First reported 14 Oct 2013•Latest report 1 Jun 2026
Definition
What this concern includes
Includes planned or unescorted leave, return from leave, failure to return and absence without leave when a dedicated leave or absence control is deficient.
Not included
Excludes discharge and ordinary movement within a ward.
Excludes generic risk assessment, communication or police escalation not directly tied to inpatient leave or absence.
Reports
55
Distinct published reports
Individual concerns
119
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
134
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 Care8
Sussex Partnership NHS Foundation Trust6
Essex Partnership University NHS Foundation Trust5
Greater Manchester Mental Health NHS Foundation Trust4
NHS England4
Surrey and Borders Partnership NHS Foundation Trust4
Lancashire & South Cumbria NHS Foundation Trust3
Tees, Esk and Wear Valleys NHS Foundation Trust3
Central and North West London NHS Foundation Trust2
Coventry and Warwickshire Partnership NHS Trust2
East London NHS Foundation Trust2
Metropolitan Police Service2
Nottinghamshire Healthcare NHS Foundation Trust2
Oxford Health NHS Foundation Trust2
South London and Maudsley NHS Foundation Trust2
NHS trust47
Ministerial department8
Police force5
Executive non-departmental public body4
Healthcare site2
Clinical commissioning group1
Company limited by guarantee1
Coronial office1
Devolved government1
English county council1
Health and care professional regulator1
Integrated care board1
Local health board1
National policing body1
Prison or young offender institution1
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.
Essex
Concerns raised2
Failure to prevent and scrutinise access to unauthorised or rescinded Section 17 Leave
Electronic Section 17 Leave recording failing to preserve leave timings, conditions and return visibility
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
West Sussex, Brighton and Hove
Concerns raised2
Failure of nursing staff to know leave conditions
Failure to properly monitor leave conditions
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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.4
Action
Test and retest nursing staff competency in understanding and complying with section 17 leave conditions.
Stated by SPFTStated completedThe respondent said that this action was complete when they made their response on 22 June 2026.
Action
Monitor and audit compliance with section 17 leave conditions through matrons, ward managers and governance processes, with resulting actions overseen.
Stated by SPFTStated completedThe respondent said that this action was complete when they made their response on 22 June 2026.
Action
Reinforce section 17 leave standards through team meetings, safety discussions and multidisciplinary team processes.
Stated by SPFTStated completedThe respondent said that this action was complete when they made their response on 22 June 2026.
Action
Provide bespoke section 17 leave training, including learning from Kristian Allen’s inquest.
Stated by SPFTStated in progressThe respondent said that this action was in progress when they made their response on 22 June 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing Trust actions embedded in policy, training, governance and ward-level processes are considered sufficient; no further new actions are needed.
Stated by SPFTExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Kent and Medway
Concerns raised4
Inadequate monitoring and escalation of patients on leave who do not return
Failure to conduct leave risk assessments consistently with NICE Guidelines
Inadequate communication and recording of leave decisions
Inconsistent approach to leave and return for detained and voluntary patients
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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.11
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 TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 July 2026.
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 TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 July 2026.
Action
Replace paper hourly observation checks with electronic well-being checks linked to leave monitoring and audit processes.
Stated by South London and Maudsley NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 28 July 2026.
Action
Investigate and explore producing the leave form electronically, including with the new EPR provider, to improve access, recording and monitoring.
Stated by South London and Maudsley NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 July 2026.
Action
Introduce and maintain a ward whiteboard recording patient leave and expected return times.
Stated by South London and Maudsley NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2026.
Action
Issue and disseminate a Blue Light Bulletin reinforcing prompt checks and escalation when patients fail to return from leave.
Stated by South London and Maudsley NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2026.
Action
Adopt a personalised, NICE- and NHSE-aligned approach to risk formulation, management planning and safety planning.
Stated by South London and Maudsley NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2026.
Action
Update mandatory clinical risk training to reflect the revised risk assessment and harm management policy.
Stated by South London and Maudsley NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2026.
Action
Implement electronic ward-round templates for documenting leave discussions, risk considerations, plans and actions and sharing them across multidisciplinary teams and shifts.
Stated by South London and Maudsley NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2026.
Action
Publish and disseminate patient-safety learning on informal leave management, documentation and failure to return to relevant staff.
Stated by South London and Maudsley NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2026.
Action
Develop a standardised leave log suitable for detained and informal patients.
Stated by South London and Maudsley NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Trust cannot mandate time limits for informal leave because doing so would be contrary to the legal framework governing informal patients’ leave.
Stated by South London and Maudsley NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
South Yorkshire (Eastern)
Concerns raised1
Failure to undertake and document mental state examinations and risk assessments before granting ward leave
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Cheshire
Concerns raised3
Failure to fully consider recent substance misuse history in unescorted-leave decisions
Failure to document and formalise leave reinstatement decisions
Leave management by a non-s12 doctor during responsible-clinician absence
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Reissue section 17 guidance and use separate escorted/emergency and unescorted leave forms for each patient.
Stated by Alternative Futures Group LimitedStated completedThe respondent said that this action was complete when they made their response on 12 March 2026.
Action
Revise MDT documentation to include a current risk summary and the patient’s perspective, informed by review of patient documentation and interactions.
Stated by Alternative Futures Group LimitedStated completedThe respondent said that this action was complete when they made their response on 12 March 2026.
Action
Document all clinical and Mental Health Act decisions in patient files, the DSR system and relevant meeting minutes.
Stated by Alternative Futures Group LimitedStated completedThe respondent said that this action was complete when they made their response on 12 March 2026.
County Durham and Darlington
Concerns raised1
Failure of the section 17 leave policy to reference the new leave processes
Responses linked to these concerns
Each 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
Action
Amend the Section 17 leave policy to direct staff to PIPA procedures, leave-risk documentation and electronic-care-record leave-plan procedures.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 March 2026.
Action
Conduct a full stakeholder review of the Section 17 Leave Policy, including people with lived experience and carers.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 2 March 2026.
Inner West London
Concerns raised2
Failure to align acute ward operational, leave and risk management policies
Failure to give leave and off-ward safety planning sufficient prominence in review, handover and planning templates
Responses linked to these concerns
Each 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.6
Action
Revise the Trust Leave Policy to strengthen leave risk assessment, multidisciplinary collaboration, safety planning and holding-power guidance.
Stated by South West London and St George'S Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 13 August 2025.
Action
Add leave procedures, safety-planning, escalation and documentation requirements to the Adult Inpatient Operational Policy and admission checklist, aligned with related policies.
Stated by South West London and St George'S Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 13 August 2025.
Action
Reinforce risk-assessment processes for informal patient leave.
Stated by South West London and St George'S Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 13 August 2025.
Action
Establish an inpatient-rotation induction programme covering risk assessment and documentation for junior doctors.
Stated by South West London and St George'S Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 13 August 2025.
Action
Update multidisciplinary, nursing handover and care-plan review templates with dedicated leave safety-plan sections.
Stated by South West London and St George'S Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 13 August 2025.
Action
Update Collaborative Clinical Safety Training to cover leave safety planning, risk assessment and the legal framework for informal patients.
Stated by South West London and St George'S Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 13 August 2025.
South London
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 concerns
Each 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
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 TrustStated completedThe respondent said that this action was complete when they made their response on 11 April 2025.
Essex
Concerns raised2
Failure to complete appropriate risk assessments before high-risk patients leave the acute ward
Failure to ensure hospital staff know when high-risk patients leave the acute ward
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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.5
Action
Review and update policies and flowcharts guiding risk assessment and supervision of inpatients at high risk of self-harm.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
Action
Include Section 5(2) Mental Health Act guidance in the Trust’s Mental Health policy for high-risk patients attempting or intending to leave the ward.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
Action
Raise awareness of the updated Section 5(2) guidance through the Nurses’ Grand Rounds programme.
Stated by Mid and South Essex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 20 January 2026.
Action
Deliver Section 5(2) Mental Health Act training to FY2 doctors every six months during induction.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
Action
Add Section 5(2) Mental Health Act assessment to the Trust’s monthly online Mental Health Act training.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
MSE is responsible for responding to the risk of high-risk self-harm patients leaving the acute ward without appropriate risk assessment.
Stated by Essex Partnership University NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
MSE is responsible for responding to the risk of high-risk self-harm patients leaving the acute ward without hospital staff knowing.
Stated by Essex Partnership University NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Gwent
Concerns raised2
Failure to conduct and understand the requirements of post-leave assessments
Failure to suitably document post-leave assessment findings
Responses linked to these concerns
Each 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.4
Action
Develop a revised leave policy addressing risk assessment, documentation, post-leave feedback, and distinct Ground Leave and Section 17 processes.
Stated by Elysium Healthcare LimitedStated in progressThe respondent said that this action was in progress when they made their response on 3 February 2025.
Action
Adopt and roll out the revised leave policy across all units.
Stated by Elysium Healthcare LimitedStated plannedThe respondent said that this action was planned when they made their response on 3 February 2025.
Action
Audit a weekly sample of patient records to verify that Ground Leave records are completed.
Stated by Elysium Healthcare LimitedStated in progressThe respondent said that this action was in progress when they made their response on 3 February 2025.
Action
Remind ward staff to document Ground Leave issues and feedback on specific leave conditions in patient records.
Stated by Elysium Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 3 February 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The patient’s leave assessments had taken place, including assessment in multidisciplinary and other staff meetings and documented Ground Leave episodes.
Stated by Elysium Healthcare LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
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Includes planned or unescorted leave, return from leave, failure to return and absence without leave when a dedicated leave or absence control is deficient.
