Background This is the first long-term follow-up of patients discharged from a medium secure unit. Aims To describe the short- and long-term outcomes of admission for all patients discharged during a 14-year period. Method A longitudinal cohort study of all 234 patients discharged from the Denis Hill Unit, Bethlem Royal Hospital, between 1980 and 1994, followed for an average 6.6 years. Results Although 48% of admissions were from prison, only 8% returned there, with most being transferred to another psychiatric bed. One-fifth of patients spent none of the follow-up time in the community; 75% of patients had at least one readmission; only 24% were convicted of further offences. Conclusions Re-offending rates are comparable with those for patients discharged from high-security hospitals, and much lower than those for released prisoners. The high readmission rates indicate the need for a range of services to maintain former patients in the community. Declaration of interest The project was funded by a grant from the Department of Health.