There are few things more tragic in mental health care than the preventable return of someone to services because the system failed to support them after discharge. For too long, the transition from hospital to home has been treated as a boundary rather than a bridge. And for too many, it becomes a revolving door.
The evidence is sobering. According to the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) (2022), 27% of all suicides in the UK from 2009 to 2019 involved people who had contact with mental health services in the previous year. Critically, the period immediately following discharge from inpatient care is associated with the highest risk, with a suicide rate of 14.5 per 10,000 discharges within three months of leaving hospital.
These figures are not isolated findings. The Parliamentary and Health Service Ombudsman (2023) report Broken Trust highlights repeated failures in discharge planning, communication breakdowns, and lack of post-discharge support. Similarly, the Health Services Safety Investigations Body (HSSIB) found that many patients are discharged with inadequate care coordination, often without essential services in place. These systemic shortcomings contribute directly to avoidable harm.
At Cygnet Health Care, we recognise that safe discharge is not an administrative milestone — it is a crucial phase of therapeutic recovery. Earlier this month, we convened leaders across the sector at our “Sustaining Hope: No More Revolving Doors” conference in Salford. It was a space to share evidence, innovation, and lived experience with the shared aim of closing the revolving door for good.
In her opening address to the conference Dr Geraldine Strathdee emphasised the need for discharge planning to begin from admission, advocating for a proactive, integrated, and patient-centered approach. She highlighted the importance of assessing comprehensive needs—including physical health, social, and psychological factors—at the outset of care to facilitate a smooth and effective transition back into the community. The need for robust communication between mental health services, GPs, and families, to ensure care plans are shared, holistic, and continually reviewed, with a strong focus on preventing readmission and promoting long-term well-being through integrated care and early intervention.
Hence, our focus extends beyond the discharge moment itself. We are actively redesigning inpatient care to ensure it prepares people meaningfully for life in the community.
The scale of the revolving door problem is significant. Research suggests that approximately one in five psychiatric inpatients are readmitted within 30 days of discharge (Vigod et al., 2015; using the READMIT index), and nearly 40% within a year (Steffen et al., 2009). Factors driving readmission include inadequate post-discharge support, poor integration between inpatient and community services, and insufficient attention to social determinants such as housing and employment.
A case example might be an individual who, after stabilisation during an acute admission, was discharged without robust social support. Despite clinical improvement, social isolation and lack of practical coping strategies led to a deterioration in mental health and a return to crisis services within weeks. This highlights the critical need for discharge planning that addresses not just clinical stability, but social resilience too.
At Cygnet Health Care, we have embedded initiatives that ensure inpatient care is truly therapeutic and recovery-focused. This includes:
- The creation of Social Hubs in our hospitals, providing recovery-focused activities, peer interaction, and structured occupational therapy. These hubs foster confidence, connection, and purpose — key factors in long-term stability.
- The implementation of a national PRN Activity Project, where reducing pro re nata (PRN) medication through expanded access to therapeutic activity led to a measurable drop in sedative use and empowered patients with emotional regulation tools.
These initiatives align closely with NHS England’s Staying Safe from Suicide guidance (2025), which I was privileged to contribute to. This national resource moves us away from actuarial risk prediction and toward relational safety planning — co-created, person-centred plans that acknowledge individual triggers, protective factors, and preferred responses.
Academic literature supports this shift. Killaspy et al. (2000) demonstrated that disengagement from outpatient care is a key risk factor for readmission. Steffen et al. (2009) underscore the importance of structured discharge planning and continuity, while Krupa and Clark (2004) show how occupational engagement during and after hospitalisation improves recovery trajectories. Tse et al. (2014) further emphasise the benefit of peer support roles in maintaining engagement post-discharge.
However, onward issues in the community can still hamper recovery. Inadequate community mental health provision, fragmented housing pathways, and social isolation are critical risk factors for relapse.
Findings from the National Confidential Inquiry into Suicide and Safety in Mental Health (2022) also underline that transitions of care — particularly discharge periods — are associated with increased risks if not well managed. Service users have repeatedly highlighted the importance of continuity of care, clear communication, and having someone they trust in the community post-discharge.
Our approach at Cygnet has been to strengthen partnerships with community teams, social care, and voluntary organisations wherever possible, to ensure smoother transitions and maintain therapeutic engagement after discharge.
Ultimately, the message is clear: if discharge is to be safe, it must be planned early, co-produced with the individual and their network, and integrated into a broader ecosystem of support.
A single readmission can undo weeks of therapeutic progress. A missed appointment can be a warning sign. A well-timed check-in can save a life. These are not marginal gains — they are the heart of what effective mental health care looks like.
We must now embed this learning into policy, commissioning, and frontline practice. The recent Safer Discharge conference hosted by Cygnet Health Care brought together service users, clinicians, commissioners, and patient safety leaders to discuss practical innovations for safe discharge planning. Themes included the importance of relational discharge planning — where trust, shared decision-making, and empowerment of the individual underpin every transition from hospital to home.
The next phase of our work will focus on implementation and evaluation — ensuring that hope does not end at the ward door, but travels with the person into their future.