Recurring concern

Unreliable sharing of information about absent mental-health patients with police

First to latest report 8 Nov 2013 — 6 Feb 2026

Reports that mention this concern
5
Times this concern has been raised
5
Stated actions linked to this concern
11

What this concern includes

Includes failures in hospital or mental-health-service arrangements for compiling, accessing, communicating, updating or handing over clinically and operationally relevant information to police when a patient is absent, missing or reported AWOL, including information needed for police enquiries, risk assessment, location and return arrangements.

What is not included
  • Excludes the broader missing-person response, including search, classification or location failures, when the information-sharing process with police is not itself deficient.
  • Excludes generic police or healthcare information-sharing failures without an absent, missing or AWOL mental-health-patient context.
  • Excludes failures in leave authorisation, supervision or return decisions where police information sharing is not the shared unsafe condition.
  • Excludes failures to act after police have received complete and timely information, including subsequent police attendance or investigation deficiencies.

Reports and published responses 5 reports

See individual reports that have raised this concern, and the actions taken in response

  1. East London

    AI-generated summary

    Mansoor Zaman · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mansoor Zaman, a 27-year-old man with a history of suicidality, substance misuse and EUPD, absconded from a mental health ward on 8 December 2024 after displaying suicidal intent and erratic and aggressive behaviour. His body was recovered on 29 December 2024. The substantive concerns included failures to use available mental health authorisations, reassess risk and observation levels, adequately document care, and promptly report him missing to police; the inquest jury identified some of these failures as factors that probably or possibly contributed to his death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Delays in reporting an absconded patient as missing to the police

    Wider context from the report

    “6. The dilatory response of staff on the ward to report Mr Zaman as a missing person to the police, an action that did not happen for almost three hours after it was known that he had absconded. ”

    Source location

    Mansoor Zaman · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Deliver refresher training to ward staff on applying the Trust and Pan-London AWOL policies together in practice.

    Verbatim wording from the response

    “29. You heard at the inquest that the Trust’s AWOL policy has been refined and makes it clear when 999 should be called. Additionally, within the next two months, the ward staff will undergo refresher training on both policies and understand how they apply together in practice, so that AWOL procedures are followed consistently and safely.”

    Source location

    2026-0072 - Response from East London NHS Foundation Trust
    Page 6 · response
    Published 12 February 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop and implement mandatory AWOL policy training for all clinical staff, including competency assessment against both applicable AWOL policies.

    Verbatim wording from the response

    “30. The senior clinical team will also develop and implement mandatory AWOL policy training for all clinical staff, including a competency assessment covering both the Trust AWOL Policy and the Pan-London Joint AWOL Policy.”

    Source location

    2026-0072 - Response from East London NHS Foundation Trust
    Page 6 · response
    Published 12 February 2026

    Open published response

  2. Birmingham and Solihull

    AI-generated summary

    Tcherno Bari · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Tcherno Bari, who had been detained under the Mental Health Act and admitted to a psychiatric unit with psychotic depression, left the hospital grounds while assessed as at high risk of suicide. He was found deceased the following day, 26 September 2023, hanging from a tree in parkland outside the police search area. The principal concerns were significant gaps in multi-agency coordination, communication of risk information, use of risk-assessment procedures, and the handling of differing assessments between mental health staff and police.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide attending police officers with the written risk rating

    Wider context from the report

    “(1) I am not reassured BSMHFT staff are handing attending police officers ‘appendix C – risk rating’ as required by their missing person policy. I am not reassured WMP officers are aware they should be provided with ‘appendix C – risk rating’. Context: I did not accept the Nurse-in-Charge routinely used ‘appendix C – risk rating’, and police witnesses - including a Locate Sergeant, and the Head of Locate, a Detective Chief Inspector - indicated they had never seen ‘appendix C – risk rating’. ”

    Source location

    Tcherno Bari · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Replace Appendix C with a decision-recording form documenting the reasons for critical concern and provide it to attending police officers.

    Verbatim wording from the response

    “At the time of the inquest the Missing Persons Policy was being updated, in line with changes from Right Care Right Person (RCRP). Since this time the update has been completed and there have been a number of changes made. In addition the Trust have a new Executive Director of Quality and Safety/Chief Nursing officer who will be accountable for the policy. The updated policy has included valued feedback from the inquest. I can inform you that the appendix C risk rating form that you saw at the inquest has been stepped down, due to emerging evidence in the area. The new version of Appendix C form is a decision recording form which also includes a section which sets out ‘why is the risk is considered to be present’. The form will be read out to the police in the recorded phone call and it will also be handed over to the police when they attend.”

    Source location

    Response from BSMHFT
    Page 1 · response
    Published 6 June 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Establish a process for officers to request electronic risk assessments through a central Locate Team inbox with overnight supervisory monitoring.

    Verbatim wording from the response

    “WMP recognise the importance that the BSMHFT risk assessment is shared with officers (referred to as ‘Appendix C’ in the PFD report) and that attending constables know to request this. Whilst officers will be reminded, within the policy update, to request a copy of the risk assessment and to take possession of it they will also be given an email address to provide to BSMHFT. BSMHFT will be asked to provide the risk assessment (Appendix C) electronically to this email address. The risk assessment will be received into the central Locate Team inbox ensuring a hard copy document is not misplaced and enabling timely supervisory review, if required. The Locate Team inbox is only monitored until 10pm. Therefore, for overnight issues the Duty Sergeant will be asked to monitor the inbox and to escalate any issues through supervision where appropriate.”

    Source location

    Response from West Midlands Police
    Page 4 · response
    Published 6 June 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Operational and clinical partners are best placed to respond to relevant concerns and reassess local risk, communication and escalation processes.

    Verbatim wording from the response

    “Your report raises concerns about missing persons policy and Right Care, Right Person (RCRP), and I note that you have directed your report to the Department of Health and Social Care (DHSC) as a party to the National Partnership Agreement (NPA) on RCRP. I also note that you have raised concerns with other relevant partners, including representatives from Birmingham and Solihull Mental Health NHS Foundation Trust, West Midlands Police and NHS England. Given the operational independence of police forces and the autonomy of clinical decision making, those partners are best placed to respond to some of the concerns you raise. DHSC does have a role in setting guidance and direction to the mental health sector and I will respond on these points in particular.”

    Source location

    Response from DHSC
    Page 1 · response
    Published 6 June 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Specific issues concerning police ways of working are for the National Police Chiefs’ Council, College of Policing and West Midlands Police to address.

    Verbatim wording from the response

    “As you are aware, police forces are operationally independent and so it is for the National Police Chiefs’ Council, the College of Policing and West Midlands Police to address the specific issues raised about their ways of working as they relate to the inquest into the death of Mr Bari, and I know they have written to you separately on this matter.”

    Source location

    Response from the Home Office
    Page 1 · response
    Published 6 June 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Missing Persons is outside Right Care Right Person, so existing police procedures for police involvement should continue.

    Verbatim wording from the response

    “healthcare facilities. Missing Persons is not a part of this and existing police procedure regarding police involvement should continue to operate.”

    Source location

    Response from the Home Office
    Page 2 · response
    Published 6 June 2024

    Open published response

  3. Inner North London

    AI-generated summary

    Heather FINDLAY · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Heather Findlay was detained under section 2 of the Mental Health Act at Mile End Hospital and ran away while on escorted leave on 11 June 2020. She was later found by a member of the public in a nearby park; the inquest concluded that she died by suicide, with a medical cause of death of hypoxic ischaemic encephalopathy and ████████ toxicity. The principal concerns included staff preparedness and procedures when a detained patient absconds, unclear responsibilities between ELFT and the police, communication of suicide risk, and the adequacy of risk grading and organisational learning.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Confusion about police contact when a patient is missing

    Wider context from the report

    “6. ELFT staff all told me that, after Ms Findlay had run off, they still graded her as medium rather than high risk. She had had long term suicidal thoughts, had made previous attempts on her life and, prior to being admitted to hospital on 20 May 2020 had purchased ████████ and had planned to take this to kill herself. However, she had appeared to improve in hospital, and had been granted 15 minutes’ escorted leave twice a day since 1 June without incident. At one point in her evidence it appeared to me that the matron, taking the point that by running away Ms Findlay had acted in a manner that was wholly unexpected by the trust, was of the view that Ms Findlay should then have been re-categorised as high risk. However, following re-examination by counsel for ELFT the matron appeared to retract this and to return to her former position that, even after she had run away Ms Findlay was only of medium risk to herself. It is of course a matter of clinical opinion what risk grading a patient should be given, and no person can see into the future. However, • the jury found a failure by ELFT to recognise that, by 11 June 2020, Ms Findlay was at imminent risk of suicide by ████████; and • any investigation following a death like Heather Findlay’s presents an opportunity for sober and searching reflection. So I am concerned that an element of positional bias may have influenced the thinking of ELFT staff. I am concerned about this particularly because, when giving evidence at inquest, the ELFT serious incident investigation author was adamant that it was only appropriate for the HCA who called the police on 11 June 2020 after Ms Findlay had run away, to tell the police of a risk of self harm not of a risk of suicide. Her rationale for this was that the last time Ms Findlay had articulated a plan to kill herself, was when she was found in hospital with a ligature round her neck on 28 May 2020. This position seems lacking the necessary reflection. I draw your attention to earlier prevention of future deaths reports (PFDs) as follows: • Sent to ELFT on 8 June 2023 by Assistant Coroner Buckett following the inquest touching the death of Hilary (Billy) Guedalla, including concern regarding the failure of ELFT to inform the police of the serious suicide risk that the deceased posed to themselves; and the confusion among staff about who should be contacted and in what manner, once a patient was found to be missing. • Sent to ELFT on 25 January 2023 by me following the inquest touching the death of Andrew Largin, including concern about omissions from a serious incident investigation. • Sent to ELFT on 20 October 2021 by me following the inquest touching the death of Freeda Glausiusz, including concern about a lack of learning culture at ELFT. ”

    Source location

    Heather FINDLAY · Prevention of Future Deaths report
    Page 6 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement the Right Care, Right Person approach with health partners, aligning policies, terminology and information requirements for risk assessment and police support.

    Verbatim wording from the response

    “The Commissioner of the Metropolitan Police, ████████, wrote to Health and Social Care Partners on 24th May 2023, to set out the Met Police’s intention to implement the national Right Care, Right Person approach. Under Assistant Commissioner ████████ a team is now working to put this in place, and an initial senior board has taken place with senior health and social care providers to work towards RCRP implementation. This is also in parallel with the work being done by health care providers on the London mental health concordat. A key aspect of this is working with all of the”

    Source location

    Response from Metropolitan Police
    Page 5 · response
    Published 22 June 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review the Trust’s responses and related reports to determine whether further action is needed.

    Verbatim wording from the response

    “I do however take the concerns raised seriously, and I thank you for bringing them to my attention, together with the other Reports to Prevent Future Deaths you highlight concerning the care of other patients at the Trust. I have asked that NHS England is sighted on the Trust’s response to your Report, as well as the responses to the other cases and we will consider these carefully, to include whether any further action needs to be taken. I have already been sighted on the Trust’s Patient Safety Serious Incident Review Report on this matter and note that they have taken a learning to ensure that the police are provided with a direct dial number whenever reporting a patient absconding, which did not happen in this case.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 22 June 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Revise the Missing and AWOL Policy to clarify safe responses when patients abscond from escorted leave.

    Verbatim wording from the response

    “Although this was the practice in operation at the time, the Trust has taken action to review the relevant part of its Missing and Absent Without Leave (AWOL) Policy to reflect this practice. The updated version will read as below:”

    Source location

    Response from East London NHS Foundation Trust
    Page 1 · response
    Published 22 June 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Operational decisions about missing-person investigations are outside the Home Office’s authority.

    Verbatim wording from the response

    “With regards to the response to the missing person report made by the East London Foundation Trust (ELFT) to the Metropolitan Police Service (MPS), the police investigation of a missing person report is an operational decision for individual police forces. The Home Office has no authority to intervene in operational policing matters. I cannot comment on the action and decisions taken by police officers in the course of their duties because operational matters are the responsibility of the Chief Officer of the force concerned. However, my officials have consulted the MPS to gain assurance that the correct protocols are in place in order to prevent future incidents of this nature.”

    Source location

    Response from Home Office
    Page 2 · response
    Published 22 June 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Responsibility for operational missing-person decisions rests with individual police forces and their Chief Officers.

    Verbatim wording from the response

    “With regards to the response to the missing person report made by the East London Foundation Trust (ELFT) to the Metropolitan Police Service (MPS), the police investigation of a missing person report is an operational decision for individual police forces. The Home Office has no authority to intervene in operational policing matters. I cannot comment on the action and decisions taken by police officers in the course of their duties because operational matters are the responsibility of the Chief Officer of the force concerned. However, my officials have consulted the MPS to gain assurance that the correct protocols are in place in order to prevent future incidents of this nature.”

    Source location

    Response from Home Office
    Page 2 · response
    Published 22 June 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The MPS Affinity Protocol is considered sufficient because it reflects the NPCC framework for missing persons from healthcare settings.

    Verbatim wording from the response

    “The MPS response will set out details of its Affinity Protocol, a joint agreement between the MPS and ELFT, which aligns with the NPCC’s framework, published in October 2020, and accessible at https://www.gov.uk/government/publications/the-multi-agency-response-for-adults-missing-from-health-and-care-settings-a-national-framework-for-england.”

    Source location

    Response from Home Office
    Page 2 · response
    Published 22 June 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Many concerns concern East London Foundation Trust and Metropolitan Police policy, making NHS England inappropriate to respond to them.

    Verbatim wording from the response

    “The concerns in your Report relate to organisational policy at East London Foundation Trust as well as policy within the Metropolitan Police Service. NHS England is not therefore the appropriate organisation to respond to many of the concerns raised.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 22 June 2023

    Open published response

  4. West Sussex

    AI-generated summary

    Jack Stephen TAYLOR · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jack Stephen TAYLOR was a detained inpatient who left escorted leave on 17 March 2021 and was found unresponsive at premises in Worthing on 19 March 2021, where he died despite urgent medical assistance. The report raised concerns about Mill View Hospital’s reliance on police support and failure to consider the full range of powers for returning absconded patients, as well as weaknesses in joint hospital-police AWOL and missing-person procedures that could delay locating and returning high-risk patients.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to require early provision of current risk assessments and completed AWOL forms

    Wider context from the report

    “2. The joint Sussex Partnership NHS Trust & Sussex Police ‘Absent Without Leave (AWOL) Policy’ I heard evidence that the risk assessment grading criteria set out in Appendix B of this policy did not match the risk assessment grading criteria for missing persons as defined by the College of Policing. I heard evidence that the policy did not require the PICU staff to provide a copy of an up-to-date risk assessment document or their completed AWOL forms at an early stage when reporting a patient as having absconded. I heard evidence that the PICU staff did not routinely discuss the clinician’s assessment of the grading of the level of risk (i.e. high, medium, low) with the police call-taker nor ask for the police call-taker’s decision on such risk level despite it being a requirement of the policy document. I am concerned that the lack of effective joint working may hamper the swift return of high risk patients to the secure environment of the ward which is necessary for their own and others protection. ”

    Source location

    Jack Stephen TAYLOR · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Co-develop a Missing Persons Template and accompanying action plan to improve information sharing and joint risk assessment.

    Verbatim wording from the response

    “Developing a Missing Persons Template (including an action plan)”

    Source location

    2022-0029-Response-from-Sussex-Police_Published
    Page 1 · response
    Published 3 February 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Embed the completed Missing Persons Template, protocol and joint action plan into the revised multi-agency AWOL policy and practice.

    Verbatim wording from the response

    “Work will take place to move towards having a final draft in May 2022, when the completed template and accompanying protocol surrounding it will then be embedded into the multi-agency Absence Without Leave (AWOL) policy which is currently subject to multi-agency review and revision.”

    Source location

    2022-0029-Response-from-Sussex-Police_Published
    Page 2 · response
    Published 3 February 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Co-develop a missing persons template and accompanying protocol for timely information-sharing and joint risk assessment.

    Verbatim wording from the response

    “Developing a Missing Persons Template (including an action plan)”

    Source location

    2022-0029-Response-from-Sussex-Partnership-NHS-Foundation-Trust_Published
    Page 2 · response
    Published 3 February 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Revise the multi-agency AWOL Policy and embed the missing persons template, protocol and action plan into policy and practice.

    Verbatim wording from the response

    “Work will take place to move towards having a final draft in May, when the completed template and accompanying protocol surrounding it will then be embedded into the multi-agency Absent Without Leave (AWOL) Policy which is currently subject to multi-agency review and revision.”

    Source location

    2022-0029-Response-from-Sussex-Partnership-NHS-Foundation-Trust_Published
    Page 2 · response
    Published 3 February 2022

    Open published response

  5. West Yorkshire (West)

    AI-generated summary

    Peter Patrick Adrian Barnes · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Peter Patrick Adrian Barnes died from asphyxia caused by hanging in the grounds of Cygnet Hospital, Wyke, while detained under Section 3 of the Mental Health Act 1983. Serious incidents known to nursing staff, including comments about suicide and marks on his neck, were not communicated to the Responsible Clinician, who granted unescorted leave. The report raised concerns about systems for communicating and auditing information and care decisions, involving families in care decisions, and sharing information with police when patients were absent without leave.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inadequate access by staff reporting absent patients to information required by police

    Wider context from the report

    “(5) The hospital’s procedure for responding to patients being absent without leave included reporting such patients to the police as missing persons, but did not appear to be adequate to ensure that members of staff so reporting, or thereafter giving further information, to the police had access to all of the information about the patient which was likely to be required by the police for the purpose of their enquiries. ”

    Source location

    Peter Patrick Adrian Barnes · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Back to top

Data last updated 7 September 2026