Recurring concern
Unreliable mental-health patient leave arrangements
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Request correctionFirst reported 21 Oct 2013•Latest report 1 Jun 2026
What this concern includes
Includes failures in dedicated mental-health patient-leave arrangements, including assessment of readiness and community risks, use of extended or escorted leave to assess functioning, leave decision-making, communication of conditions, documentation, family or staff information, and agreed actions if the leave plan breaks down.
Not included
- Excludes general mental-health assessment, discharge or care-planning failures where patient leave is not the deficient process.
- Excludes generic documentation, communication, staffing or risk-assessment deficiencies unless they directly impair a mental-health patient-leave arrangement.
- Excludes substance-use investigation during leave unless it is part of the leave-safety decision or response process.
- Excludes routine absence, travel or tenancy-support concerns outside a mental-health patient-leave context.
- Reports
- 22
- Individual concerns
- 32
- Date range
- 2013–2026
- Stated actions
- 29
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
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Concerns raised2
Failure to prevent and scrutinise access to unauthorised or rescinded Section 17 Leave
Failure to ensure staff understand Section 17 Leave requirements and conduct required risk assessments
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Inconsistent approach to leave and return for detained and voluntary patients
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Develop a replacement electronic patient record system incorporating redesigned risk assessment, safety planning, leave documentation and monitoring capabilities.
Stated by South London and Maudsley NHS Foundation Trust -
Action
Review and update the leave, informal-patient leave, and absent-or-missing-person policies to align practice, NICE guidance and legal requirements, including photographs and voluntary-patient checklists.
Stated by South London and Maudsley NHS Foundation Trust -
Action
Develop a standardised leave log suitable for detained and informal patients.
Stated by South London and Maudsley NHS Foundation Trust
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Concerns raised2
Failure to document and formalise leave reinstatement decisions
Leave management by a non-s12 doctor during responsible-clinician absence
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Document all clinical and Mental Health Act decisions in patient files, the DSR system and relevant meeting minutes.
Stated by Alternative Futures Group Limited -
Action
Reissue section 17 guidance and use separate escorted/emergency and unescorted leave forms for each patient.
Stated by Alternative Futures Group Limited
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Concerns raised1
Failure to individually assess whether to suspend section 17 leave when a patient goes AWOL
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Mandate MDT risk assessment after every AWOL incident and prompt Responsible Clinician review of leave status.
Stated by South London and Maudsley NHS Foundation Trust
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Concerns raised4
Lack of guidance on staff bathroom arrangements while accompanying patients on leave
Capacity-shaped local policies for Section 17 leave
Lack of consistency in definitions of accompanied and escorted leave
Inconsistent guidance on whether patients should remain within eyeline or at a reasonable distance during leave
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Revise the Mental Health Act Code of Practice after introducing the reform legislation.
Stated by Department of Health and Social Care -
Action
Consider the reported inconsistencies and identify further changes to strengthen statutory guidance.
Stated by Department of Health and Social Care
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Concerns raised1
Failure to consult medical notes and records during leave risk assessment
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Remind Gardner Ward and City and Hackney inpatient staff to record clinical decisions, review RIO notes, and discuss leave-recording requirements at scheduled away days.
Stated by East London NHS Foundation Trust
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Concerns raised1
Inadequate risk assessment and planning for s.17 leave
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Share learning on documented risk assessment through supervision, consultant meetings, trust-wide dissemination and the Care Hub Quality Learning forum.
Stated by Pennine Care NHS Foundation Trust -
Action
Continue booking staff onto Clinical Risk Formulation and STORM training, while monitoring uptake and compliance with essential-to-role training.
Stated by Pennine Care NHS Foundation Trust
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Concerns raised2
Failure to provide the family with the Section 17 leave form
Failure to record completion of a pre-leave risk assessment
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Introduce the new Record of Patient Leaving Ward document across Trust wards and provide local staff training on its consistent use.
Stated by Sussex Partnership NHS Foundation Trust
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Concerns raised1
Failure to consider and approve or refuse patients' escorted leave requests
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised2
Failure to determine sufficient escort numbers for ground leave
Failure to define permissible physical interventions during escorted leave
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Develop and incorporate scenario-based escorting and leave-risk decision-making training into initial and updated PMVA training for all staff, including bank staff.
Stated by Leeds and York Partnership NHS Foundation Trust -
Action
Communicate case learning through procedures and provide staff with clear guidance on actions when escorted leave breaks down or a patient leaves the escort.
Stated by Leeds and York Partnership NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Physical touch was considered likely to increase distress and emotional dysregulation, so alternative support strategies were preferred.
Stated by Leeds and York Partnership NHS Foundation Trust
Data last updated 7 September 2026