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. 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
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Data last updated 7 September 2026