Safe discharge or transfer of patients from adult and older persons mental health service inpatient wards procedure

1 Aim

Safe, effective, and timely discharge from the adult and older persons mental health service inpatient wards is a shared responsibility between the Rotherham Doncaster and South Humber Trust and other service providers, and discharge planning should begin as soon as a patient is admitted to hospital.

However, it is important that any transfer between, or discharge from a service is not viewed by clinical colleagues as an isolated event as it is only one component of the patient’s care pathway, and as far as possible be seen as one seamless and integrated process. To not view it in this way can result in patients experiencing a disjointed, delayed, or unsatisfactory episode of inpatient care.

The aim of this procedure is to provide colleagues working within the adult and older persons mental health in-patient services clear guidance on how to safely manage the discharge and, or transfer of patients.

2 Scope

The contents of this procedure only applies to clinical colleagues working across the adult and older person’s mental health inpatient services.

3 Link to overarching policy, and or procedure

This procedure links into the admission, transfer and discharge manual including patient flow and out of hours (OOH) procedures and should also be read in conjunction with the following trust policies:

4 Procedure or implementation

Discharge planning will commence at the point of admission in collaboration with a range of multi agencies, multi-disciplinary team (MDT) disciplines, the patient and the patients’ relatives and carers and, or advocate (where consent is given) throughout their stay.

The discharge of any patient from the inpatient services will be a planned event which only takes place after full consultation with all the relevant people involved in the patient’s care (including where consent is given with relatives, carers and, or their advocate). Discharge planning will be collaborative, person-centred, and suitably placed, so that the patient does not feel their discharge is sudden or premature.

As there could be any number of circumstances which make the discharge of a particular patient more complex, the following guidance is not exhaustive and will need to be adapted to meet the needs of each individual patient.

4.1 Action on admission

On admission the patient, and where appropriate their family, carer and, or advocate will be advised of the purpose of admission and the means by which they will be involved in the discharge planning process.
Within 72 hours of admission the MDT will review the admission assessment, consider the patients needs (short and long term) and commence the discharge care plan to meet the needs of the patient. The discharge care plan will identify if the patient is to be discharged home or to an alternative care setting where applicable. Relevant community mental health services (CMHS) will also engage in planned MDT meetings (ward rounds) and other planning arenas.
To ensure the inpatient admission is focussed on active treatment and supports timely discharge, within 72 hours the MDT will identify and record in the electronic patient record (EPR) the estimated date of discharge (EDD). These decisions will be reviewed, and both the discharge care plan and EDD updated throughout the patient’s stay.

4.2 Discharge and crisis care planning

Within 72 hours of admission all patients will have a discharge care plan. This will detail follow-up arrangements by the service or after care arrangements, including prioritising follow-up within 48 hours of discharge for patients who presented with a risk of suicide during their inpatient stay.

As a minimum the discharge care plan should include:

the plans that are in place to manage any identified risk. Including the heightened risk of suicide in the first three months following discharge
possible relapse signs
the arrangements for promoting the patients ongoing recovery and engagement with service support
actions to be taken by patient or carer in the event of deterioration
who to contact
where to go in a crisis or emergency
budgeting and benefits
handling personal budgets (if applicable)
social networks
educational, work related and social activities
details of medication including any monitoring arrangements
details of treatment and support plan
physical healthcare needs including health promotion and information about contraception (where applicable)
date of review of the care plan
explicit plans for how the service will respond in the event of the patient becoming non-compliant or disengaging with the service

A determination should be made as early as possible in discharge planning about the status and views of any carers who provide care, including that they are willing and able to do so. This will need to be age appropriate if this is a young carer under the age of 18.

Before discharge, the MDT should consider and offer a series of individualised psychoeducation sessions to promote learning and awareness.

Sessions should:

start while the person is in hospital
be conducted by the same practitioner throughout if possible
continue after discharge, so the person can test new approaches in the community

and cover:

symptoms and their causes
what might cause the person to relapse, and how that can be prevented
psychological treatment
coping strategies to help the person if they become distressed
risk factors
how the person can be helped to look after themselves
phased leave (the patient can have trial periods out of hospital before discharge) with support where necessary (consider community mental health team, home treatment)
phased return to employment or education
This is important for people who have been in hospital for an extended period and who have had restricted access to the community

During discharge planning MDTs also need to consider group psychoeducation support for carers this should include signposting to information on the specific condition of the person they care for.

People in hospital should be supported to participate actively in making informed choices about their care, including, for people who fund their own care, the potential longer-term financial impact of different care options after discharge. These conversations should begin early in a hospital stay, and not when a person is ready to be discharged. This should also include, where appropriate, information about housing options (adaptation of the existing home and possible alternative housing, for example supported living).

On discharge from hospital people who have new or additional needs should be offered of onward care and support to aid their recovery. The choices available should be suitable for their short-term recovery needs and available at the time of discharge.

Where the patient is discharged to a community team the discharge care plan should be reviewed by the care coordinator or lead professional within one month of the patient’s discharge.

4.3 Discharge assessment criteria and record keeping

The assessment criteria to determine the patient’s fitness for discharge are:

a clinical decision has been made that a patient is ready for discharge
an MDT decision has been made that the patient is ready for discharge
the patient is safe to discharge

MDT in this context includes nursing and other health and social care professionals. It is acknowledged that circumstances of discharge will vary and the MDT should consider the individual circumstances of the patient when determining if the discharge is delayed. This determination should consider the following factors against each of the criteria.

Once the MDT have made the decision that the patient is fit for discharge or transfer this will be documented in the EPR.

At a time when the clinical decision has been made that the patient is ready for discharge the MDT or ward round will discuss plans for aftercare and ensure an appropriate package of care is in place and agreed with consideration of the patient’s consent and capacity.

If a person’s preferred care placement or package is not available once they are clinically ready for discharge, an available alternative, or alternatives appropriate for their short-term recovery needs should be offered, while they await availability of their preferred choice. People do not have the right to remain in a hospital bed if they no longer require acute care, including to wait for their preferred option to become available.

Where the person is assessed to lack capacity to make the specific decision or there is dispute between the clinical team and the patient’s family regarding capacity, a best interest’s decision should be made in line with the MCA Mental Capacity Act 2005 policy and recorded on the relevant templates in the electronic patient record (EPR).

Where an individual wishes to return home and their family member or unpaid carer is unwilling or unable to provide the care needed, NHS bodies, local authorities and care providers should work together to assess and provide the appropriate health and care provision required to facilitate the individual’s choice, where possible, and enable a safe discharge.

Where there is disagreement between a person and their unpaid carers or family members, and the person is deemed by the appropriate professional to have capacity to make decisions relevant to their discharge, the person’s right to make these decisions should be respected. If the person or their family are objecting to the proposed discharge especially, where they involve a change of residence then consideration will be needed whether the matter needs to be referred to the Court of Protection. Advice should be sought from the Mental Capacity Act lead.

4.4 Risk assessment

Prior to discharge a thorough assessment of the patient’s personal, social, safety and practical needs to reduce the risk of suicide on discharge must be undertaken with the aid of the FACE clinical risk assessment tool. This must take into account:

any change in the risk profile once the patient is discharged from the ward
the setting the patient is being discharged to
patient engagement
carer involvement (if the patient agrees)
the possibility of using a personal health or social care budget and ensure the person understands about charges for social care
aftercare support, in line with section 117 of the Mental Health Act (1983)
aspects of the person’s life including:
daytime activities such as employment, education, and leisure
food, transport, budgeting, and benefits
pre-existing family and social issues and stressors that may have triggered the person’s admission
ways in which the person can manage their own condition
suitability of accommodation
risks to children
risks to the patient from others due to their vulnerability
risk of domestic abuse

This is undertaken and reviewed by the MDT in the discharge meeting. Where timeframes do not allow for this, for example, when a patient requests discharge at short notice, it will be the responsibility of the nurse in charge of the ward at the time to complete the review of the clinical risk assessment.

The management of any identified risks will be included in the discharge care plan.

4.5 Pre discharge meetings

A pre-discharge meeting must be organised by the named nurse in liaison with the nominated community-based care co-ordinator or lead professional where applicable. This meeting should include the patient, carers (where patient consent has been given) and all members of the MDT involved in the inpatient care, as well as the nominated community-based care co-ordinator or lead professional, family, carer and, or advocate where appropriate and will be recorded electronically in the form of a CPA review summary (or equivalent).

The following will be agreed at the meeting:

CPA status or equivalent (all inpatients are automatically placed on CPA, any decision to remove CPA must be documented with a clear rationale from the MDT in the electronic patient record EPR)
follow-up requirements, either a minimum of 48 hours (for patients identified having a risk of suicide on preparation for discharge) or 72 hours including location, date, time and by whom, see appendix U, 72 hours follow-up technical guide for further information
current clinical risks including a review and update of the FACE risk assessment
eligibility for section 117 aftercare including any provision for aftercare services required or in place colleagues should refer to trust section 117 Mental Health Act (1983) policy for further guidance
details of carers and offer of carer’s assessment if one has not already been offered
identification of any unmet needs
crisis and contingency plans
any required support around administration of medication or management of side effects
use of personal budgets to support identified social care needs
any aftercare arrangements agreed with other services (for example, substance misuse, older adults or learning disability services)
any transport requirements which may be required
referral to the home treatment team

At this meeting it will be ascertained if the patient will require a statement of fitness for work (form med 3 is required) and if so, arrangements made for the doctor to complete one. The patient will be given a copy of the discharge pack and the discussion and agreement from the pre-discharge meeting will be recorded in the patient’s EPR, and a discharge care plan formulated which will include all agreed actions. The nurse who was present in the pre-discharge meeting will arrange for a prescriber to order any prescribed take home medication to ensure that it will be on the ward ready for when the patient leaves.

4.6 A clinical decision has been made that a patient is ready for discharge

A patient is medically ready to be discharged when, as at 8am that morning, they meet all of the following three criteria.

No further interventions are needed that can only be carried out in an inpatient setting. The person could be assessed, cared for, and treated in their home or less restrictive setting.

The MDT have concluded that the person is medically fit and ready for discharge. The MDT should include parties external to the trust, for example social care colleagues. This step involves considering issues such as housing, family or carer needs and the support available in the community, to decide whether discharge would be appropriate. When deciding whether someone is ready for discharge, members of the MDT should explicitly consider the person and their family or carers’ views about whether the person feels ready for discharge and engage with them about the proposed discharge plan.

This criterion is likely to be met when:

the MDT responsible for the care and treatment in hospital has agreed that the patient no longer requires an inpatient bed to meet their continuing health need
the MDT has recorded a consensus decision that inpatient stay is no longer required to meet the patient’s continuing health need
an appropriate level of care (including accommodation with care) required to meet the patient’s needs has been defined
an adequate person-centred discharge plan has been agreed with the person to carry on any necessary assessments, care, and treatment in the community. The plan should provide clear information about the proposed discharge process and enable the person and their family or carers to shape decisions about discharge. Medically fit does not indicate complete recovery, instead it is the point at which the person could be safely assessed, cared for, and treated in their home or less restrictive setting. It is important that all three criteria are met rather than only one or two. Being medically ready for discharge does not mean that patients should be rushed to be discharged if the conditions are not in place to continue their recovery outside of hospital. Rather it is an indication that the person could continue their recovery outside of hospital were the adequate support or services in place

This criterion is likely to be met when:

an aftercare plan has been determined which will maintain the patient’s safety
the patient no longer requires an inpatient stay to maintain basic safety
the defined aftercare plan is assessed as appropriate to maintain safety

All medically ready for discharge dates are to be recorded on the patient electronic record. Once a patient meets all three of the above criteria but cannot be discharged that day, they become a delayed transfer of care (DToC), standards for recording and reporting Delayed transfers of care (staff access only) (opens in new window) and expected date of discharge medically ready for discharge and delayed transfers of care SystmOne guidance (staff access only) (opens in new window).

4.7 Recording of a delayed transfer of care

The NHS England 2018 Monthly Delayed Transfers of Care Situation Report, Principles, Definitions and Guidance defines a DToC as follows:

“a delayed transfer of care (DToC) from NHS-funded acute or non-acute care occurs when an adult (18 and over years) patient is ready to go home and is still occupying a bed. A patient is ready to go home when the criteria detailed in section 4.2.1 are met”

A DToC will be recorded on the patient electronic record when the patient is medically ready for discharge but unable to transfer due to external delays. See standards for recording and reporting delayed transfers of care (staff access only) (opens in new window) and expected date of discharge medically ready for discharge and delayed transfers of care SystmOne guidance (staff access only) (opens in new window).

4.7.1 Internal delayed transfer of care definition

An internal delayed transfer of care is when the patient is medically ready for discharge but unable to transfer due to an internal delay. This should not be recorded on SystmOne as a DToC however it is good practice for clinical teams to discuss any internal delays in the weekly multi-disciplinary care group DToC meetings and escalate to the Patient Flow team, as necessary.

4.7.2 Process

It is the responsibility of the MDT to determine the EDD, medically fit for discharge and DToC; the nurse representative at the MDT is responsible for ensuring the outcome of the discussion is recorded in the EPR. The nurse may choose to delegate this task where appropriate but will remain responsible for ensuring the record is updated.

4.7.3 Monitoring

Patient flow and performance will carry out weekly reconciliations to verify the numbers of DToC and other delays, comparing system recording with information shared at the weekly DToC meetings, to ensure accuracy. This will be supported by other processes, for example audit, as needed.

4.8 Communication with carers

The engagement and active participation of carer(s) as equal partners is central to the delivery of care and in the planning of a successful discharge. However, there may be times when a patient with capacity refuses to give consent for the sharing of any information about their care and treatment with their carer(s). In such a situation the patient’s decision is to be recorded under information sharing on the general information template in the EPR. Colleagues must then revisit this decision with the patient at regular intervals throughout their stay on the ward.

The carer is to be informed of the patient’s wishes, but consideration must also be given to the fact that there is some information which can be shared without breaching patient confidentiality. In addition, if there are any risks posed to the carer the organisation may have a duty to keep the carer informed of the fact that the patient will be leaving the ward. If colleagues are unclear as to what can be shared, they should seek advice from the modern matron.

Before the person is discharged, the following must have happened subject to patient confidentiality and risk considerations outlined above:

inform carers of the plans for discharge
discuss with carers the person’s progress during their hospital stay and how ready they are for discharge
ensure that carers know the likely date of discharge well in advance
determine any change in carers’ circumstances since admission which may affect discharge planning

4.9 Medication management

Medicines management plays an important role in preparing patients and their carer(s) for their discharge from hospital. Compliance with medication has an impact on a patient’s recovery and, or maintenance of their condition once they leave hospital.

An assessment of the patients’ ability to self-medicate must also be made. If the patent requires assistance on discharge this must be communicated to the appropriate health and social care professionals.

As part of this assessment the patient is to be provided with the relevant information leaflets in respect of the medication they are taking, and the most common side effects they may experience.

It must be made clear to the patient who to seek advice from should they experience any side effects which are causing them concern.

Any medication required by the patient on discharge from hospital should be requested from the pharmacy supplier at least 24 hours in advance.

The nurse in charge has the responsibility for ensuring that the patient understands the importance of the medication being taken to support concordance.

It is also important that patients are fully informed both verbally and in writing as to the medication they have been prescribed, when to take it, and where to go for advice or further supplies.

At discharge, patients will normally be provided with a 14-day supply of their medication. The exception to this is finishing off a course of medication or when required medication. In the case of patients who have a high risk of overdose, a decision may be made by the prescriber to provide the medication in smaller supplies. In this case it is important that the patient’s general practitioner is aware of this, and arrangements must be in place for the patient to collect their repeat prescriptions.

For any patient prescribed clozapine they must be referred to clozapine clinic prior to discharge. Colleagues in the clinic must be informed of the proposed discharge date for the patient so that the next appointment can be booked within the correct timeframe and arrangements for clozapine prescriptions confirmed.

For any patient prescribed lithium, consideration must be given to the arrangements for ongoing monitoring in the community. In most cases this will be via the community lithium clinic (responsible for routine monitoring for stable treatment). Referrals must be made with sufficient notice and the following criteria met and information shared:

Criteria:

stable dose of lithium established
next bloods due in 3 months (if not, still refer but make arrangements for interim monitoring)
information required for referral:
- brand and dose of lithium
- indication
- other medications prescribed
- relevant history, medical
- relevant risks, for example, compliance, medical, mental health
- date and results of last lithium monitoring bloods

For any patient prescribed an injectable antipsychotic (depot, long-acting injection) consideration must be given to arrangements for the ongoing administration and this must be agreed with plans in place at the point of discharge. The prescription must be available for the community prescriber to view on SystmOne including (i) the last administration date so that the next administration date is clear and (ii) any side effects or problems at injection sites.

4.10 Information for patients

Patients who are being discharged from hospital have the right to be fully involved in the arrangements and should receive the following:

full information regarding their diagnosis and assessment of their health and social needs, in preparation for discharge
a copy of their discharge care plan
a copy of the discharge pack which will include:
- information on the services available in the community relevant to their care, including voluntary organisations and support groups
- information on PALS and advocacy support
- a copy of the trust “your opinion counts form”
- contact names and numbers for help or advice post-discharge
- copy of the discharge notification

In addition, patients should be made aware of the fact that they have the right to receive copies of any correspondence issued by the service which relates to their care and treatment, and colleagues are to refer to the healthcare record keeping policy for full details and information for copying letters to service users.

4.11 Action on the day of discharge

On the day of discharge the nurse who is responsible for assisting the patient or overseeing them safely leaving the ward will:

assess if there has been any change to the patient’s presentation or risk profile. Any change should be discussed with the MDT
reconfirm follow-up arrangements if not made on the same day and provide the patient with a discharge card with the follow-up arrangements (including location, date, time and by whom) and name of relevant professionals and their contact number (for example, care coordinator), ward number and details of whom to contact in an emergency and how
check dispensed take home medications against prescriptions to ensure correct medication and doses have been dispensed
talk the patient and, or carers through the prescribed medication and how to obtain further supplies, answering any queries which they may have. Advice must also be given on whom the patient is to contact should they experience any side effects from their medication. If there is any concern identified in respect of the patient’s ability to manage their own medication the discharge is to be delayed whilst advice is sought from a member of the medical team
return any personal belongings held in safe keeping to the patient and document return on SystmOne
check if the patient needs a medical certificate, med 10 can be issued by a registered nurse or doctor and only covers the duration of their inpatient stay; med 3 can cover a further period of sick leave following discharge from an inpatient bed but can only be issued by a doctor
check that patients have the means to access the property they are being discharged to or that someone will be there to receive them
confirm any required transport arrangements are in place
contact the care coordinator or team providing follow-up to confirm discharge has taken place if not present at a discharge meeting held on the same day
notify other people or services that may need to be informed of the patient’s discharge if they are not already aware, for example, probation, public protection unit, the police etc. and document this in the clinical records
once the patient has left the ward an entry to this effect will be made in the patient’s clinical record on the EPR which will also confirm the actual time the patient left the ward, their destination, and any other relevant information. The ward bed status will then be updated
if the person is subject to a deprivation of liberty authorisation the supervisory body should be informed of the changes and a DOLS form 10 completed. If the request for authorisation has not yet been granted an email should be sent to the supervisory body to cancel the request. See MCA deprivation of liberty (DoL) policy for further guidance

Patients should be made aware that they have the right to receive copies of any correspondence issued by the service which relates to their care and treatment. Wishes to receive a copy of letters should be recorded in their clinical record.

Patients discharged from inpatient care have their care plan sent to everyone identified in the plan as involved in their ongoing care within 24 hours of discharge.

Any paper copies of the patient’s records are to be filed and forwarded to the ward clerk for scanning onto the electronic patient record or archived.

4.12 Transport arrangements

Most patients will make their own transport arrangements, but it is important that the nurse in charge checks that this is the case before the patient leaves the ward.

For patients who are being transferred to another service provider the nurse in charge of the ward will organise appropriate transport taking into account safe transportation of patients and staff (adult and older person’s mental health and learning disability).

Clinical risk.
Risk of violence, and, or absconding.
Least restrictive methods to manage any identified risk.
Size of transport required to accommodate both the patient and any escorting colleagues.
Distance to the new provider.

If a patient is considered too high a risk for trust colleagues to safely escort the nurse in charge will speak to the modern matron about the need to employ a specialist transfer and escort company.

Colleagues should refer to the safe transportation of patients and staff (adult and older person’s mental health and learning disability) for full guidance. This guidance also includes the roles and responsibilities of the escorting colleagues.

4.13 72-hour follow-up

Prior to discharge a discussion will take place with the patient in relation to follow-up support post discharge. Support will be arranged according to their mental and physical health needs. This could include contact details, for example of:

a community psychiatric nurse or social worker
the out-of-hours service
support and plans for the first week
practical help if needed
employment support

The inpatient team makes sure that follow-up arrangements (within 48 or 72 hours of discharge) are in place before patients are discharged from hospital. The patient is made aware of these arrangements, and they are documented on SystmOne. This includes location, date, time and by whom. This applies to all patients regardless of CPA status on discharge. All 72-hour follow-ups must be face to face unless there are significant exceptions such as patient refusal or non-engagement, removal from the country or transfer to another mental health inpatient facility.

Consideration should be given to contacting adults admitted for self-harm, who are not receiving treatment in the community after discharge, and providing advice on:

services in the community that may be able to offer support or reassurance
how to get in touch with them if they want to

The arrangements for 72-hour follow-up will be agreed at the pre-discharge meeting and the trust information department has in place an automatic notification system to remind clinicians of all discharges and the latest date by which the 72-hour follow-up visit has to have taken place.

However, any patient who presented with a risk of suicide during their inpatient stay should be seen within 48 hours of discharge. If a face-to-face visit is not possible for any reason the care coordinator should arrange to contact them by phone.

5 Patients with additional or alternative needs

5.1 Patients who require specialist equipment or home adaptations

Any equipment and, or home adaptation requirements should be assessed in advance of discharge and arrangements put in place to secure delivery in alignment with the date of discharge.

If deemed appropriate by the MDT a home visit may be arranged prior to discharge to assess and identify the patient’s induvial needs and requirements. The MDT may wish to consider referrals to other agencies at this stage.

Prior to discharge, the patient and their carer(s) should be trained in the use of any equipment. This may require the organisation of a home visit facilitated in conjunction with the provider of the equipment.

Follow-up arrangements with the appropriate service will be in place to check that the equipment and, or home adaptation provided is adequately meeting the patient’s needs and being used correctly.

The patient will be provided with information around how to report any fault with the equipment or to arrange its return once it is no longer needed.

5.2 Patients who require funding for specialist placements

The assessment for, and delivery of, continuing health and social care, is organised so that individuals understand the continuum of health and social care services, their rights and receive advice and information to enable them to make informed decisions about their future care. In situations where a patient does not have the capacity to make such decisions, it will be necessary to first ascertain if there are decision-making mechanisms in place within either the Mental Health Act (1983) or the MCA (2005).

Once it has been decided that the patient requires the funding of a specialist placement the named nurse will first complete the continuing care checklist to determine if the patient is eligible and, where applicable, complete the full decision support tool with support from the MDT.

Any decision around the most appropriate placement to meet the patient identified needs will be made by the MDT. The MDT will also be responsible for approaching any identified placements and organising assessments and pricing.

For patients who are assessed as requiring an alternative care setting or enhanced care needs the relevant funding requests processes and subsequent documentation should be initiated with the respective local authority (LA) or integrated care boards (ICBs). Where section 117 is applicable a statement of need document (located on SystmOne) should be completed to support decision-making in respect of funding where a need is identified. If during the admission a new need arises an assessment should be undertaken as soon as practicable.

5.3 Patients being discharged into the community who have been identified as a significant risk to others or are known to undertake offending behaviour

If the patient is subject to multi agency public protection arrangements (MAPPA) a MAPPA 1 is to be completed and submitted to the MAPPA coordination unit. This is not a referral but gives the opportunity for the sharing of clinical information and the opportunity to request information from the police and probation services to inform decision-making. The completed forms are to be submitted to either the South Yorkshire or North Lincolnshire MAPPA unit. Prior to the discharge of the patient a decision will need to be made whether a multi-agency public protection meeting needs to be held.

For patients not currently subject to multi-agency public protection arrangements a MAPPA referral is to be completed and include the following information.

Likelihood of the patient offending.
The risk of serious harm including to whom and when.
Who needs to be invited to the MAPPA meeting.
A copy of the patients’ clinical risk assessment.
A copy of the risk management plan.

The referral also needs to demonstrate that there are specific risks which require inter agency involvement beyond that which is normally provided.

If a MAPPA referral is made the patient is to remain on the ward as an inpatient until the referral has been processed and if deemed necessary, a strategy meeting should be held.

Colleagues should refer to the multi agency protection panel arrangements page (staff access only) (opens in new window) for further advice.

5.4 Patients who are homeless

Patients, who have recently been homeless, or who are at risk of being made homeless, should be identified as soon as possible on or before admission, so that the appropriate agencies in both health and social care can be involved at an early stage. This will ensure that appropriate and timely needs assessments have been actioned to develop a discharge plan proportionate to individual need. If for any reason it has not been possible to secure appropriate accommodation and the patient is no longer requiring an inpatient bed, the patient is to be directed to either the:

Citizen’s advice Bureau
Local Authority Housing Department Crisis Accommodation team

Any patient who needs to attend one of these departments to sort out accommodation is not to be discharged outside of normal working hours as they will not be open to offer advice to the patients.

For any homeless patient subject to CPA there must be explicit plans in place to maintain contact and enable the 72-hour follow-up to take place before they leave the ward.

5.5 Patients subject to community treatment orders

Colleagues should refer to the trust community treatment order policy for full guidance, however the general steps of application are as follows.

6 Communication

6.1 Discharge letters

A discharge notification will be completed within 24hrs by a member of the medical team on the approved template in the EPR on SystmOne which contains the following information:

date of admission
date of discharge
legal status of patient
medication at discharge
ICD 10, diagnosis
medication recommendations
relevant physical findings or investigation results
any known allergies
details of any medication changes during admission
circumstances of admission
summary of admission
identified risks including any infection risks
follow-up arrangements
CPA requirements
details of community workers involved

6.2 Communication with general practice (GP)

At the point of admission and discharge the GP should be notified. Within 24 hours, a discharge letter (or interim discharge summary) is emailed to the person’s GP. A copy should be given to the person and, if appropriate, the community team and other specialist services.

A full or detailed discharge summary is sent within a week to the patient’s GP and others concerned (with the patient’s consent), including why the patient was admitted and how their condition has changed, diagnosis, medication, and formulation. Where relevant a copy of the do not attempt cardiopulmonary resuscitation (DNACPR) and ReSPECT form should also be included.

Guidance note, this should include relevant physical health information such as new diagnoses, new concerns, outcomes or pending investigations, information regarding referrals, changes to physical health treatments and management and relevant updates on existing conditions.

6.3 Infection control

The Infection Prevention and Control team (IPCT) should be contacted for advice and support ideally prior to admission if it is suspected that the patient may have an infection or pose an infection risk to themselves or others.

Where this is not possible, the following timescales should be adhered to as a maximum:

those being cared for onwards providing primarily physical healthcare should ideally contact the IPCT within 24 hours
those being cared for onwards providing primarily mental health care this timescale is within 48 hours

The infection prevention and control manual is available for further.

7 Requests for discharge

7.1 Discharge against medical advice

Should a patient request discharge against medical advice the following process should be followed:

a senior member of the nursing team should discuss this issue with the patient and try to elicit their rationale for leaving, taking their wishes into account as far as possible, at the same time ascertaining the patient’s capacity to make the decision
where the person does have capacity, colleagues should utilise their local procedure for supporting an appropriate discharge. Colleagues have no power to make them stay unless they believe that the patient is suffering from a mental disorder, in which case the provisions of the Mental Health Act may be considered
if there is any question about the patients’ capacity to make this decision then colleagues must undertake a mental capacity assessment and document in line with the Mental Capacity Act (2005) policy. If the patient is found to lack capacity to make an informed decision regarding remaining in hospital, then medical opinion should be sought
the doctor should consider whether it is in the patient’s best interest to remain in hospital. If this is the case, and the patient does not meet the criteria for detention under the Mental Health Act (1983), then this is likely to lead to the patient being deprived of their liberty and colleagues should consider making an urgent authorisation under the deprivation of liberty safeguards
in all cases a full record of the assessment (including MCA) and any discussions must be documented in the patient’s records
note, where a patient is expressing an objection to being in hospital for mental health treatment either verbal or non-verbal, DoLS is not applicable

7.2 Request by a nearest relative for the discharge of a patient subject to detention under the Mental Health Act (1983)

Some sections of the Mental Health Act (1983) give the right to the patient’s nearest relative to request discharge from detention. Such a request must be made in writing to the hospital managers who then have 72 hours in which to respond to the request. During this period the patient’s responsible clinician will be required to review the patient and assess whether they wish to issue a barring order to prevent the discharge going ahead. For full guidance colleagues must refer to the trust procedure for the discharge of a patient detained under the Mental Health Act (1983) (amended 2007).

8 Transfers

8.1 General principles

During an episode of inpatient care they need may arise for a patient to be transferred to another care setting either within or outside the trust. Any such transfer of care should wherever possible be planned so that there is minimal interruption to the patient’s treatment programme and carried out with their consent or using the appropriate legal framework.

Where appropriate, the patient, carers and any legal representatives must be given adequate and timely information as to why the transfer is taking place. Transfers should take place ideally within working hours. For any out of hours transfers, a handover summary should be completed as soon as practicable by the referring or originating team.

Clear discussion in relation to transfer should take place and involve the patient and carers and members of the multidisciplinary team.

A detailed record is to be made in the patient’s clinical records of all aspects of patient transfer, this should include:

follow the instructions detailed in the ward transfer guide (staff access only) (opens in new window) to maintain an accurate patient record
all information provided to the receiving service
the date on which it was provided
any additional information requested prior to the transfer
discussion with the patient and carers about the planned transfer

For any patients with an existing do not attempt cardio-pulmonary resuscitation (DNACPR) or ReSPECT order, the order should be reviewed upon arrival at RDaSH services. Upon transfer outside services, the original form must be sent with the patient and handed over to the receiving service.

8.2 Transfer within the trust

It is recognised that there may be times when a patient has to transfer from one ward to another. Good communication and documentation underpins effective transfer processes.

The named nurse will complete an entry with the following details:

date and time of transfer
named nurse, on transferring ward
responsible clinician, on transferring ward
reason for transfer
MHA status, record and ensure this is correctly captured on SystmOne MHA office informed, who informed and when if applicable
care plans, ensure care plans are up-to-date
risks, ensure these are updated and captured in the FACE risk assessment including any safeguarding risks
physical health, ensure care plans are up-to-date and reflect these
plan from formulation or CPA meeting or most recent care planning meeting
medication on transfer and items issued to transferring ward
family or carers informed of the transfer
patient property transfer (valuables)
suggestions and outstanding tasks for receiving team

A member of the medical team will create an entry with the following information for a medical handover:

reason for admission
agreed purpose of admission
relevant history
progress, summary of progress, response to treatment, key risk incidents and relevant events
physical health, any relevant medical handover in relation to existing or new conditions or concerns, medication-related monitoring and investigations
treatment, treatment plan with respect to medications and other planned interventions
handover of plans and, or outstanding tasks

A review of the admission assessments should occur to determine if there is any change that needs to be reflected in new documentation and consideration of the impact of transfer on the patient. This will include reviewing:

admission clerking
physical examination
risk assessment
care plans
prescribed medications
ensuring all admission tasks have been completed and are updated

8.3 Transfer of patients to or from another mental health care provider

For those people receiving mental health care, the principles of the care programme approach should be considered in line with the CPA framework (or equivalent).

The standard discharge letter can also be used as a summary of transfer outside the trust.

Information relating to medications and allergies should be provided.

For any patients subject to detention under the Mental Health Act (1983) colleagues also need to refer to the trust section 19 transfer of patients detained under the Mental Health Act (1983) to another hospital or unit procedure.

8.4 Transfer of patients who lack capacity

Where consideration is being given to transfer a patient to another hospital and the patient who is not subject to the Mental Health Act lacks the capacity to make this decision, a best interest decision should be made involving all the relevant people (for example, family or carers).

If the person or their family are objecting to the proposed transfer arrangements then consideration will be needed whether the matter needs to be referred to the Court of Protection. Advice should be sought from the Mental Capacity Act lead.

Where a patient does not have any family or carers and the period of stay is likely to exceed 8 weeks the named nurse or nurse in charge must make a referral to the Independent mental capacity advocate (IMCA).

All decisions regarding capacity must be recorded on the appropriate templates in the EPR.

If the person is subject to a deprivation of liberty authorisation the supervisory body should be informed of the transfer and a DOLS form 10 completed. If the request for authorisation has not yet been granted an email should be sent to the supervisory body to cancel the request. See the Mental Capacity Act (2005) Deprivation of Liberty (DoL) policy for further guidance.

8.5 Transfer of patients to and from a physical health care provider

If at any point during an episode of care a patient need to be transferred to a general or acute hospital bed colleagues must refer to the following for full guidance:

care of informal Inpatients who require care in the local acute hospital policy

Procedure for the care and treatment of a patient detained under the Mental Health Act (1983) to a general hospital under section 17 Mental Health Legislation, Section 19 transfer of patients detained under the Mental Health Act (1983) to another hospital or unit procedure.

8.6 Transfer and discharge of patients who have a do not attempt cardiopulmonary resuscitation order in place

DNACPR status, it is the responsibility of the discharging clinician to ensure that the patients GP is informed of a DNACPR order via the discharge letter, and that all agencies involved in the patients care in the community are informed of the order. The DNACPR order must be reviewed before discharge. It may not be possible to review the DNACPR for out of hours transfers, at this point the review will be done by the accepting service.
The original DNACPR order should be given to the patient or carer. Colleagues should ensure that the patient or carer is aware of and fully understands the order.

9 Contingencies

9.1 The discharge of patients in their absence

Whilst it is acknowledged that there are occasions when a voluntary patient goes on planned leave and then refuses to return the ward; the discharge of such a patient in their absence should not normally go ahead until they have been seen and assessed by either the home treatment team or their care coordinator or lead professional, and a pre discharge meeting held in their absence. Robust MDT working between the inpatient and community teams must ensure that all relevant actions detailed in this Procedure are considered and adhered to where practicable. As a minimum, consideration should be given to notifying relevant services or individuals of the discharge, including any risk posed by the patient to self or others, any appropriate safeguarding or MAPPA referrals, arrangements for ongoing treatment or medication where applicable and arrangements for 72-hour follow-up from the date of discharge.

9.2 Patients who refuse to leave the ward

There may be occasions when a patient refuses to leave the hospital, particularly if they are not happy with the placement they are to be discharged to. Any patient fit for discharge does not have a right to occupy a hospital bed, but consideration must be given as to how best to deal with each individual refusal to leave the ward.

Usually, the matter can be resolved by talking to the patient and discussing their reasons for not wanting to leave. The use of force to remove a patient should only ever be considered if all other means have failed. Before resorting to this advice should be sought from the modern matron, or the senior manager on call if outside of normal working hours.

10 Appendices

Please see admission, transfer and discharge manual including patient flow and out of hours (OOH) procedures webpage for appendices attached to this procedure.

Appendix U 72-hour follow-up technical guide

Document control

Version: 2.1.
Unique reference number: 620.
Approved by: Clinical policy review and approval group.
Date approved: 3 December 2024.
Name of originator or author: Head of patient flow.
Name of responsible individual: Executive director of nursing and allied health professionals.
Date issued: 20 December 2024.
Review date: 31 July 2025.
Target audience: Clinical colleagues working in the adult and older person’s mental health inpatient services.
Description of change: Changed references from staff to colleagues throughout, all documents listed above, updated appendices references

Page last reviewed: December 20, 2024
Next review due: December 20, 2025

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