Recurring concern

Unreliable mental-health patient leave arrangements

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First reported 21 Oct 2013•Latest report 1 Jun 2026

Definition

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

Distinct published reports

Individual concerns
32

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
29

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.

Department of Health and Social Care3
Surrey and Borders Partnership NHS Foundation Trust3
Metropolitan Police Service2
South London and Maudsley NHS Foundation Trust2
Sussex Partnership NHS Foundation Trust2
Alternative Futures Group Limited1
Ashford and St Peter'S Hospitals NHS Foundation Trust1
Berrywood Hospital1
Cambridgeshire and Peterborough NHS Foundation Trust1
Central and North West London NHS Foundation Trust1
College of Policing1
East London NHS Foundation Trust1
Epsom and St Helier University Hospitals NHS Trust1
Essex Partnership University NHS Foundation Trust1
Frimley Health NHS Foundation Trust1

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.

  1. Surrey

    AI-generated summary

    Kimberley Smith · 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

    Kimberley Smith, who had a history of mental health conditions, alcohol dependency and self-harm, died by suicide after leaving an inpatient psychiatric unit while on unescorted leave and being found with a plastic bag over her head. The concerns included inadequate risk assessment and management of alcohol use and leave, failures in observation and missing-person procedures, and the absence of clear written policies for informal and detained patients leaving the unit.

    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

    Alcohol detoxification protocols lacking management of leave requests during treatment

    Wider context from the report

    “During the course of the inquest the court also heard that following Miss Smith’s death SABP carried out a Serious Incident investigation which resulted in the following recommendation, ‘To develop a protocol for managing alcohol detoxification on mental health wards, including specific care plans, minimum monitoring and how to manage leave requests during treatment.’ The court heard that a protocol has been developed to manage the medical aspects of alcohol detoxification but does not cover care plans, minimum monitoring or the management of leave request during treatment. It is of concern that these aspects of the recommendation remain outstanding and consideration should be given to implementing them as a matter of urgency. ”

    Source location

    Kimberley Smith · 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

    Complete guidance on alcohol detoxification for people admitted to inpatient wards.

    Verbatim wording from the response

    “Our response: The Trust has now completed its guidance regarding “Alcohol detoxification for people admitted to inpatient wards”.”

    Source location

    2020-0279-Response-from-Surrey-and-Borders-Partnership-NHS-Foundation-Trust-Redacted
    Page 2 · response
    Published 6 January 2021

    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 guidelines for managing people with alcohol use disorders on mental health wards, covering withdrawal monitoring, leave, risk assessments and care planning.

    Verbatim wording from the response

    “We are also developing new guidelines for “Management of People with Alcohol Use Disorders (AuDs) Admitted to Mental Health Wards”. The new guidelines cover the following: monitoring of patients during withdrawal and detoxification (both physical and mental health), leave, risk assessments and care planning.”

    Source location

    2020-0279-Response-from-Surrey-and-Borders-Partnership-NHS-Foundation-Trust-Redacted
    Page 3 · response
    Published 6 January 2021

    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

    Train and support inpatient staff to implement the alcohol-use-disorder guidelines through collaboration between detoxification nurses and inpatient Advanced Clinical Practitioners.

    Verbatim wording from the response

    “Once complete, i-access detoxification nurses will work with the inpatient Advanced Clinical Practitioners to train and support inpatient staff to put the guidelines into practice.”

    Source location

    2020-0279-Response-from-Surrey-and-Borders-Partnership-NHS-Foundation-Trust-Redacted
    Page 3 · response
    Published 6 January 2021

    Open published response

  2. Central Hampshire

    AI-generated summary

    Sasha Sabrina FORSTER · 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

    Sasha Sabrina FORSTER, a 20-year-old woman with a lengthy history of mental health disorders, self-harm and overdoses, died by suicide following deliberate ingestion of a fatal overdose of Propranolol tablets. The inquest identified concerns that hospitals and police forces were not always aware of their powers and responsibilities when her section 17 leave was revoked, or had not agreed and updated a common plan, resulting in inconsistent actions and an increased risk to Sasha.

    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 finalise the formal revocation of s.17 leave

    Wider context from the report

    “(1) Evidence was given during the inquest by SBP staff on the ward concerned, that the reason SBP staff did not arrange to collect Sasha and return her to the ward when her s.17 leave had been revoked, was that they did not have the resources to allow them to do this, despite it being their legal responsibility so to do. (2) Sasha’s mother gave evidence that SBP’s reliance on her bringing Sasha back to the ward when s.17 leave had been revoked, placed an unfair and intolerable burden on her, in circumstances when she and the rest of the family were struggling to keep Sasha safe. Knowing that SBP would not send someone out to collect Sasha made her feel that she had no choice but to agree to their request. (3) The last such occasion when SBP staff on the ward decided that Sasha’s s.17 leave should be revoked was on the afternoon of her death on 31.3.17. Although formal revocation of leave was never finalised, Sasha’s mother was given to believe that it would be, and again reluctantly agreed to bring Sasha back to the ward. Whilst with her mother, Sasha was able to run off and take the substantial Propranolol overdose which proved to be fatal. ”

    Source location

    Sasha Sabrina FORSTER · 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

    Develop and include a section 17 leave revocation template in the Trust’s section 17 leave policy.

    Verbatim wording from the response

    “If the decision is made to revoke the person’s leave this should be documented in the person’s notes before the SABP section 18 form or any other paperwork is completed (this means it will be visible to others accessing the record on SystmOne). It is preferable for this to be documented by the clinician who makes the decision to revoke the leave.”

    Source location

    Sasha-Forster-R2019-01692
    Page 5 · response
    Published 2 August 2019

    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

    Include a written-authority template in the AWOL policy, update the policy with PFD learning, and present it to the Policy Assurance Group by September 2019.

    Verbatim wording from the response

    “If the person is known to frequent emergency departments, frequently call the emergency services, or frequent another place where professionals are present, early consideration should be given to providing those services with written authority to take the person into custody and return them to the ward (they should be supported by SABP, the Police, and ambulance services (NHS or private / secure), in doing this as appropriate).”

    Source location

    Sasha-Forster-R2019-01692
    Page 5 · response
    Published 2 August 2019

    Open published response

  3. West Sussex

    AI-generated summary

    John Peter RICHARDSON · 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

    John Peter Richardson was admitted as a voluntary patient to Meadowfields Hospital with suicidal thoughts and went missing after leaving the hospital grounds on 3 February 2018. His body was found in woodlands on 4 February 2018, and death was confirmed at the scene. The report identified concerns including the absence of a further risk assessment and care plan, poor communication and record keeping, and confusion about his leave arrangements.

    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

    Lack of a specific leave policy for voluntary patients

    Wider context from the report

    “(2) However the death of Mr Richardson appears to have occurred when there was some confusion amongst staff with regards to Mr Richardson’s leave status. This was identified by the Jury in their conclusion. Whilst some guidance is provided to staff, with regards to voluntary patients taking leave, there is no specific Leave Policy for Voluntary Patients in the same way as there is one for those patients sectioned under the Mental Health Act. ”

    Source location

    John Peter RICHARDSON · 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

    Include guidance on voluntary patients leaving wards in the new Acute Care Operational Policy.

    Verbatim wording from the response

    “Following receipt of your letter, we have given considerable further thought as to how best we might improve our staff’s understanding of the principles to be followed when voluntary patients leave the wards. The decision we have taken is to include guidance in our new Acute Care Operational Policy. I have enclosed a copy of that guidance for your information. As you will see, it covers both s.17 leave as well as the principles that need to be applied to voluntary patients. Presenting the guidance in this way was considered to be preferable to any further stand-alone policy. It is hoped that this will be highly accessible and provide immediate access to the key principles, coupled with signposting to other documents if more information is required.”

    Source location

    2019-0084-Response-by-Sussex-Partnership-NHS-Trust
    Page 1 · response
    Published 9 June 2019

    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

    No further standalone policy is considered necessary because the principles are incorporated into the new Acute Care Operational Policy.

    Verbatim wording from the response

    “Following receipt of your letter, we have given considerable further thought as to how best we might improve our staff’s understanding of the principles to be followed when voluntary patients leave the wards. The decision we have taken is to include guidance in our new Acute Care Operational Policy. I have enclosed a copy of that guidance for your information. As you will see, it covers both s.17 leave as well as the principles that need to be applied to voluntary patients. Presenting the guidance in this way was considered to be preferable to any further stand-alone policy. It is hoped that this will be highly accessible and provide immediate access to the key principles, coupled with signposting to other documents if more information is required.”

    Source location

    2019-0084-Response-by-Sussex-Partnership-NHS-Trust
    Page 1 · response
    Published 9 June 2019

    Open published response

  4. Blackpool and the Fylde

    AI-generated summary

    Adam James Carter · 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

    Adam James Carter died on 10 September 2017 after absconding from The Harbour mental health facility during escorted leave and falling from the fifth floor of a car park. The principal concern was inadequate record keeping about Adam’s risks, leave arrangements, leave authorisation and assessment before leave, which could affect staff decisions about patient safety.

    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

    Insufficient recording and care planning of patient leave, including its rationale, benefits and risks

    Wider context from the report

    “The concern relates to record keeping. During his independent review of this matter, a Consultant Psychiatrist identified some discrepancies within the medical records including the following: • Although he felt that the therapeutic team had an understanding of the extent to which Adam posed a risk of: - aggression and violence; - self harm; - suicidal behaviour; - absconding; He did not feel that these risks were documented or clearly formulated in the medical notes. • He stated that there was very little detail in the documentation as regards Adam’s use of leave nor of care planning of his leave. The rationale for leave having been granted was not recorded nor were the benefits and risks associated with leave. • He was unable to find a record of an assessment of Adam’s clinical state by nursing staff immediately before the period of escorted ground leave on 10th September 2017 as required by trust policy (although he did not feel that this would have any bearing on the decision to afford Adam leave on this occasion). • He could not find a copy of the Leave Authorisation that granted Adam leave and felt that documentation of leave fell short of the guidance laid out in the Trust policy for the authorisation of section 17 leave of absence. Clearly the quality of record keeping is important in the context of a detained mental health patient. Adam had spent some time in a Psychiatric Intensive Care Unit and then a number of days on an acute inpatient ward prior to the events of 10th September 2017. The level of risk such a patient poses as regards issues such as the risk of self harm and absconding are fundamental to the care provided. Plans were being made for Adam to be discharged and into the community rather than back to his parents’ home and he was being afforded the opportunity to build towards that discharge by granting him leave which was an important step in progressing towards that goal. However, such decisions need to be made appropriately and informed by how the risk a patient poses is viewed at that time. It is vital that the basis for such decisions is clear from the records. If this does not happen then I have a concern that future deaths may result – inevitably patients such as Adam are cared for by a team consisting of different staff performing different shifts. Staff taking over the care of a patient such as Adam ought not to have to rely on the verbal information provided to them and handover of that patient’s care but need to have the opportunity to read the records and to remind themselves how the risk their patient poses is viewed by for example the relevant Consultant Psychiatrist, and why he or she has been granted leave. The court heard that escorted grounds leave was granted to Adam but that nursing staff had discretion as regards whether that leave went ahead and they may exercise such discretion subject to how Adam presented, his behaviour on the ward etc. If they cannot access accurate and informative records, such staff may make decisions that are not in the interests of their patients. Leave may proceed on a basis not felt to be safe. Leave may be declined because the staff member – unable to access the relevant information – decides to err on the side of caution and declines leave to the detriment of that patient’s progress and the condition of his / her mental health. It seems to me that if an independent consultant psychiatrist has conducted a review and identified these issues in relation to records it should inevitably prompt a concern on my part that unless I write a report such as this one future deaths may result. I therefore raise the concern. I cannot be prescriptive about what action should be taken and I make no recommendations but simply raise the issue. At the conclusion of the inquest, I indicated to the Properly Interested Persons that I proposed to write to the Department of Health by way of a report in accordance with the provisions of paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009. ”

    Source location

    Adam James Carter · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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 retain leave authorisation documentation in accordance with section 17 leave guidance

    Wider context from the report

    “The concern relates to record keeping. During his independent review of this matter, a Consultant Psychiatrist identified some discrepancies within the medical records including the following: • Although he felt that the therapeutic team had an understanding of the extent to which Adam posed a risk of: - aggression and violence; - self harm; - suicidal behaviour; - absconding; He did not feel that these risks were documented or clearly formulated in the medical notes. • He stated that there was very little detail in the documentation as regards Adam’s use of leave nor of care planning of his leave. The rationale for leave having been granted was not recorded nor were the benefits and risks associated with leave. • He was unable to find a record of an assessment of Adam’s clinical state by nursing staff immediately before the period of escorted ground leave on 10th September 2017 as required by trust policy (although he did not feel that this would have any bearing on the decision to afford Adam leave on this occasion). • He could not find a copy of the Leave Authorisation that granted Adam leave and felt that documentation of leave fell short of the guidance laid out in the Trust policy for the authorisation of section 17 leave of absence. Clearly the quality of record keeping is important in the context of a detained mental health patient. Adam had spent some time in a Psychiatric Intensive Care Unit and then a number of days on an acute inpatient ward prior to the events of 10th September 2017. The level of risk such a patient poses as regards issues such as the risk of self harm and absconding are fundamental to the care provided. Plans were being made for Adam to be discharged and into the community rather than back to his parents’ home and he was being afforded the opportunity to build towards that discharge by granting him leave which was an important step in progressing towards that goal. However, such decisions need to be made appropriately and informed by how the risk a patient poses is viewed at that time. It is vital that the basis for such decisions is clear from the records. If this does not happen then I have a concern that future deaths may result – inevitably patients such as Adam are cared for by a team consisting of different staff performing different shifts. Staff taking over the care of a patient such as Adam ought not to have to rely on the verbal information provided to them and handover of that patient’s care but need to have the opportunity to read the records and to remind themselves how the risk their patient poses is viewed by for example the relevant Consultant Psychiatrist, and why he or she has been granted leave. The court heard that escorted grounds leave was granted to Adam but that nursing staff had discretion as regards whether that leave went ahead and they may exercise such discretion subject to how Adam presented, his behaviour on the ward etc. If they cannot access accurate and informative records, such staff may make decisions that are not in the interests of their patients. Leave may proceed on a basis not felt to be safe. Leave may be declined because the staff member – unable to access the relevant information – decides to err on the side of caution and declines leave to the detriment of that patient’s progress and the condition of his / her mental health. It seems to me that if an independent consultant psychiatrist has conducted a review and identified these issues in relation to records it should inevitably prompt a concern on my part that unless I write a report such as this one future deaths may result. I therefore raise the concern. I cannot be prescriptive about what action should be taken and I make no recommendations but simply raise the issue. At the conclusion of the inquest, I indicated to the Properly Interested Persons that I proposed to write to the Department of Health by way of a report in accordance with the provisions of paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009. ”

    Source location

    Adam James Carter · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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 record nursing assessment of clinical state immediately before escorted ground leave

    Wider context from the report

    “The concern relates to record keeping. During his independent review of this matter, a Consultant Psychiatrist identified some discrepancies within the medical records including the following: • Although he felt that the therapeutic team had an understanding of the extent to which Adam posed a risk of: - aggression and violence; - self harm; - suicidal behaviour; - absconding; He did not feel that these risks were documented or clearly formulated in the medical notes. • He stated that there was very little detail in the documentation as regards Adam’s use of leave nor of care planning of his leave. The rationale for leave having been granted was not recorded nor were the benefits and risks associated with leave. • He was unable to find a record of an assessment of Adam’s clinical state by nursing staff immediately before the period of escorted ground leave on 10th September 2017 as required by trust policy (although he did not feel that this would have any bearing on the decision to afford Adam leave on this occasion). • He could not find a copy of the Leave Authorisation that granted Adam leave and felt that documentation of leave fell short of the guidance laid out in the Trust policy for the authorisation of section 17 leave of absence. Clearly the quality of record keeping is important in the context of a detained mental health patient. Adam had spent some time in a Psychiatric Intensive Care Unit and then a number of days on an acute inpatient ward prior to the events of 10th September 2017. The level of risk such a patient poses as regards issues such as the risk of self harm and absconding are fundamental to the care provided. Plans were being made for Adam to be discharged and into the community rather than back to his parents’ home and he was being afforded the opportunity to build towards that discharge by granting him leave which was an important step in progressing towards that goal. However, such decisions need to be made appropriately and informed by how the risk a patient poses is viewed at that time. It is vital that the basis for such decisions is clear from the records. If this does not happen then I have a concern that future deaths may result – inevitably patients such as Adam are cared for by a team consisting of different staff performing different shifts. Staff taking over the care of a patient such as Adam ought not to have to rely on the verbal information provided to them and handover of that patient’s care but need to have the opportunity to read the records and to remind themselves how the risk their patient poses is viewed by for example the relevant Consultant Psychiatrist, and why he or she has been granted leave. The court heard that escorted grounds leave was granted to Adam but that nursing staff had discretion as regards whether that leave went ahead and they may exercise such discretion subject to how Adam presented, his behaviour on the ward etc. If they cannot access accurate and informative records, such staff may make decisions that are not in the interests of their patients. Leave may proceed on a basis not felt to be safe. Leave may be declined because the staff member – unable to access the relevant information – decides to err on the side of caution and declines leave to the detriment of that patient’s progress and the condition of his / her mental health. It seems to me that if an independent consultant psychiatrist has conducted a review and identified these issues in relation to records it should inevitably prompt a concern on my part that unless I write a report such as this one future deaths may result. I therefore raise the concern. I cannot be prescriptive about what action should be taken and I make no recommendations but simply raise the issue. At the conclusion of the inquest, I indicated to the Properly Interested Persons that I proposed to write to the Department of Health by way of a report in accordance with the provisions of paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009. ”

    Source location

    Adam James Carter · 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

    Consider amending the Leave Policy to include additional requirements for care planning regular patient leave.

    Verbatim wording from the response

    “Leave that is given regularly to a patient is already discussed and agreed in the context of the Multi Disciplinary Team, and should be documented in the clinical record, however some points around how this is care planned are not currently included in our Leave Policy and so the Mental Health Law Manager will consider a minor amendment to the policy by 28 September 2018.”

    Source location

    2018-0226-Response-by-Lancashire-Care-NHS-Trust
    Page 2 · response
    Published 23 September 2018

    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

    Pilot leave diaries in secure services to assess whether they improve the quality of post-leave documentation.

    Verbatim wording from the response

    “How leave went for the patient should already be documented and discussed in the wider MDT forum; in addition a pilot of “leave diaries” is currently taking place in our secure services, if it is found to increase the quality of post leave documentation this will later be rolled out to all wards.”

    Source location

    2018-0226-Response-by-Lancashire-Care-NHS-Trust
    Page 2 · response
    Published 23 September 2018

    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

    Write to consultants and ward managers reiterating the need to document the rationale, risks and benefits for each patient accessing leave.

    Verbatim wording from the response

    “The Clinical Director will write to consultants and ward managers about these actions by 14 September 2018 and reiterate the importance of documenting the rationale, risks and benefits for each individual accessing leave.”

    Source location

    2018-0226-Response-by-Lancashire-Care-NHS-Trust
    Page 2 · response
    Published 23 September 2018

    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

    Include the actions’ impact in a clinical audit, then review findings and provide feedback through team clinical supervision.

    Verbatim wording from the response

    “The impact of the above actions will be included in a clinical audit in January 2019. Matrons and ward managers will then review the findings from these audits and feed the results back during clinical supervision with their teams.”

    Source location

    2018-0226-Response-by-Lancashire-Care-NHS-Trust
    Page 2 · response
    Published 23 September 2018

    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

    Prompt nursing teams to reassess patients’ risks and mental state immediately before leave and document the decision in clinical records.

    Verbatim wording from the response

    “Once leave has been agreed by the Multi Disciplinary Team, the nursing team on each ward will be prompted to fully consider the patients risks and state of mind immediately prior to the patient taking this leave, and reminded to document their up to date decision in the clinical record.”

    Source location

    2018-0226-Response-by-Lancashire-Care-NHS-Trust
    Page 1 · response
    Published 23 September 2018

    Open published response

  5. Inner South London

    AI-generated summary

    Rastislav Petrisko · 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

    Rastislav Petrisko, who had a history of suicide attempts, drug and alcohol misuse, and mental health admissions, took a fatal overdose after being granted unescorted leave from a mental health ward. The concerns included an apparently unsuitable low-risk assessment, inappropriate unescorted leave, delayed notification of police when he failed to return, and differing approaches to risk assessment.

    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 use a consistent risk-assessment method for vulnerable patients granted leave

    Wider context from the report

    “The responsible clinician (RC) assessed the patient as low risk on granting an hour’s unescorted leave in the local area from 13th. He said that he was not mentally unstable, which would trigger an escort. He was no longer expressing suicidal thoughts. The RC did not consider that Mr Petrisko was an immediate risk to himself, although the past medical history established a higher long term risk. He had already taken leave several times without self-harming (although unknown to the doctor he had returned drunk on 8th whilst in another unit). Although there was reference to recent or pending drug testing there was no record of the result of any drug screening on return from leave in this admission. A nurse indicated that being high risk made no difference to the likelihood of drug screening and the RC indicated that he may still be given leave if he was high risk. However a mental health nurse on the ward said that he was given leave as he was low risk. The risk assessments were guided by the statutory guidance of the Mental Health Act and were not subject to further local guidance. In retrospect the RC did not change his risk assessment. A missing persons form was completed by the ward. His risk was described as concern he would take large amount of drugs and alcohol, which would affect his mental state and that it was not out of character. In answer to the question whether he was likely to commit suicide, was written: “Was admitted with overdose cocaine and medication with suicidal intent”. The police were called at 21.56 and attended at 23.30, by which time emergency services were already in attendance to him in the car park, following a 999 call. As he was low risk the local policy on handling patients who had absconded at the time indicated that he could be given a period of grace before the police were notified, if he did not return at the allotted time. This was given as he had a history of being late back from leave. The ward notified the police 1 hour 49 minutes after he was due back, a period of time acknowledged to be too long. The policy in place made clear that a high risk patient should be reported immediately. The revised Trust policy continues that requirement, removes the period of grace but leaves it to the discretion of the clinicians when to call the police, if the patient is deemed not to be high risk. The DI from the Metropolitan Police Service indicated on reviewing the case, that he would be classed as medium risk, not low risk. High risk is an immediate risk to life, when a DI is deployed immediately to investigate and search. Medium Risk is that the risk to life is not immediate, but is a concern. An investigation and search is begun within the hour. Low risk is where there are no immediate concerns. The investigation may not begin straight away but take a few days. She further said that an immediate action would be to identify the places from which he had been admitted before. The medical records indicated that of the last three admissions he had been brought in from the Calderwood Street Car Park on two occasions (13.12.16 and 05.01.17). That was the site where he took the final fatal overdose. Thus if the police had been rung immediately, and assuming they took no action for the whole of the first hour, they would have had at least 49 minutes to find him in this site, which on the facts of the present case would enable an inference to be drawn that his life would have been saved. Thus the risk assessment by the police would seem to enable some deaths to be prevented, which would not necessarily on application of the assessment of the responsible physician, as immediate reporting only occurs if the patient is high risk. It is of concern that there are two different methods of assessing the risk when a vulnerable patient is granted leave, both in operation, one with greater potential of saving his life than the other. ”

    Source location

    Rastislav Petrisko · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. South Wales Central

    AI-generated summary

    Khuong Lam · 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

    Khuong Lam, a 42-year-old man with schizophrenia, died after absconding while on Section 17 leave, following a struggle involving pressure to the neck. The concerns included the lack of review or revocation of Section 17 leave when he was transferred to the Psychiatric Intensive Care Ward, the arrangements for escorts during leave, and the need to share related learning across Wales.

    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 determine the number of escorts required for Section 17 leave

    Wider context from the report

    “(2) The inquest heard evidence that two escorts can provide a deterrent effect against absconsion, and are better able to deal with absconsions. Cardiff and Vale Health Board have now concluded a two month study of the efficacy of having two escorts to a patient on Section 17 leave and the lessons of this study should be applied across Wales. ”

    Source location

    Khuong Lam · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Buckinghamshire

    AI-generated summary

    JACK OLIVER PORTLAND · 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 Oliver Portland was a prisoner who was diagnosed with substance-induced psychosis and later detained under the Mental Health Act. He died on 27 December 2015 at Wycombe Hospital while on unescorted leave from the Whiteleaf Centre; the medical cause of death was morphine and ethanol toxicity. Concerns included the management and communication of ACCT documents, family communication, discharge planning for a vulnerable and homeless prisoner, and the coordination of coronial disclosure.

    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 establish and communicate a clear AWOL and leave authorisation procedure

    Wider context from the report

    “(3) The implementation of the AWOL procedure and checklist, including the application of 10-minute buffer time immediately at the end of scheduled leave was not clearly understood by witnesses in person and there appeared to be no proper overarching leave policy including proper recording of who assessed a patient prior to leave and who authorised a particular leave. There was no proper contemporaneous record of all the steps actually taken in connection of Mr Portland’s AWOL. ”

    Source location

    JACK OLIVER PORTLAND · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    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 S17 leave records to required recipients

    Wider context from the report

    “(1) The practical implementation of S17 leave involved, firstly, the grant of leave by the consultant psychiatrist and it was mandatory to provide copies of those Records of Grant not only to the patient, but also to the family of a patient along with the Inpatient clinical team and the MHA administrator. The Care Co-ordinator and GP were also optional recipients. No copies of any of Mr Portland’s S17 Records of Grant of Leave appeared to have been provided to anyone other than the patient. The family were unaware of changes to leave and were unable to participate in the leave process or assist Whiteleaf with regard to any heightened risks. ”

    Source location

    JACK OLIVER PORTLAND · 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

    Complete governance approval and implement the amended section 17 leave form, including recording whether copies should be provided and to whom.

    Verbatim wording from the response

    “The provision of copies of leave forms is not in fact mandatory under either the Mental Health Act Code of Practice or Trust policy (the Trust’s current granting of leave form, which suggests that this is the case, is misleading). Nevertheless, it is acknowledged that in many cases patients and their families find it useful to have a copy of the form in addition to being involved in discussions around the granting of any leave and conditions. The section 17 leave form has been amended and is currently going through the Trust’s governance processes for approval. It is anticipated that use of the new form will be implemented no later than 28th April 2017. The newly designed form allows the consultant to indicate, following discussions with patients and families, if copies should be provided and, if so, to whom.”

    Source location

    2017-0049-Response-by-Oxford-Health-NHS-Trust
    Page 1 · response
    Published 5 March 2017

    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

    Test the new leave-management SOP on Sapphire ward, review it, and expand implementation across all adult wards.

    Verbatim wording from the response

    “In addition, a new standard operating procedure (SOP) for managing leave (appendix 1) includes the need for staff to have a discussion with the family, where appropriate consent is given by the patient, regarding the patient’s leave from the ward and to do this every time there is a change to the leave agreed.”

    Source location

    2017-0049-Response-by-Oxford-Health-NHS-Trust
    Page 1 · response
    Published 5 March 2017

    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

    Communicate AWOL procedures to staff and provide guidance and Missing Patient Action Checklists on all acute inpatient wards.

    Verbatim wording from the response

    “The responsibility for ensuring that patients are back from leave now clearly rests with the person allocated to carry out general observations. That staff member is also responsible for informing the shift co-ordinator, who will co-ordinate the implementation of the AWOL policy, if a patient does not return on time (appendix 3). The shift co-ordinator is always a qualified nurse.”

    Source location

    2017-0049-Response-by-Oxford-Health-NHS-Trust
    Page 2 · response
    Published 5 March 2017

    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

    Providing patients or families copies of leave forms is not mandatory under the Mental Health Act Code of Practice or Trust policy.

    Verbatim wording from the response

    “The provision of copies of leave forms is not in fact mandatory under either the Mental Health Act Code of Practice or Trust policy (the Trust’s current granting of leave form, which suggests that this is the case, is misleading). Nevertheless, it is acknowledged that in many cases patients and their families find it useful to have a copy of the form in addition to being involved in discussions around the granting of any leave and conditions. The section 17 leave form has been amended and is currently going through the Trust’s governance processes for approval. It is anticipated that use of the new form will be implemented no later than 28th April 2017. The newly designed form allows the consultant to indicate, following discussions with patients and families, if copies should be provided and, if so, to whom.”

    Source location

    2017-0049-Response-by-Oxford-Health-NHS-Trust
    Page 1 · response
    Published 5 March 2017

    Open published response

  8. County Durham and Darlington

    AI-generated summary

    Michael Peter McMonigle · 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

    Michael Peter McMonigle was admitted as an informal patient to Farnham Ward at Lanchester Road Hospital and was assessed as being at significant risk of self-harm. On 11 August 2015 he left the hospital during accompanied leave, was later found suspended by a ligature, and was declared dead on 12 August. The principal concerns included failures to update and communicate risk information and leave arrangements, inadequate handover and policy implementation, and delays and omissions in responding to his absence.

    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 ensure that leave arrangements are understood by patients and communicated to relatives

    Wider context from the report

    “(1) The lack of knowledge of the policy for leave for informal patients amongst ward staff and the Consultant Psychiatrist in particular. (2) The failure to follow the policy in terms of conducting an assessment prior to the handover. (3) The failure to apply the policy in terms of ensuring that leave arrangements are clearly understood by the patient and communicated to relatives. See paragraphs 6.7 and 6.8, the policy of Leave from Hospital and Leave of Absence under Section 17 Mental Health Act 1973, policy no CLIN00025. (4) The Face risk assessment, PARIS case notes and intervention plan were not updated with assessment of risk of self-harm or suicide and details of conditions for escorted leave following the formulation meeting on 10th August 2015. Instead, it fell to staff to verbally convey this information to colleagues who had not attended at the formulation meeting and to members of the family. (5) Failure to respond to Michael’s absence until well after 19:20 hrs, when it was admitted by ward staff in evidence that interventions could have been commenced, alternatively at 21:00hrs when it was conceded that the alarm could have been raised given that was the normal time for return from leave. (6) The response to Michael’s absence did not conform with paragraphs 7.3 of the Missing Patients Procedure, ref. CLIN-0006-V4 in that there was no search of the hospital internally, a search of the grounds, enquiry with other staff users, check of CCTV footage. (6) The following responses were undertaken after 19.20 and 21.00 when in conclusion of the jury the alarm could have been raised: enquiry with friends or relatives from 22:30hrs at earliest, an attempt to telephone Michael from 22:40 hrs at earliest, contact with relatives from 22:30 hrs at the earliest (Michael’s mother said 23.15), Police at 23:45hrs at the earliest, other hospital staff at 00:15hr on 12th August at the earliest, the medical staff at 12:20hrs at the earliest. Staff knowledge of the Leave policy and Missing Patients Procedure was inadequate. ”

    Source location

    Michael Peter McMonigle · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  9. Northamptonshire

    AI-generated summary

    Jane Marie Clark and Isobel Griffin · 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

    Jane Marie Clark died by suicide after leaving Berrywood Hospital on 22 August 2013 with an inadequate risk assessment, following recent suicide-related concerns and possession of a ligature. Isobel Griffin died after hanging herself on the ward on 17 August 2013, with death pronounced on 21 August 2013. The principal concerns included inadequate handover and risk assessments, failures to review relevant clinical information and treatment, and insufficient measures to minimise ligature risk.

    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 set boundaries for patient leave

    Wider context from the report

    “Re Jane Marie Clark 1. The very challenging events of the previous evening and that morning do not appear to have been handed over and the nurse in charge did not read the notes before granting leave. Her risk assessment then was ill informed. It was not discussed with anyone nor properly documented. 2. She did not place any boundaries on the leave for example providing a time by which Jane was to return. 3. Risk assessment documentation generally was poor and appeared perfunctory. Re Isobel Griffin 1. Mrs Griffin was admitted on 1 August and was not allocated a key worker until 8th August. The key worker did not read the notes so was not aware of the events of the 7th. 2. The risk assessment was not updated with the events of the 7th. 3. Mrs Griffin’s responsible clinician saw her on only one occasion on 14 August 2013 at which time he did not read the notes so he was unaware of events on the 7th when she handed in a belt and scissors and said she had 3-4 times tried to hang herself using a ligature. 4. A planned review of medication, diagnosis and treatment never took place despite a number of references in the notes to it from 6 August 2013. Mrs Griffin had been substantially unmedicated for most of the admission despite concerns expressed by her family. 5. On 11 August Mrs Griffin started to express thoughts to harm others. These thoughts distressed her. She did not intend to act on them but they were something new and a measure of her distress. These thoughts and their significance were not included in any risk assessment. 6. A risk assessment concluded on the 18th, the day after she had hanged herself on the ward, purports to be made with her agreement. It was evidence that risk assessment documentation is cut and pasted rather than reflecting the true circumstances. 7. The doors do not appear to be ligature proof and little was made available by way of evidence as to what measures would now be taken to minimise this risk. ”

    Source location

    Jane Marie Clark and Isobel Griffin · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  10. Surrey

    AI-generated summary

    Katherine Liana Bonaventura · 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

    Katherine Liana Bonaventura, a patient detained under the Mental Health Act, returned to the Abraham Cowley Unit on 7 December 2012 after overnight leave with a concealed knife and fatally stabbed herself a few hours later. The principal concerns were that relevant information about her leave was not elicited from her family member, her mental state was not assessed sufficiently and immediately on return, and there was no system to ensure thorough consultation and assessment or recording of the assessment outcome.

    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

    Lack of a system ensuring sufficient mental state assessment of patients returning from inpatient leave

    Wider context from the report

    “It was clear from the evidence that the Trust had and has in place Guidelines entitled “Working Age Adults Inpatient Leave of Absence Guidelines for Detained Patients” dated November 2011 and reviewed in July 2012. Those guidelines state, “Upon return from leave, an assessment of the patient should occur and the family member, carer should be consulted to ensure any issues arising during leave are noted. The outcome of this discussion should be documented in the patient’s clinical record.” It was apparent from the evidence that (i) the consultation with the family member / carer may consist of no more than an exchange of a few words in the presence of the patient, (ii) it is sometimes difficult for a family member / carer to provide all relevant information to staff in those circumstances and (iii) if staff are not immediately aware of any issues arising, their “assessment of the patient” may consist of no more than an exchange of a few words in the reception area. It is, therefore, of great importance that staff elicit as much information as possible about the leave and any concerns arising, at the point of the patient’s return. It is of concern that there is no system in place to ensure that a sufficiently thorough consultation takes place with the family member / carer, which is designed to elicit as much information as possible as soon as possible. One nurse stated in evidence that it is now his personal habit to escort the family member / carer off the Unit so that he can conduct a further, private, consultation, but that not all nurses do so. It is also of concern that there is no system in place to ensure that a sufficient mental state assessment of the patient is conducted, and its outcome is recorded, at the time of arrival back on the Unit. ”

    Source location

    Katherine Liana Bonaventura · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026