknowledges concerns about psychiatric bed capacity in Birmingham and Solihull. They note BSMHFT's 12-month project to address bed shortages, the implementation of a …
Responded
Luke Whitelaw
Concerns: Missed opportunities for urgent psychiatric review and readmission occurred, alongside a lack of "professional curiosity," poor documentation, and inadequate risk assessment formulation in patient care.
Response (Oxleas NHS Foundation Trust): Oxleas NHS Foundation Trust updated its Acute Mental Health Patient Flow and Bed Management policy in December 2023, and introduced a single crisis assessment form on 22 January 2024. They …
Responded
Jessica Eastland-Seares
Concerns: Critically inadequate community provision and insufficient financial investment for autistic individuals force unnecessary inpatient admissions and A&E attendances due to a severe lack of suitable support placements.
Response (Department of Health and Social Care): The Department of Health and Social Care is prioritising updating the Autism Act statutory guidance to support the NHS and local authorities to deliver improved outcomes for autistic people. They …
Responded
Committee Recommendations (6)
#11 — Require Government to set out plans for reducing autistic detentions and improving community alternatives.
Recommendation: In response to this report, the Government should set out: • The reasons why the number of autistic people detained in mental health hospitals has increased; and how it plans to reduce that number, and by when. • The steps …
Response Pending
#10 — Accelerate progress in reducing detentions by increasing support for community-based alternatives.
Recommendation: The Government must make more progress in reducing the number of people with learning disabilities and/or autism detained in mental health settings. To achieve this the Government needs to learn from previous failings and increase support for community-based alternatives to …
Response Pending
#27 —
Recommendation: We therefore recommend that the Department accelerates the shift towards increased community-based provision and a reduced inpatient bed base as a national priority to ensure that children and young people with the most complex needs receive good quality care in …
Gov response: We accept this recommendation in part. All patients detained in hospital under the Mental Health Act are continually assessed and supported, and their need for detention is regularly reviewed. The Government does not see the …
Not Addressed
#26 —
Recommendation: Inpatient units have a role to play in treating some of the most severe and complex mental health conditions, especially those that are resistant to community treatment. However, in most cases the most compassionate and effective care for children and …
Gov response: We accept this recommendation in part. All patients detained in hospital under the Mental Health Act are continually assessed and supported, and their need for detention is regularly reviewed. The Government does not see the …
Not Addressed
#22 — Rural communities receive minimal NHS mental health support during and after crisis events.
Recommendation: Crisis events can have short- and long-term effects on people’s mental health, but civil society groups told us NHS support is minimal or short-term, despite greater support being likely to help people deal more successfully with trauma. Rural health providers …
Gov response: Defra contributed to the UK Health Security Agency’s published guidance on providing advice about the impacts of being flooded on people’s mental health: • Flooding health advice: mental health - GOV.UK (www.gov.uk), • Flooding and …
Accepted
#4 — Establish clear support for mentally unwell prisoners remitted to prison from secure hospitals
Recommendation: Additionally, there are a small number of mentally unwell prisoners who are subsequently transferred to a secure mental hospital. For these prisoners, the process for post-tariff release is more complex, and we are not clear what support is offered to …
Gov response: Reasoning: We would first like to clarify a misunderstanding in the report index, which includes a reference as a header ‘HMPPS Psychology Service’ with 3 subheadings: Offender Behaviour Programmes (OBP) and interventions; availability and access …
Partially Accepted
PPO Death in Custody Recommendations (8)
The Governor and Head of Healthcare
The Governor and Head of Healthcare should update the out of therapy policy, ensure staff are familiar with it and that it includes guidance on: • How to ensure that a prisoner’s risk to himself is explicitly and holistically considered …
Head of Yorkshire and Humber Probation Delivery Unit
Mr Bennett’s COM did not refer him to community substance misuse services prior to his release because Mr Bennett said he would self-refer if he needed support after release. We consider that given Mr Bennett’s history of drug and alcohol …
The Director and Head of Healthcare at Parc
The Director and Head of Healthcare at Parc should liaise with the Medical Director for G4S and arrange an urgent meeting with the Chief Executive of Abertawe Bro Morgannwg University Health Board to ensure that full service provision for patients …
The Head of Healthcare
The Head of Healthcare should ensure that mental health services meet the needs of prisoners by: implementing a referral system that results in a timely, face-to-face assessment using all relevant information for appropriate continuity of care and follow-up; ensuring that …
The HMPPS Executive Director for Wales
The HMPPS Executive Director for Wales should: satisfy himself that effective action has been taken to ensure the provision of a full service for prisoners with suspected dementia at Parc; satisfy himself that there are no barriers to the provision …
The Head of Healthcare
The Head of Healthcare should ensure that there are systems and processes in place to support ongoing clinical management of prisoners with challenging behaviour, which should include assessing mental capacity.
The Head of Healthcare
The Head of Healthcare should ensure that when senior staff indicate that a new prisoner should be located in the healthcare unit, the reception nurse is made aware and consults with senior staff if they propose to locate the prisoner …
The Head of Healthcare
The Head of Healthcare should ensure that staff refer newly arrived prisoners who are taking antipsychotic medication to the mental health team for assessment.
IMB Annual Reports (38)
Leicester (2021)
HMP Leicester is a well-run local male adult prison that maintained strong leadership and an engaged staff during a challenging year of COVID-19 restrictions. Despite prisoners being largely confined to cells for 23 hours daily, the prison saw significant reductions in violence, self-harm, and drug use, partly due to the restricted regime and enhanced security. The Board commended improvements in accommodation, healthcare, and resettlement support for homeless prisoners, though concerns remain regarding long waits for mental health transfers, IPP prisoner progress, and the impact of the ongoing restricted regime.
PRISON
Key concerns
Moorland (2021)
HMP and YOI Moorland adapted to the COVID-19 pandemic with a restricted regime, leading to reductions in violence and self-harm, and high reported safety levels. However, it also resulted in significant limitations on education, work, and association, impacting prisoner mental wellbeing and progression. Persistent national challenges, such as a shortage of secure psychiatric beds and inadequate food budgeting, continue to hinder effective prisoner care and resettlement despite local efforts.
PRISON
Key concerns
Low Newton (2021)
This IMB report for HMP/YOI Low Newton covers March 2020 – February 2021, a period significantly impacted by Covid-19. The Board found the prison generally safe and prisoners treated humanely, commending staff for adapting well to pandemic challenges. Key concerns remain regarding the high number of prisoners with severe mental health issues, the need for funding for educational initiatives, and ongoing estate issues impacting purposeful activity.
PRISON
Key concerns
Eastwood Park (2022)
HMP/YOI Eastwood Park faced a challenging reporting year (Nov 2021 – Oct 2022), marked by critical staffing shortages (17.5% below target), two deaths in custody, and exceptionally high self-harm levels, leading the IMB to no longer consider it safe for all women. The prison struggled with an increasing number of women with complex mental health needs, exacerbated by inadequate facilities and a lack of external secure placements, resulting in extended periods of segregation for some. Despite these issues, the Board commended staff professionalism, welcomed the new ONE women’s centre, and noted the prison’s high functional skills achievements.
PRISON
Key concerns
Lowdham Grange (2021)
HMP Lowdham Grange operated a restricted regime throughout the year due to COVID-19, which impacted various aspects of prison life and the Board's monitoring capabilities. Despite these challenges, the prison was generally well-managed, maintaining safety with reduced violence, effective healthcare provision, and positive staff-prisoner relationships, though staff morale declined. Key concerns remain around mental health transfers, property management, drug availability, and the progression of IPP prisoners, as well as the overall impact of lockdown on wellbeing.
PRISON
Key concerns
Nottingham (2021)
This IMB report for HMP Nottingham covers a period entirely dominated by the COVID-19 pandemic, leading to severely restricted regimes with prisoners spending extended periods in cell and limited access to activities. While staff are commended for their commitment and efforts to mitigate the impact, significant concerns remain regarding the humane treatment of prisoners, particularly the extended cell confinement. Key issues include inadequate mental health provision leading to long segregation stays, the situation of IPP prisoners, and the lack of arrangements for second vaccine doses upon release.
PRISON
Key concerns
Peterborough (Women) (2021)
The reporting year was dominated by the Covid-19 pandemic, during which HMP Peterborough (Women) managed the emergency well, leading to significant improvements in safety outcomes. However, the restrictive regime severely impacted women's wellbeing and rehabilitation. Key concerns remain regarding national support for complex needs women, the effectiveness of the key worker system, and the need to adapt the regime better to women's specific needs.
PRISON
Key concerns
Ranby (2021)
For the reporting period ending March 2021, HMP Ranby operated under severe Covid-19 restrictions, including a 22-hour lockdown. Despite this, the prison commendably controlled Covid-19 outbreaks and saw significant reductions in self-harm and violence. However, the Board highlighted recurring concerns regarding mental health provision, cell sharing, resettlement issues, and deficiencies in prisoner complaint handling and transfer processes.
PRISON
Key concerns
Manchester (2021)
HMP Manchester's reporting year (ending Feb 2021) was defined by the COVID-19 pandemic and its re-categorisation to a Category B training prison. While the reduced population saw a positive decrease in violence and self-harm, the pandemic severely impacted the regime, leading to curtailed purposeful activity and extended periods of cell confinement. The Board expressed significant concern over the mental health of prisoners awaiting secure hospital transfers, highlighting unacceptable waiting times.
PRISON
Key concerns
Hollesley Bay (2021)
HMP/YOI Hollesley Bay commendably managed 2021 amidst Covid-19, maintaining a safe environment and strong communications. The prison successfully implemented new strategies focused on rehabilitation, earned progression, and employability, which have been largely welcomed. Key areas for development include addressing the ageing estate infrastructure, improving food quality, implementing a key worker system, and resolving issues with property loss and missed healthcare appointments, while also boosting education participation.
PRISON
Key concerns
Long Lartin (2021)
HMP Long Lartin, a Category A/B dispersal prison, operated under a severely restricted Covid-19 regime throughout 2021, leading to reduced activities and frustrations. While the prison was orderly and staff generally humane, violence increased, and self-harm incidents were high, largely due to a few complex individuals. Significant concerns persist regarding the inhumane night sanitation system, inadequate estate maintenance by Amey, and persistent delays in mental health hospital transfers.
PRISON
Key concerns
Isis (2021)
HMP/YOI Isis, a training prison for young adults, faced significant challenges during 2021 due to the ongoing pandemic and its transition to a younger population. Self-harm and violence incidents rose considerably, though some safety measures like ACCT cases decreased. The Board expressed ongoing concerns about property issues, delays in mental health transfers, and the impact of reduced face-to-face education and purposeful activity on rehabilitation.
PRISON
Key concerns
Humber (2021)
HMP Humber navigated 2021 under significant Covid-19 restrictions, with commendations for management and staff for maintaining stability and low violence. However, the Board expresses grave concerns about the long-term mental health impact of extended lock-up, critical staffing shortages, and issues with healthcare access. Resettlement efforts were hampered by probation service changes, and property loss remained an unresolved, recurring problem.
PRISON
Key concerns
Liverpool (2021)
HMP Liverpool operated under severe Covid-19 restrictions in 2021, leading to prisoners spending only one hour a day out of cell, though the environment remained calm. While healthcare and education were maintained at appropriate levels, significant concerns persisted regarding the holding of mentally ill prisoners in unsuitable conditions and the lack of progress in engaging all prisoners in purposeful activity. The Board also highlighted issues with the use of body-worn cameras, prisoner property management, and the effectiveness of the new resettlement contractor.
PRISON
Key concerns
Downview (2022)
HMP/YOI Downview experienced another year significantly impacted by the Covid-19 pandemic, leading to a restricted regime and challenges across various departments. While the Board found the prison safe and prisoners treated fairly, it raised significant concerns regarding the management and provision of healthcare, staffing pressures, and the lack of digital access for education. These issues highlight the ongoing difficulties in maintaining optimal conditions and services for prisoners under pandemic and resource constraints.
PRISON
Key concerns
Feltham (2022)
HMP/YOI Feltham reported a population of 348 young people and young adults at the end of the reporting year. While physical health and general well-being are met, the prison struggles with serious long-term mental health issues. Safety remains a significant concern, with a notable increase in violence and use of force incidents post-Covid, alongside challenges related to staffing, disrepair of the estate, and the regime's adaptation to larger groups. The IMB identified several key concerns, including inadequate time out of cell, insufficient support for looked after children, and issues with prison fabric and gang culture.
PRISON
Key concerns
Foston Hall (2022)
HMP/YOI Foston Hall faced significant challenges in the reporting year, primarily due to acute staff shortages which severely impacted the regime, leading to frequent curtailments and long periods of cell confinement. Key concerns included high levels of self-harm and violence, inadequate accommodation, and slow progress in healthcare provision and resettlement outcomes. Despite these difficulties, the Board commended staff dedication and noted some improvements, such as the opening of better quality accommodation and enhanced chaplaincy services.
PRISON
Key concerns
Guys Marsh (2022)
HMP Guys Marsh saw a return to a more normal regime after Covid restrictions, but persistent challenges remained, notably in staffing, safety, and healthcare provision. Violence, often driven by illicit substances, and the lack of effective key working were significant concerns. While some areas like the ISMS team and chaplaincy were commended, mental health services were hampered by the absence of a psychiatrist, and a death in custody highlighted communication and ACCT deficiencies. The Board also raised concerns about low attendance at purposeful activity, the condition of the estate's infrastructure, and the slow complaints process.
PRISON
Key concerns
High Down (2022)
HMP High Down transitioned to a Category C training and resettlement prison in 2022, implementing gradual regime changes that have positively impacted prisoner life, including improved time out of cell and new community units. The Board noted reductions in self-harm and assaults, and commended improvements in induction and the visits hall. However, significant concerns remain regarding the welfare of IPP prisoners, long delays in transferring mentally unwell individuals, and a high proportion of prisoners leaving without settled accommodation. Persistent issues with lost property, inconsistent key work, and a lack of high-quality employment opportunities continue to hinder effective resettlement and overall humane treatment.
PRISON
Key concerns
Heathrow Immigration Removal Centre (2022)
The IMB annual report for Heathrow Immigration Removal Centre (HIRC) for 2022 highlights persistent issues despite generally safe conditions. Key concerns include the safety implications of processing South Coast Arrivals, the continued detention of individuals with severe mental health issues, and a dilapidated infrastructure leading to major service disruptions and a site evacuation. The report also raises concerns about the quality of food, the inappropriate use of the Care and Separation Unit, and a lack of effective engagement from the Detention Engagement Team.
IRC
Key concerns
Gatwick IRC/RSTHF (2022)
Gatwick IRC, comprising Brook House and Tinsley House, generally provided a safe environment in 2022 despite high rates of detainee distress and an increase in violence. The Board noted improvements in safeguarding governance, positive staff interactions, and expanded healthcare services. However, significant concerns remain regarding the detention of vulnerable individuals, ineffective Rule 35 processes, persistent issues with legal and accommodation support, and Home Office data provision.
IRC
Key concerns
The Verne (2023)
HMP The Verne maintains a generally safe and respectful environment, successfully implementing a new self-harm monitoring system and demonstrating strong staff-prisoner relationships. The Board commends the high-quality physical healthcare provision, including excellent vaccination rates, and welcomes the establishment of a new 16-room social care unit aimed at addressing the long-standing concern for elderly and frail prisoners. However, significant challenges persist, particularly in resettlement provision, severe understaffing in the Offender Management Unit leading to backlogs, and long waiting times for mental health services and external healthcare appointments due to staff shortages.
PRISON
Key concerns
New Hall (2024)
HMP/YOI New Hall, a closed category prison for women, held 365 residents against an operational capacity of 381. The Board noted positive developments in reception, staff-prisoner relationships, and the introduction of a drug recovery wing. However, significant concerns persist regarding the inadequate funding and suitability of the prison environment for women with complex mental health needs, leading to unacceptable delays in transfers to secure units. There was also a notable increase in healthcare-related applications to the IMB and issues impacting access to Release on Temporary Licence (ROTL).
PRISON
Key concerns
Lancaster Farms (2021)
HMP Lancaster Farms, a Category C resettlement prison, maintained a safe environment despite the COVID-19 pandemic, which significantly reduced violence and drug use through an emergency regime. However, this regime led to extensive confinement, severely impacting purposeful activity, education, and family contact, raising concerns about humane treatment and mental health. The Board highlighted persistent issues with self-harm, use of force, inadequate mental health staffing, property management, and accommodation, while also noting improvements in complaints handling and key worker interactions.
PRISON
Key concerns
Norwich (2021)
HMP/YOI Norwich, a multi-functional category B, C, D, and YOI prison, experienced significant operational challenges during the COVID-19 pandemic, leading to severely restricted regimes. Key concerns include persistent overcrowding with inadequate toilet privacy, a severe rat infestation, and the lack of rehabilitative programmes for IPP prisoners. Despite strong local leadership and staff teamwork, issues such as staffing shortages, poor healthcare access, and inadequate induction processes remain pressing concerns for the Board.
PRISON
Key concerns
North Sea Camp (2021)
The IMB report for HMP North Sea Camp for 2020-21 highlights an exceptionally difficult year marked by the Covid-19 pandemic and associated lockdowns. While the Board found the prison generally safe and humane with good healthcare, severe regime restrictions led to prisoner confinement and frustration. Key concerns include inadequate and aging accommodation, especially cramped double rooms, slow responses from the Offender Management Unit, and the lack of a dedicated end-of-life care facility.
PRISON
Key concerns
Preston (2021)
HMP/YOI Preston operated under severe Covid-19 restrictions throughout the reporting year, facing two outbreaks that significantly impacted regime, staffing, and services. Despite these challenges, there were no prisoner deaths, and staff maintained good relations with prisoners, with some positive developments in digital communication and body scanner integration. However, key concerns persist around the outdated physical estate, chronic staffing shortages, and lengthy delays for mental health transfers.
PRISON
Key concerns
Peterborough (Men) (2021)
HMP/YOI Peterborough (Men) operated under restricted Covid-19 regimes for the entire reporting year, impacting daily routines and rehabilitation. Despite this, the prison received credit for managing the pandemic well, leading to good safety outcomes, including significant reductions in violence and self-harm. Key concerns persist regarding resettlement accommodation, mental health provision in segregation, the future 'full regime,' and the full return of the key worker scheme.
PRISON
Key concerns
Kirkham (2021)
HMP Kirkham, a Category D open prison, faced significant challenges during the reporting period due to the COVID-19 pandemic, impacting regime consistency and leading to periods of lockdown and outbreak declarations. While the prison maintained fair and humane treatment and received commendations for its healthcare provision and resettlement efforts through the accelerator project, key concerns remain. These include the continued transfer of unsuitable prisoners, high drug use, infrastructure deficiencies, and issues with senior management cohesion and dedicated staffing for diversity and resettlement.
PRISON
Key concerns
Northumberland (2021)
HMP Northumberland, a Category C prison, successfully managed the Covid-19 pandemic during 2021, maintaining a safe and humane environment with commendable staff dedication. While the regime was restricted, efforts were made to provide in-cell activities and gradually reopen purposeful activity. Key concerns remain around the lasting impact on prisoner mental health, insufficient opportunities for rehabilitation, and the unacceptable issue of prisoners being released into homelessness.
PRISON
Key concerns
Haverigg (2022)
HMP Haverigg, an open Category D prison, maintains a safe and settled environment with very low levels of self-harm and violence. Despite significant staffing challenges, particularly in healthcare and offender management, the Board notes improvements in OMU staffing and highly regarded healthcare provision. Key concerns include the ineffective management of transfers from closed estates, inconsistencies across prisons, the need for enhanced IPP prisoner support, and persistent issues with prisoner property and communication from offender managers.
PRISON
Key concerns
Grendon (2022)
HMP Grendon, a Category B therapeutic prison, saw improvements in its regime post-Covid restrictions, with low levels of self-harm, assaults, and no deaths in custody. Staff-prisoner relationships remained excellent, and initiatives in diversity and family contact were strong. However, the prison faced ongoing challenges from a protracted fire safety project, persistent issues with night sanitation, and a noticeable erosion of its therapeutic culture post-pandemic. Significant concerns remain regarding staffing shortages in key areas, delays in transferring men out of therapy, and inadequate governance of healthcare data, all contributing to a difficult operational environment despite the positive progress in other areas.
PRISON
Key concerns
Garth (2022)
HMP Garth, a Category B training prison, grapples with severe staff recruitment and retention issues, resulting in a largely inexperienced workforce and an ineffective key worker scheme. The restrictive regime, a consequence of staffing problems and post-pandemic recovery, limits prisoners' time out of cell and access to purposeful activity. Key concerns include the deteriorating estate, inadequate provisions for disabled individuals, and the persistent challenges faced by IPP prisoners, alongside ongoing issues with property transfers and an understaffed Offender Management Unit.
PRISON
Key concerns
Isle of Wight (2022)
HMP Isle of Wight experienced a challenging 2022, marked by a population increase and the gradual easing of Covid restrictions, which allowed for a return to some normal regime activities. However, chronic staff shortages significantly hampered access to work, education, and healthcare, leading to prisoners spending considerable time locked up. The Board raised serious concerns regarding the inadequacy of mental health provision, the impact of staff shortages on all aspects of prison life, and the need for clarity and funding for the estate and the management of the Category C prisoner population.
PRISON
Key concerns
Doncaster (2024)
The Independent Monitoring Board at HMP Doncaster reports a generally fair and humane treatment of prisoners, with good staff-prisoner relationships and improved education attendance. However, the prison faces significant challenges, primarily due to severe overcrowding and population pressures, leading to inhumane double occupancy of cells and restricted regimes. Key concerns include extended waits for mental health transfers, a problematic reception and induction process, and insufficient community support for released prisoners.
PRISON
Key concerns
Lincoln (2021)
HMP/YOI Lincoln is deemed a well-run Category B local prison, effectively managed by the Governor's team, which maintained a humane regime and kept prisoners safe despite severe COVID-19 restrictions. The reporting year saw significant reductions in self-harm and violence, coupled with improvements in the physical environment and infectious disease management. Key concerns include slow maintenance, high prisoner homelessness on release, long waits for mental health transfers, and the ongoing issue of IPP prisoners held beyond tariff.
PRISON
Key concerns
Kirklevington Grange (2021)
HMP/YOI Kirklevington Grange is a Category D open prison operating in a year significantly impacted by Covid-19 restrictions. The report highlights the prison's successful management of the pandemic, leading to a safe environment, high ROTL success, and good healthcare provision. Key concerns include reduced operational capacity, delays in new accommodation, issues with property transfers, and difficulties with prisoners obtaining debit cards, alongside an altered perception of the open regime due to restrictions.
PRISON
Key concerns
Dovegate (2022)
HMP Dovegate, a Category B training prison, operated in a calm and settled manner despite ongoing Covid challenges and staff shortages. The Board commended improvements in staff culture, the effective use of body-worn cameras, and the high standards of cleanliness and food provision. However, significant concerns persist regarding the lack of a national electronic system for property transfers, the slow progress on converting the healthcare inpatient unit, and the increasing number of remand prisoners. The Board has made recommendations to the Minister, Prison Service, and Director to address these issues, many of which have been highlighted in previous reports.
PRISON
Key concerns
IMB Recommendations (120) — showing 50 strongest matches
Preston (2024)
The policy whereby the NHS Reconnect service rejects some prisoners as not being suitable for their support on release is a gap in provision, which potentially results in early reoffending. What steps will the Minister take to rectify this issue?
NHS / Healthcare Provider
Dartmoor (2020)
Will the Minister ask the Prison Service to work with other Government Departments to put in place processes to ensure that prisoners with severe mental health issues do not spend extensive periods in the CSU and are transferred rapidly to facilities better able to care for them?
Ministry of Justice
Foston Hall (2021)
Are there plans to address: the inadequate provision for mental health throughout the criminal justice system, which is a serious concern? This is manifested in Foston Hall in a high level of unmet need for mental health treatment and delays in transferring prisoners to secure hospitals
Ministry of Justice
Wakefield (2023)
We ask the Minister to explain how the Government intends to address longstanding and yet unresolved problems with the assessment and transfer of prisoners who present with serious mental health and personality disorders from HMP Wakefield to hospital (section 47, Mental Health Act 1983).
Other
Swansea (2023)
The Board is particularly concerned about the number of prisoners who have significant mental health issues and who are often on short-term sentences. Short-term sentences mitigate against constructive interventions on their behalf and, in any event, the prison is not equipped to deal with the complexity of problems these prisoners have. When will the Minister introduce measures that enable prisoners …
Ministry of Justice
Leeds (2023)
There are an increasing number of prisoners who are subject to gatekeeping and for whom the prison is not equipped to provide sufficient care. Referrals for specialist, secure accommodation result in lengthy gatekeeping processes, which can mean that prisoners are held for many months before they move on to more appropriate accommodation. How will the Prison Service ensure the process …
HMPPS
Guys Marsh (2023)
A total of 16 of the 22 prisoners serving IPP sentences at HMP Guys Marsh have been recalled to prison because of licence breaches. Does the Minister have concerns that there may be insufficient support for these prisoners in the community, given the human and financial costs of such recalls?
Ministry of Justice
Liverpool (2024)
The Prison Service is aware of the inhumane length of time some prisoners have been in the CSU at HMP Liverpool whilst waiting for transfer to an appropriate mental health establishment. In the absence of any change will the Prison Service seek to bring additional resources to the site?
HMPPS
Lindholme (2024)
The Board, once again, requests that more emphasis and engagement is given to implementing the HMPPS strategy to prepare these prisoners for release.
HMPPS
Berwyn (2024)
How does the Minister plan to tackle the very serious issue of long waiting times for men with severe mental health issues or personality disorders to be transferred to a secure unit, given that transfers can take many months to accomplish?
Ministry of Justice
Norwich (2025)
The Board is concerned about the lack of process reintegrating prisoners who self-isolate back into the normal prison regime. What action will the Governor take to rectify the situation?
Governor / Director
New Hall (2025)
The continued development of appropriate support for vulnerable prisoners on release.
Governor / Director
Berwyn (2025)
The Board continues to be concerned about men with diagnosed, or obviously diagnosable, mental health issues not being transferred to a secure mental health facility within the timescale specified in the protocol. This is evidenced by 26 men transferred from HMP Berwyn in 2022-2023 and 36 in 2023-2024, but only 18 in 2024-2025. It is further exacerbated by prisoners waiting …
Ministry of Justice
Wetherby (2020)
For the fifth consecutive year, the Board asks in its annual report what, if anything, is being done to increase the number of secure mental health hospital beds available to meet the needs of the complex YP who are in urgent need of such support, and for whom prison is clearly not the correct place? What is being done to …
Ministry of Justice
Thameside (2020)
The wait for a secure outside hospital bed for severely mentally ill prisoners held in HMP Thameside continues to be a serious inhumanity which requires greater government priority.
Ministry of Justice
Isis (2020)
We urge the minister to require HMPPS, working with NHS England, to develop concrete action plans to address the continued detention of prisoners with enduring or chronic mental health problems and those with personality disorders, as a prison environment that will not deliver the positive changes needed.
Ministry of Justice
Bristol (2020)
Improved prison-led support is required for those with anxiety, stress, depression, autism and/or personality disorder in order to supplement the input from the mental health and healthcare teams, and hence better mirror the opportunities available in the community.
HMPPS
Bristol (2020)
For those with more complex needs, the minister should encourage and support much faster transfer times to specialist mental health units, given the disruption and drain on prison resources of housing these prisoners in a local prison.
Ministry of Justice
Lowdham Grange (2021)
Continue to work with colleagues in other government departments to ensure that appropriate facilities are available for those prisoners with mental health issues, in order to prevent the need for prisons to hold such prisoners in segregation for extended periods.
Ministry of Justice
Lincoln (2021)
Despite best local efforts, the board is concerned that prisoners who are in need of transfer to a mental health institution sometimes wait far too long for an appropriate placement (see paragraph 6.2.3.3). The absence of a comprehensive and readily accessible personality disorder treatment service is a continuing concern.
Ministry of Justice
Leicester (2021)
Does the minister agree that assisting them to make progress to safe discharge should have a higher priority?
Ministry of Justice
Hollesley Bay (2021)
That effective support for mental health issues is developed within prisons and after leaving should they still be required.
Ministry of Justice
Hindley (2021)
As raised last year, Covid-19 and the introduction of new contracts have had a negative impact on the information advice and guidance available to men prior to and on release. Resolving this now needs to be a priority to ensure prisoners receive comprehensive support at this time of potential vulnerability.
Governor / Director
Berwyn (2021)
The Board notes that the prison experienced significant delays in being able to transfer men to more appropriate establishments and settings, especially those relating to mental ill-health. The Board considers that this lack of secure mental health facilities needs to be addressed as a matter of urgency.
Ministry of Justice
Wormwood Scrubs (2022)
We urge the Minister to heed the CPT’s request for rapid transfer of people with serious mental illness to appropriate mental health settings, and to put in place sufficient funds to enable this to happen.
Ministry of Justice
Send (2022)
Provision should be made in appropriate secure specialist mental health facilities for the small number of very challenging women with highly complex mental health needs. These are often a result of traumatic lives and manifest as prolific self-harm. Prison is a totally inadequate ‘revolving door’ for these prisoners (4.2).
Ministry of Justice
Peterborough (Women) (2022)
The Board would expect to see the full range of resettlement support provided following the handover from community rehabilitation companies (CRCs) to the National Probation Service (NPS), especially as NPS will be restricting their activities further.
HMPPS
Northumberland (2022)
The Board remains concerned about the availability of mental health support for prisoners and the delay in identifying appropriate placements for prisoners with serious mental health conditions.
HMPPS
Lowdham Grange (2022)
To provide a framework in the post-Covid structured regime that supports and funds innovative programmes of rehabilitation, mental health provision, education, skills development and self-improvement for prisoners instead of requiring them to be locked in their cells for long periods.
HMPPS
Lincoln (2022)
With regard to prisoners with mental health issues, the Board continues to be concerned about the absence of a comprehensive and readily accessible personality disorder treatment service (see paragraph 6.3.1).
NHS / Healthcare Provider
Wormwood Scrubs (2023)
The Minister should outline plans in coordination with the Department of Health and Social Care to ensure adequate provision for prisoners with acute mental health needs.
Ministry of Justice
Rye Hill (2023)
The Board is aware of the Justice Select Committee’s IPP review and announcements at the end of the reporting period and also the new initiatives Rye Hill is putting in place to support this cohort. However, we are still concerned that they will make little material difference to those with complex needs without dedicated budget provision. The issue of IPP …
Ministry of Justice
Liverpool (2023)
The Prison Service is aware of the inhumane length of time some prisoners have been in the CSU at HMP Liverpool whilst waiting for transfer to an appropriate mental health establishment. What will the Prison Service do to ensure that prisoners at HMP Liverpool are not waiting for inhumane periods of time for such transfers?
HMPPS
Heathrow immigration removal centre (2023)
The numbers of people experiencing mental health issues are increasing at Heathrow IRC. It is important that external mental health beds in the community are made available to detained people who present with a severe mental condition, that cannot be managed within Heathrow IRC.
NHS / Healthcare Provider
Heathrow immigration removal centre (2023)
People with severe mental health problems should not be detained in the CSU for extended periods of time. Detained individuals with severe mental health issues should be treated in a mental health setting external to the Heathrow Detention Centre. The Home Office should reduce the use of CSU for those who do not wish to share a room with another …
Home Office
Heathrow immigration removal centre (2023)
The Board is very concerned about the deterioration in the mental health of many detained people and too many detained people are resorting to self-harm. It is imperative that appropriate support, care, and mental health services are promptly provided to individuals grappling with mental health vulnerabilities.
Home Office
Heathrow immigration removal centre (2023)
More work is required to consider different ways of dealing with those who have mental health problems. There should be an increase in external mental health beds for people in detention who display increased or increasing levels of mental health problems. A clear mental health pathway should be made available to those with mental health difficulties, the detention centre is …
Ministry of Justice
Heathrow immigration removal centre (2023)
The Board consider Rules 40 and 42 are being misused. There were several instances in 2023 where Rule 40 and 42 have been used for prolonged situations. It is imperative that Rules 40 and 42 are used for the shortest possible time and as a means of last resort. It should not be used to hold mentally ill detained people …
Ministry of Justice
Heathrow immigration removal centre (2023)
The Home Office has a duty of care for those with mental health problems and to ensure that they are safe in the community they are released into. Robust support is required for detained people with mental health people who are released on bail.
Ministry of Justice
Garth (2023)
The population of the Segregation Unit continues to highlight the high number of prisoners with serious mental health needs. What steps are being made to improve mental health support and treatments, including timely move-on to more appropriate prisons and secure mental health hospitals?
Governor / Director
Downview (2023)
There seems to be some limitations in communication between HMP Bronzefield and the prison (for example, with regards to transferred prisoners with significant mental health conditions and with missing property and medication issues). Is this because HMP Bronzefield is a private prison, and systems and processes may not be compatible?
HMPPS
Styal (2024)
Will the Minister speak to colleagues in the Department for Health and Social Care to improve prisoners’ timely access to specialist mental health facilities in the community, where required?
Other
Lincoln (2024)
Will the Minister review prisoners serving indefinite sentences under IPP (imprisonment for public protection) sentences?
Ministry of Justice
Leyhill (2024)
What further action will be taken to speed up the release and resettlement in the community of the prisoners serving IPP sentences, many of whom have spent far longer in custody than recommended in their indicative tariffs?
HMPPS
Forest Bank (2024)
What progress has been made to ensure prisoners in need of secure mental health facilities are transferred in a reasonable timeframe?
Other
Berwyn (2024)
Does the Prison Service agree with the Board’s recommendation that extra, targeted training would be appropriate for staff in segregation on how to deal with severe mental health problems, and if so, what steps will it take to make this happen?
HMPPS
Aylesbury (2024)
Create a wider range of secure custody settings to meet the needs of: neurodiverse prisoners, those with severe mental illness, some of whom may be suffering from age-related dementia, and those with marked intellectual disability. Prisoners with extreme needs divert disproportionate amounts of staff time and effort from the majority of prisoners. At best, this approach simply manages a bad …
HMPPS
The Mount (2025)
The Minister should ensure the Probation Service in the community is structured and resourced to be able to provide the specialist help and support that IPP prisoners will need as they return to life after a long period in prison.
Ministry of Justice
Styal (2025)
Too many vulnerable and very mentally unwell prisoners have been sent to prison due to a lack of suitable services in the community. What progress has been made to increase the number of secure mental health placements in the region and improve timely access?
Ministry of Justice
Hewell (2025)
What is being done to ensure that the 28-day limit for transfer of prisoners to a mental health hospital is enforceable?
Ministry of Justice
Detention Investigations (2)
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R29
Serco should open discussions with G4S, NHS England and local mental health care providers to consider how best to meet the needs of detainees with severe mental health issues, and ensure that they are assessed and receive care and treatment in a timely and appropriate fashion.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 39
as a minimum, every centre should engage the services of an in-reach psychiatric nurse and that the service be actively promoted on induction and afterwards.
Immigration Detention
PHSO Casework Decisions (28)
P-001986 — Livewell Southwest
Mr N complains a doctor was not interested during an appointment and did not know anything about his circumstances. He also complains Livewell Southwest refused to give him a new psychiatrist and discharged him from mental health services in September 2022.
NHS in England
May 2023
P-002645 — North Staffordshire Combined Healthcare NHS Trust
Ms H complains the Trust discharged her from its mental health support service without looking into the root causes of her problems and without arranging a care plan for her. She also complains the Trust broke data protection by losing a statement she had written that included sensitive information about …
NHS in England
May 2024
P-003034 — Essex Partnership University NHS Foundation Trust
Miss R complains that the Trust should not have removed her from the care coordination service in November 2021. She also complains that despite planning to see her in June 2022, after a psychiatry outpatient appointment in February, the Trust did not invite her for a review until December.
NHS in England
Oct 2024
P-003265 — Mersey Care NHS Foundation Trust
Mr A complains that the Trust inappropriately discharged him from its CMHT in December 2022. He says the Trust labelled him a ‘troublemaker’ and decided to discharge him prior to his assessment.
NHS in England
Jan 2025
P-003678 — Tees, Esk and Wear Valleys NHS Foundation Trust
Miss U complains that her daughter Miss R’s death was preventable and resulted from inadequate risk management, unsafe transition, poor communication, and repeated service failures between 10–12 January 2024.
NHS in England
Jul 2025
P-004570 — Sussex Partnership NHS Foundation Trust
Miss O complains Sussex Partnership NHS Foundation Trust (the Trust) did not provide her with support or treatment since March 2024 and incorrectly discharged her from the service in October 2024. She also complains the Trust’s communication was poor.
NHS in England
Jan 2026
P-001626 — Lancashire and South Cumbria NHS Foundation Trust
Mr U complains the Trust discharged Mr E from its mental health service although he still needed 24-hour care and support. He complains the Trust did not take Mr E's vulnerability into account and did not communicate its decision with them.
NHS in England
Nov 2022
P-001819 — Cheshire and Wirral Partnership NHS Foundation Trust
Mr O complains the Trust prescribed him anti-psychotic drugs without checking their suitability and did not monitor their effect. He says the Trust misdiagnosed him and discharged him without the follow-up counselling he needed.
NHS in England
Feb 2023
P-001907 — Mersey Care NHS Foundation Trust
Mrs E complains the Trust changed its mind about helping her get specialised funding to treat her son's obsessive compulsive disorder (OCD). She says the Trust discharged her son without putting a treatment plan in place.
NHS in England
Mar 2023
P-002332 — Nottinghamshire Healthcare NHS Foundation Trust
Mr A complains the Trust failed to put a plan in place for his brother when it was clear his parents could not care for him, failed to make sure his brother was taking his medication correctly and made no effort to contact his brother shortly before his death.
NHS in England
Sep 2023
P-002505 — Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Ms E complains that when the Trust's Crisis Team visited her they did not listen to her concerns. She complains that staff did not give her options for engagement with mental health services or offer access to community support groups or further health support.
NHS in England
Mar 2024
P-002745 — Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Mrs I complains on behalf of her daughter after she was referred to the Trust’s Children and Young People’s Services for mental health purposes in November 2020. Mrs I says no action was taken until an initial assessment in July 2021. She also complains the support promised was not given, …
NHS in England
Upheld
May 2024
P-002857 — Herefordshire and Worcestershire Health and Care NHS Trust
Mr A complains about the Adult Mental Health Team at the Trust. He specifically complains he was misdiagnosed with a mixed personality disorder in February 2019 when he had bipolar affective disorder. He also says he was not provided with psychological help for anxiety and other mental health issues including …
NHS in England
Partly Upheld
Aug 2024
P-003236 — A practice in the City of Southampton area
Mr R complains the Surgery withdrew mental health support for him in February 2023 and failed to communicate this decision with him or provide alternative support.
NHS in England
Dec 2024
P-003463 — A practice in the Bristol area
Mr G complains Practice mental health specialists failed to contact or support him.
NHS in England
Mar 2025
P-004047 — An independent provider in the West Berkshire area
Ms X complains about her care and treatment whilst in custody between April to May 2024. She says that PPG failed to manage her eating disorder causing her to relapse and require hospitalisation.
NHS in England
Sep 2025
P-004418 — Hampshire and Isle of Wight Healthcare NHS Foundation …
Miss A complains about the standard of care her daughter; Miss B, received from the Trust's mental health team from February to May 2023.
NHS in England
Upheld
Dec 2025
P-001933 — South Tyneside and Sunderland NHS Foundation Trust
Miss D complains the Trust delayed giving her father medication and its nursing care was poor. She also says there was not enough mental health support.
NHS in England
Apr 2023
P-003835 — Sussex Partnership NHS Foundation Trust
Mrs B complains about the care the Trust's Child and Adolescent Mental Health Service (CAMHS) gave to her daughter. She complains it did not offer one-to-one support, it did not monitor her physical health and it did not arrange medication for her.
NHS in England
Jul 2023
P-002304 — Coventry and Warwickshire Partnership NHS Trust
Ms M complains about aspects of the care and treatment Coventry and Warwickshire Partnership NHS Trust provided to her between May 2018 and May 2021.
NHS in England
Nov 2023
P-002418 — Mersey Care NHS Foundation Trust
Ms E complains about the Trust's service saying there was no consistency with which psychiatrist or psychologist she saw, her medication kept on changing, appointments were cancelled, helpful referrals were not made and there was a lack of support and grief counselling.
NHS in England
Jan 2024
P-002499 — Avon and Wiltshire Mental Health Partnership NHS Trust
Ms E complains that when the Trust's Crisis Team visited her they did not listen to her concerns. She complains that staff did not give her options for engagement with mental health services or offer access to community support groups or further health support.
NHS in England
Mar 2024
P-002557 — Lancashire and South Cumbria NHS Foundation Trust
Mrs E complains that between December 2021 and May 2022 the Trust did not give her mother enough medication or therapy, it prematurely discharged her without a suitable care plan in place and it did not communicate well with her family.
NHS in England
Apr 2024
P-003355 — Birmingham and Solihull Mental Health NHS Foundation Trust
Mr R complains Birmingham and Solihull Mental Health NHS Foundation Trust incorrectly rejected his referrals to its community mental health team between August 2023 and February 2024.
NHS in England
Feb 2025
P-003363 — East London NHS Foundation Trust
Mr O complains about aspects of the care provided to his brother by the Trust’s Community Mental Health Team between December 2021 and May 2022.
NHS in England
Upheld
Feb 2025
P-003600 — Rotherham, Doncaster and South Humber NHS Foundation Trust
Mr A complains the Trust has wrongly discharged him from its services following an appointment on 16 October 2023 and it will not provide him with any care or treatment for his psychological health.
NHS in England
Jun 2025
P-003582 — Midlands Partnership University NHS Foundation Trust
Miss D complains about the care and treatment the Trust provided to her daughter between January 2023 and December 2023, regarding diagnosis and support for her mental health.
NHS in England
Jun 2025
P-003803 — University Hospitals Coventry and Warwickshire NHS Trust
Mrs T complains about several different aspects of the care and treatment clinicians at a hospital gave to her husband in April 2021. She is particularly concerned about the management of her husband's PTSD.
NHS in England
Aug 2025
LGO / SPSO Decisions (21)
21-013-816b — Bromley Healthcare CIC Ltd (21 013 816b)
Summary: Mrs D complained about the way the Council, the Trust and Bromley Healthcare dealt with her late brother Mr S’s discharge from hospital, wheelchair provision and social care. We have not upheld the complaints about the Council and Bromley Healthcare. Most complaints about the Trust are also not upheld. …
LGO (Local Government & …
Health
Not Upheld
Oct 2022
21-013-816a — Kings College Hospital NHS Foundation Trust (21 013 …
Summary: Mrs D complained about the way the Council, the Trust and Bromley Healthcare dealt with her late brother Mr S’s discharge from hospital, wheelchair provision and social care. We have not upheld the complaints about the Council and Bromley Healthcare. Most complaints about the Trust are also not upheld. …
LGO (Local Government & …
Health
Upheld
Oct 2022
NIPSO-202001941 — Southern Health and Social Care Trust
A complainant raised concerns about how the Southern Trust cared for her vulnerable sister. Our investigation found a number of failings by the Trust.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Jun 2024
NIPSO-202400242 — Belfast Health and Social Care Trust
The Belfast Trust did not provide appropriate reassurance to an elderly patient when she suffered pain and discomfort after her coronary angiogram.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Aug 2025
PSOW-202208324 — Cardiff and Vale University Health Board
Miss X complained about the alleged change to her son’s placement who is currently a patient at an assessment and treatment unit for learning disabilities under section 3. Miss X alleges that the change in placement may not meet his care and treatment needs. The Ombudsman decided that due to …
PSOW (Public Services Om…
Health
Apr 2023
24-003-061b — NHS South West London ICB (24 003 061b)
Summary: Ms M complains about the way her son’s care was managed by the Trust after he left hospital in June 2021. We will not investigate this complaint because the organisation has already admitted fault in several areas of Mr N’s care. It has investigated several times, provided five written …
LGO (Local Government & …
Health
Sep 2024
24-003-061a — South London and Maudsley NHS Foundation Trust (24 …
Summary: Ms M complains about the way her son’s care was managed by the Trust after he left hospital in June 2021. We will not investigate this complaint because the organisation has already admitted fault in several areas of Mr N’s care. It has investigated several times, provided five written …
LGO (Local Government & …
Health
Sep 2024
202106214 — Glasgow City Health and Social Care Partnership
C, an adult with autism, was receiving treatment from the Partnership as a new patient after moving into the area and was unhappy with their psychiatrist. C felt that the Partnership did not have appropriate staff who specialised in treating adults with autism. C complained that the psychiatrist questioned the …
SPSO (Scottish Public Se…
Health and Social Care
Upheld
Sep 2023
NIPSO-202004428 — Belfast Health and Social Care Trust
Our investigation found that a complainant was offered good support by the Belfast Trust during her treatment for Anorexia Nervosa.
NIPSO (NI Public Service…
Health & Social Care
Not Upheld
Sep 2024
PSOW-202108330 — Cwm Taf Morgannwg University Health Board
Ms X complained that in 2020 and 2021, there was a failure to diagnose her son’s mental health disorder which resulted in extreme mental distress. As a result, Ms X said she was required to engage a private therapist at her own cost. The Ombudsman did not consider there was …
PSOW (Public Services Om…
Health
Jul 2022
PSOW-202106332 — Cwm Taf Morgannwg University Health Board
Mr D complained that Cwm Taf Morgannwg University Health Board (“the First Health Board”) failed to provide care and support to his late daughter, Miss E, when her mental health deteriorated during 2020. Mr D said the First Health Board failed to transfer her section 117 aftercare (free help and …
PSOW (Public Services Om…
Health
Upheld
Jan 2023
22-010-012a — Leeds & York Partnership NHS Foundation Trust (22 …
Summary: The Ombudsmen will not investigate this complaint about a decision to detain someone under the Mental Health Act. We are unlikely to find fault in the actions of the Trust’s mental health team before the assessment. Investigation into the actions of the Approved Mental Health Professional is unlikely to …
LGO (Local Government & …
Health
Dec 2022
24-001-919a — Devon Partnership NHS Trust (24 001 919a)
Summary: Mr X complains about the way Devon County Council and Devon Partnership NHS Trust acted in relation to a hospital detention. We will not investigate this complaint. This is because an investigation is unlikely to find fault in the organisations’ actions.
LGO (Local Government & …
Health
Jul 2024
PSOW-202000537 — Hywel Dda University Health Board
Ms D complained that the Hywel Dda University Health Board (“the Health Board”) failed to provide her partner, Mr B, with appropriate care and treatment. In particular, Ms D complained that the Health Board failed to provide Mr B with appropriate mental health support and treatment and that Mr B …
PSOW (Public Services Om…
Health
Upheld
May 2021
24-002-680 — London Borough of Harrow
Summary: Mr C complained about how the Council carried out recommendations set out in an action plan regarding its Community Mental Health Services and how it communicated with him. We found some fault by the Council as it caused delay in implementing it plan and how it communicated with Mr …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2024
PSOW-202206899 — Aneurin Bevan University Health Board
Mrs A complained about the care that her late father, Mr B, received following his admission to hospital. She complained that the decision to insert a catheter (a tube inserted into the bladder to allow urine to drain freely) and discharge him with it in place was not clinically appropriate. …
PSOW (Public Services Om…
Health
Not Upheld
Feb 2024
PSOW-202304146 — Cwm Taf Morgannwg University Health Board
Ms C complained about the care and treatment provided to Mr B by the Health Board’s mental health services between 6 July and 7November 2022. Specifically, the investigation considered whether the care and treatment provided to Mr B in the community between 6 July and 22 September 2022 was clinically …
PSOW (Public Services Om…
Health
Upheld
Sep 2024
21-010-564a — Cumbria, Northumberland, Tyne & Wear NHS Foundation Trust …
Summary: The Ombudsman cannot consider a complaint about a Council’s actions in relation to safeguarding procedures and accommodation support because it is late.
LGO (Local Government & …
Health
Jan 2022
21-015-137 — Sheffield City Council
Summary: A tenant complained about the Council’s failure to rehouse him and its lack of support in the five years he has been on its housing register, despite his serious mental health issues. But we do not have grounds to investigate the complaint because there is not enough evidence that …
LGO (Local Government & …
Housing
Jun 2022
22-008-112b — Lancashire and South Cumbria NHS Foundation Trust (22 …
Summary: We will not investigate Mr A’s complaint about his care and treatment by a Council and two NHS Trusts.
LGO (Local Government & …
Health
Oct 2022
23-014-444a — Dorset Healthcare University NHS Foundation Trust (23 014 …
Summary: We found no fault by a Council and Trust in terms of their decision to change Miss Y’s support arrangements. However, we did find fault with how they communicated those changes to Miss Y and her mother, Mrs X. The Council and Trust will apologise for this and make …
LGO (Local Government & …
Health
Upheld
Aug 2024