A week after the country went into lockdown, Margaret went to collect her son Gary* from the psychiatric hospital in Portsmouth where he’d been detained under the mental health act.
The day before, a member of staff at the hospital had telephoned to say they could no longer keep him there. When she arrived, the nurse waiting with him in the car park handed over his holdall and a small carrier bag containing his medication.
The psychiatrist she’d met a few weeks earlier, when he’d first been admitted for a manic episode, came out from his office to wish them well.
Gary was clearly still unwell. Margaret got him into the car and began the long drive back to London, confused as to why he’d suddenly been discharged and worried that no follow-up care was in place. “I was a bit taken aback,” she says, “when he’s been discharged from hospital before there’s been like a week of planning in place”.
Gary’s case is not unique, but part of a wider picture of an already stretched mental health system, buckling under the pressure of the pandemic. Families say that patients are being discharged before they are ready and without adequate support in place, putting them at risk and their relatives under enormous stress in the process.
‘We may be discharging people sooner rather than later.’
On March 25, as the government scrambled to contain the virus, which made its way around the country at alarming speed, mental health trusts were advised by NHS England to “review all current inpatients to support safe discharge where feasible”.
“This will need to be done on a case by case assessment of patients’ needs and risks, in partnership with them and their family, carers, and onward care provider,” the 26 page document on “managing capacity” read. “Discharge plans need to reflect the risks in relation to Covid-19 for individuals.”
As well as protecting patients from the risk of catching the virus, the guidance was issued in an attempt to prepare hospitals for an expected deluge of people unwell with Covid-19.
“As providers seek to safely discharge as many patients as possible, those with beds on acute trust campuses should also consider how those will be configured in the context of increasing pressures on critical care.”
As hospitals began to prepare for the virus, patients deemed ready for discharge were told to vacate beds “to relieve pressure during the pandemic”. Wards at some mental health units were temporarily closed or merged with others.
The Maudsley hospital in London, for instance, closed some wards at the beginning of April to allow nearby Kings College Hospital to use the space for “people who are physically unwell and need an acute hospital bed,” according to their website.
And with staff unwell or self-isolating because of the virus, already stretched mental health inpatient wards became even more difficult to run.
Speaking on the situation in April, Bal Johal, Clinical Service Lead for Inpatients at the Maudsley, told BBC Newsnight “I think the truth is, with these unprecedented and difficult circumstances, there may be the occasion where we may be discharging people sooner rather than later.”
However, some families argue that in the rush to prepare for the virus, their relatives were let out too early and without sufficient safeguards and support in place.
‘The shock for us as a family was awful.’
In the week following Gary’s discharge from the Solent NHS Trust hospital, his mental health deteriorated and Margaret had to call the police several times. When she did manage to get in touch with her local mental health team she says that both the doctor and nurse who assessed him said he should not have been discharged.
“The doctor straight away said she was going to recommend that he should be sectioned again,” she explains. “It took a week though, I think because there weren’t any beds.”
Sarah’s* family went through a similar ordeal. Her cousin, Will*, was discharged unexpectedly at the beginning of April from a London mental health ward where he’d been staying and was known to be suicidal.
Will was released without any of his family being made aware and, later that night, went on to attempt suicide again. Fortunately, the police found him and he was readmitted to hospital for further treatment, but the family feel hugely let down by the experience.
“The shock for us as a family was awful,” she says. “We went from thinking our loved one was under close watch, to realising that he had been let out, alone, and had tried to kill himself again, all within 24 hours.”
Will’s mother says that subsequent conversations with hospital staff revealed his release was in part due to cases of Covid-19 on the ward. While the family are grateful for the care he received whilst there, they have huge concerns about how his discharge was handled.
“[The hospital] released a mentally ill person who was a huge danger to himself…without informing another family member,” Will’s mother says. “That should never have happened and thank God he is ok, but that is a miracle.”
The London mental health trust involved said they were unable to comment on individual cases but urged anyone “who feels they have had an unsatisfactory experience of care to contact the trust’s Patient Advice and Liaison Service”.
Sarah feels angry and says she wants to “hammer a message across” to police and hospitals that mental health liaison saves lives. “Suicide is the leading cause of death in people under the age of 34. Will was almost part of that statistic,” she says. “It was only thanks to police vigilance and sensitivity that he was taken back to A&E in time”.
She stresses that “close friends and family can, potentially, step in to safeguard the lives of people we hold dear. But only if we are told what is happening”.
‘He should never have been discharged.’
Margaret also feels she was kept in the dark about how much of a role Covid-19 played in the decision to release her son. “They were all very cagey when I asked directly [about coronavirus] and wouldn’t answer me.”
A statement from Solent NHS Trust said service users are always discharged with a care plan, are contacted within three days of discharge and that there is a full handover to local mental health services for those moving out of the area.
“People are only ever discharged from our inpatient mental health units when it is the right thing for them and in no other circumstances,” the statement read.
But Margaret maintains they were left without support:
“Obviously he should never have been discharged from the original section. All we got was a letter to say he was being released. We weren’t given any reason. It was all very strange and the worst thing is there was no follow-on care. I had to give up work a few years ago when he was unwell [and] I’ve become fairly good at navigating round the maze that is mental health services through volunteering and what-not, but if it had been another family that didn’t know, or if it had been his first episode, I wouldn’t have had a clue as to what to do.”
‘Families must be informed.’
The concern to protect patients is understandable when you consider the huge strain the service is under. There are currently 18,400 mental health beds in the UK, a huge reduction from 1980s levels, when there were more than 67,000 mental health beds.
According to recent warnings by the Royal College of Psychiatrists (RCP), the existing “dire shortage” of mental health workers has been further compounded by staff sickness due to the coronavirus outbreak. And to make matters worse, buildings are often cramped and old with “waiting rooms and shared facilities in inpatient settings [which] makes it difficult to reduce the risk of transmission”.
RCP has also raised concerns about a potential “care home style crisis” in mental health hospitals, pointing to a lack of PPE and testing amongst staff and patients.
As a result, patients and families feel even more determined to be kept in the know and made party to what is being decided behind closed doors.
“We are of course so grateful to the NHS. Covid-19 is a life or death situation,” says Sarah. “It’s important to see, though, that mental health conditions can also be fatal. When there aren’t enough beds it requires care and diplomacy, and families must be informed.”
*Identifying details have been changed to protect anonymity.
Natalie Leal is a freelance journalist who writes about social affairs and the public sector.