The Health Services Safety Investigations Body (HSSIB) report found examples of harm ranging from anxiety, physiological stress, post traumatic stress disorder and cases of patients dying by suicide.

Neil Alexander, senior safety investigator at HSSIB, said ‘our investigation sadly showed, the harm caused to patients when moved far from home or moved back and forth between settings can be distressing, for them and for their families'.

He added: ‘The investigation emphasised that inappropriate out of area placements are a symptom of wider issues within health and social care – financial and resources pressures, long waiting lists for social housing and a lack of true integration between the two.'

A Department of Health and Social Care spokesperson said: ‘Patient safety is paramount, and anyone receiving treatment in an inpatient mental health facility deserves safe, high-quality care, and to be treated with dignity and respect. We are grateful to HSSIB for this report, which highlights important concerns that can help us to improve inpatient mental health services. 

‘This Government will reform the Mental Health Act, to ensure that people with the most severe mental health conditions receive better, more personalised treatment that is appropriate, proportionate, and compassionate to their needs. 

‘We will work also with the NHS to transform care and recruit 8,500 more mental health workers across children and adult services to reduce delays and provide faster treatment.'