Recurring concern

Unreliable mental-health patient leave arrangements

First to latest report 21 Oct 2013 — 1 Jun 2026

Reports that mention this concern
22
Times this concern has been raised
32
Stated actions linked to this concern
29

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.

What is 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 and published responses 22 reports

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

  1. North and East Cambridgeshire

    AI-generated summary

    Christopher James MORGAN · 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

    Christopher Morgan, a voluntary patient at Fulbourn Hospital, died from multiple injuries after diving in front of a train at or near Ely Railway Station after leaving the hospital earlier that day. The report identified concerns about communication with family and carers before changes in risk or leave arrangements, and about staffing ratios for escorted leave from psychiatric wards.

    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 clear policy on staff-to-patient ratios for escorted leave from psychiatric wards

    Wider context from the report

    “The Trust should ensure that a clear practice and policy is adopted in relation to the ratio of staff to patient as to staff that should accompany patients on escorted leave from psychiatric wards ”

    Source location

    Christopher James MORGAN · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. North London

    AI-generated summary

    Daniel Maurice McMahon · 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

    Daniel Maurice McMahon suffered severe head injuries after being hit by a train at Willesden Junction Station on 11 January 2012, following reports that he had fallen from a bridge and moved onto the railway track. The report raised concerns about the accuracy and completeness of information recorded by police about the location of a person trespassing on the railway, procedures for stopping trains when an unwell person is on the line, support during mental-health leave, and the use of lung-decompression needles without a valve.

    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 identify difficulties experienced by patients on Section 17 leave

    Wider context from the report

    “(2) Department of Health:- Consideration to be given to using a feedback form, where a patient is on S17 of the MHA 1983 leave, to be completed by those caring for the patient in the community and the professional staff at the hospital to ensure that any difficulties that a patient has while on leave are picked up ”

    Source location

    Daniel Maurice McMahon · 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

    Review the Code of Practice on section 17 leave of absence and care planning, informed by this case.

    Verbatim wording from the response

    “We are currently reviewing the advice in the “Code of Practice Mental Health Act 1983”. This includes reviewing the chapter on leave of absence under section 17 of the Mental Health Act 1983 and the references to care planning. The experience of this case will be used to assist that review.”

    Source location

    2013-0271-Response
    Page 2 · response
    Published 19 December 2013

    Open published response

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

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Data last updated 7 September 2026