After more than three decades in multiple secure mental health services, a patient at St Andrew’s Healthcare Essex has successfully transitioned into a bespoke community placement, marking a significant milestone in a long and complex care journey.

Simon*, a 55-year-old gentleman with treatment-resistant schizophrenia and significant physical and cognitive health needs, had lived in secure settings since the mid-1990s following a referral from prison. His history included long periods in high, medium and low secure care at multiple organisations. Despite being declared clinically ready for discharge in 2019, his move to the community was delayed for four years due to the exceptional complexity of his needs and the challenges in securing an appropriate placement.

While receiving care on our Danbury male low secure ward at St Andrew’s Essex, Simon required 24-hour one-to-one support in a low-stimulus environment, alongside specialist management of dysphagia, medication side effects and behaviours linked to chronic psychosis. With no family involvement and limited engagement in formal cognitive assessments, the multidisciplinary team (MDT) had to adopt a highly personalised and pragmatic approach to planning his future care.

Progress accelerated through regular delayed discharge meetings, coordinated by the IMPACT Provider Collaborative commissioning service for the East Midlands, bringing together clinicians, commissioners, social care, legal teams and community providers. After extensive national searches, a community care service offered a bespoke bungalow placement in Nottingham with 24-hour staffed support, tailored specifically to Simon’s needs.

The transition required detailed legal frameworks, multiple capacity assessments, Court of Protection approval and complex Section 117 funding agreements across Integrated Care Boards. To ensure continuity and safety, community staff worked alongside our Danbury MDT on the ward, building therapeutic relationships in an environment where Simon felt secure. A two-week overnight transition period further supported his move.

Simon was successfully discharged in September 2025, following court approval and coordinated input from the Adult Treatment Service (ATS), and with ongoing support transferred seamlessly from the South to the North team.

This outcome reflects years of persistence, collaboration and commitment from all organisations involved.  Danbury ward MDT’s deep knowledge of Simon proved invaluable, alongside the determination of commissioning and community partners to find a least-restrictive, safe and sustainable solution.

Simon is now settled in his new home, receiving consistent support within the community for the first time in decades – a powerful example of what can be achieved through partnership working, shared responsibility and patient-centred care for those with the most complex needs.

*(Patients name has been changed to protect anonymity. Image: iStock photo)