Nursing home “no returns” policy, when residents are discharged to the emergency department at 4 am: what does the law say?

To the Editor: We note with interest the letter from Peisah and colleagues.1 A group of oft‐forgotten patients also affected by “no returns” policies is older people with mental illness. We have recent experience of a 72‐year‐old man with diagnoses of schizoaffective disorder and Alzheimer dementia who was admitted to an aged mental health inpatient unit with a relapse of his schizoaffective disorder. He was admitted from a nursing home where he had resided for 4 years, during which time his illness had been stable except for an admission some 12 months earlier.

On admission, after minor changes to his pharmacological management, supportive psychotherapy and allied health input, his condition returned to baseline. When the medical team liaised with his nursing home to arrange his return, they were informed that he could not return because they did not have the facilities required for him. When the patient was informed of this, there was subsequent deterioration in his mental state. After his brother with enduring power of attorney threatened legal action, he was accepted back at the home. The community mental health team who are continuing his care in the community have indicated that he remains stable following discharge.

There is a high proportion of nursing home residents with a mental illness other than dementia.2 United States and Canadian data suggest that older adults with mental illness experience stigma from nursing homes (mostly due to fear of aggression and other behaviour) and poor quality care.3 Such patients tend to be placed in the first instance in nursing homes with deficiencies in care and with a paucity of resources and specialised expertise to provide care for this group;4 this probably explains the recourse to the “no returns” policy experienced by our patient. Such situations cause harm to the patient and contribute to bed block in hospitals.5 The issues involving this particularly vulnerable population will hopefully be uncovered in the Royal Commission into Aged Care Quality and Safety. We encourage improved mental health literacy in Australian nursing homes.