22 Nov 2024 Nicolette Elizabeth McCARTHY · Prevention of Future Deaths report East Sussex
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Concerns raised 1
Poor supervision of patients smoking during short grounds leave View source
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.
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AI-generated summary
Nicolette Elizabeth McCARTHY · 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
Nicolette Elizabeth McCarthy was detained in a secure mental health unit after attempts to take her life and remained at risk of suicide. On 19 September 2023, she failed to return from a short period of leave and was not promptly treated as absent without leave; the inquest identified failures in systems and procedures intended to ensure her safety. The report raises concerns that smoke-free policies and unclear guidance may increase the risk of self-harm or suicide for mental health patients on unescorted leave.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Poor supervision of patients smoking during short grounds leave
Wider context from the report “1) During the course of the inquest, I heard evidence from clinicians and staff at the Trust to the effect that the NHS England smoke free policy is placing mental health in patients at an increased risk from self-harm and suicide.
2) Although smoking cessation advice and treatment (e.g. gum, vapes etc.) are routinely offered to patients, the evidence was that many struggle to give up smoking on their admission to the ward, in part because the anxiety associated with stopping exacerbates their mental health symptoms. Staff also felt that forcing patients to stop smoking against their will (e.g. by prohibiting them from smoking while on leave) would have a negative effect on their sense of autonomy and wellbeing, which are important for recovery.
3) The Trust understand that they are bound by the Health Act 2006 and by NHS England policy not to permit or facilitate smoking on the ward or anywhere on the grounds of the hospital. This is taken seriously and is interpreted to mean that staff are prohibited from facilitating smoking, for example by granting leave for the purpose of smoking or by escorting patients to smoke outside on short periods of leave. Senior staff also believed that it would be contrary to NHS policy to permit smoking in a secure area, for example the enclosed ward garden. At the same time, it was acknowledged that patients would inevitably seek leave to smoke and that this could not be denied without a negative impact on their mental health.
4) The jury heard evidence that patients, like Mrs McCarthy, were routinely given 15-minute grounds leave for the purpose of smoking, a practice that is discouraged by the Trust. Clinical staff felt that the policy placed them in a difficult position, torn between the need to comply with the smoke free policy, while also supporting patient autonomy and keeping safe those patients who are at a higher risk of self-harm or suicide.
5) There is a further contradiction caused by the smoke free policy, in that patients are not permitted to smoke on the grounds, but are not supposed to leave the grounds during short periods of ‘grounds’ leave. The result is that patients would spend their 15-minute leave smoking by the side of the road on the edge of the ward grounds, which is a poorly supervised area , and staff would avoid asking them too closely where they were going and would avoid standing close to them , even when smoking themselves. This contributed to the circumstances that allowed Mrs McCarthy to slip away unnoticed and ultimately to take her own life.
6) I also heard evidence from senior staff that the national policy guidance intended to address smoking and s17 leave (e.g. the NICE guidance and CQC guidance) does not adequately resolve these contradictions.
7) I am concerned that the NHS smoke free policy, while clearly motivated by a genuine and pressing concern to protect life and promote health, may not be adequately tailored to reflect the safety requirements of mental health wards or the reality that some mental health patients will inevitably seek short periods of leave to smoke. Action may need to be taken at the national policy level to provide clearer guidance and/or review the law to reduce the risk of patients in mental health wards absconding while on unescorted grounds leave.
” Source location Nicolette Elizabeth McCARTHY · Prevention of Future Deaths report
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual NHS trusts are responsible for locally implementing smoke-free policies, rather than NHS England’s wider Estates Team.
Verbatim wording from the response “I note that you have also addressed your concerns to NICE and the DHSC, and it would be appropriate for these organisations to respond to the Coroner, as the responsible policy holders for the issues raised. Individual NHS Trusts are responsible for the local implementation of these policies and not the wider NHS England Estates Team.” Source location Response from NHS England
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Concerns raised 1
Failure to thoroughly review or clarify Section 17 leave conditions before sign-out View source
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.
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AI-generated summary
Darren Joseph Hope · Prevention of Future Deaths report
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Report summary
Darren Joseph Hope died on 3 July 2023 after falling from the 10th-floor building where he lived while on unescorted Section 17 leave. The report identifies concerns about verifying leave conditions, ensuring people on leave can contact the facility, and the ability of the reporting system to identify and address patient-safety issues.
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× 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 thoroughly review or clarify Section 17 leave conditions before sign-out
Wider context from the report “Concern 1: Section 17 leave conditions may not always be thoroughly reviewed or clarified before a service user is signed out for leave . This lack of verification can lead to unaddressed discrepancies, which may impact the safety and appropriateness of unescorted leave.
” Source location Darren Joseph Hope · Prevention of Future Deaths report
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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 Update and disseminate the Section 17 Leave Policy through an intranet toolkit, revised forms, checklists, briefing materials and staff teaching resources.
Verbatim wording from the response “In January 2021, a cross directorate approach was undertaken to review and update the Section 17 Leave Policy taking into account staff views. The task and finish group were made up of a mix of professionals from both acute and community services including Nursing Staff, Ward Managers, Matrons, Psychiatrists, Psychologists, AHPs and Mental Health Act leads. I have set out the updates to the Section 17 Policy at appendix one. Since the update of the Section 17 Leave Policy, clear guidance is provided on the Trust intranet in the form of a section 17 toolkit which has a Step-by-step guidance to facilitating Section 17 agreed leave of absence.” Source location Response from Coventry and Warwickshire Partnership Trust
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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 Audit Section 17 leave documentation and conduct follow-up reviews through the Quality Improvement clinical audit cycle.
Verbatim wording from the response “In May 2022, an audit of the section 17 leave forms was completed, and reasonable assurance was provided. The review was undertaken to ensure that the completion of section 17 leave forms aligns with the Trust Policy, in particular:” Source location Response from Coventry and Warwickshire Partnership Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue a Quality Improvement Plan addressing absent-without-leave responses and Section 17 leave arrangements across adult male mental health wards.
Verbatim wording from the response “The investigation did not conclude with a separate action plan, but it did set out in detail that the issues identified, including AWOL response and Section 17 Leave arrangements, were already subject to improvement as part of a Quality Improvement Plan involving our adult male mental health wards.” Source location Response from Coventry and Warwickshire Partnership Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No separate investigation action plan was issued because AWOL response and Section 17 leave arrangements were already covered by a Quality Improvement Plan.
Verbatim wording from the response “The investigation did not conclude with a separate action plan, but it did set out in detail that the issues identified, including AWOL response and Section 17 Leave arrangements, were already subject to improvement as part of a Quality Improvement Plan involving our adult male mental health wards.” Source location Response from Coventry and Warwickshire Partnership Trust
Open published response
Concerns raised 3
Failure to inform accompanying carers of section 17 leave conditions View source Removal of the requirement for accompanying persons to sign section 17 leave forms View source Failure to provide section 17 leave forms to accompanying carers View source
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
Include Section 17 leave and accompanying-role responsibilities in mandatory Trust-wide preceptorship for newly joining registered nurses.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 August 2024. View source
Action
Review, amend, approve and roll out the Section 17 leave policy, including signed leave documentation, accompanying-person confirmation and ward-held copies.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 August 2024. View source
Action
Develop and deliver targeted Section 17 leave training to Associate Directors of Nursing and Quality.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 August 2024. View source
Action
Use Section 17 leave folders, flowcharts, templates and contact cards to give staff, patients and accompanying persons accessible leave requirements and contact information.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 August 2024. View source
Action
Continue auditing clinical records to assess compliance with Section 17 leave procedures.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 August 2024. View source
Action
Assess the impact of the amended Section 17 leave policy changes.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 19 August 2024. View source See 3 more actions
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AI-generated summary
Matthew Clive GALE · 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
Matthew Clive Gale died on 19 March 2023 after being detained under the Mental Health Act and granted Section 17 leave. The conditions of his leave, including that he should not be left alone, were not properly recorded or communicated to his family. The report raised concern about inconsistent compliance with providing Section 17 leave forms and the removal of a requirement for the accompanying person to sign the form, creating a risk of future deaths.
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× 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 inform accompanying carers of section 17 leave conditions
Wider context from the report “At inquest, Matthew's mother gave evidence that she was never informed of the terms upon which Matthew's section 17 leave had been authorised by those responsible for his treatment and specifically that Matthew should never be left alone or unaccompanied whilst on section 17 leave nor was she provided with a copy of Matthew's section 17 leave form.
The Trust acknowledged and admitted that there was no evidence in any records available to it that such discussions had been had with Matthew's mother or that a copy of the section 17 leave form had been provided to her. The Trust gave evidence of changes implemented since Matthew's tragic death to avoid future recurrence and I requested additional evidence from the Trust in relation to audited compliance data.
Notwithstanding changes already implemented and envisaged and by its own admission, the Trust's compliance data is "inconsistent" generally but specifically in relation to the provision of the section 17 leave form to a carer/ person accompanying a patient subject to section 17 leave. That evidence demonstrated a 50% compliance rate in December 2023, a 52% compliance rate in March 2024 and a 76% compliance rate in May 2024, with a compliance rate of 80% or above considered to be "good" by reference to the Trust's compliance criteria.
Additionally and in relation to changes already implemented, the Trust's evidence at inquest was that its revised section 17 leave policy for detained patients had removed the previous requirement that the section 17 leave form ought to be signed by the person accompanying the patient, the explanation for this being the Trust's roll-out of a new digitised system.
The inconsistent compliance audit data referenced above gives rise to a concern that there is risk that future deaths could occur consequent to this change unless action is taken.
” Source location Matthew Clive GALE · Prevention of Future Deaths report
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 Removal of the requirement for accompanying persons to sign section 17 leave forms
Wider context from the report “At inquest, Matthew's mother gave evidence that she was never informed of the terms upon which Matthew's section 17 leave had been authorised by those responsible for his treatment and specifically that Matthew should never be left alone or unaccompanied whilst on section 17 leave nor was she provided with a copy of Matthew's section 17 leave form.
The Trust acknowledged and admitted that there was no evidence in any records available to it that such discussions had been had with Matthew's mother or that a copy of the section 17 leave form had been provided to her. The Trust gave evidence of changes implemented since Matthew's tragic death to avoid future recurrence and I requested additional evidence from the Trust in relation to audited compliance data.
Notwithstanding changes already implemented and envisaged and by its own admission, the Trust's compliance data is "inconsistent" generally but specifically in relation to the provision of the section 17 leave form to a carer/ person accompanying a patient subject to section 17 leave. That evidence demonstrated a 50% compliance rate in December 2023, a 52% compliance rate in March 2024 and a 76% compliance rate in May 2024, with a compliance rate of 80% or above considered to be "good" by reference to the Trust's compliance criteria.
Additionally and in relation to changes already implemented, the Trust's evidence at inquest was that its revised section 17 leave policy for detained patients had removed the previous requirement that the section 17 leave form ought to be signed by the person accompanying the patient , the explanation for this being the Trust's roll-out of a new digitised system .
The inconsistent compliance audit data referenced above gives rise to a concern that there is risk that future deaths could occur consequent to this change unless action is taken .
” Source location Matthew Clive GALE · Prevention of Future Deaths report
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 section 17 leave forms to accompanying carers
Wider context from the report “At inquest, Matthew's mother gave evidence that she was never informed of the terms upon which Matthew's section 17 leave had been authorised by those responsible for his treatment and specifically that Matthew should never be left alone or unaccompanied whilst on section 17 leave nor was she provided with a copy of Matthew's section 17 leave form .
The Trust acknowledged and admitted that there was no evidence in any records available to it that such discussions had been had with Matthew's mother or that a copy of the section 17 leave form had been provided to her . The Trust gave evidence of changes implemented since Matthew's tragic death to avoid future recurrence and I requested additional evidence from the Trust in relation to audited compliance data.
Notwithstanding changes already implemented and envisaged and by its own admission, the Trust's compliance data is "inconsistent" generally but specifically in relation to the provision of the section 17 leave form to a carer/ person accompanying a patient subject to section 17 leave . That evidence demonstrated a 50% compliance rate in December 2023, a 52% compliance rate in March 2024 and a 76% compliance rate in May 2024 , with a compliance rate of 80% or above considered to be "good" by reference to the Trust's compliance criteria.
Additionally and in relation to changes already implemented, the Trust's evidence at inquest was that its revised section 17 leave policy for detained patients had removed the previous requirement that the section 17 leave form ought to be signed by the person accompanying the patient, the explanation for this being the Trust's roll-out of a new digitised system.
The inconsistent compliance audit data referenced above gives rise to a concern that there is risk that future deaths could occur consequent to this change unless action is taken.
” Source location Matthew Clive GALE · Prevention of Future Deaths report
Open source report
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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 Section 17 leave and accompanying-role responsibilities in mandatory Trust-wide preceptorship for newly joining registered nurses.
Verbatim wording from the response “As previously advised, following the May 2024 audit results the Trust implemented the following to improve Section 17 leave requirements:” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust
Open published response
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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, amend, approve and roll out the Section 17 leave policy, including signed leave documentation, accompanying-person confirmation and ward-held copies.
Verbatim wording from the response “The Section 17 leave policy has now been reviewed, amended and rolled out across the Trust, with a decision made that the Section 17 leave form and leave/time away from the ward monitoring form will remain in paper format, rather than going electronic. Section 17 leave forms are required to be signed by both the patient and accompanying person, to ensure they are aware of the conditions of leave and each person is provided with a copy, with a copy now also kept within a leave folder on the ward to ensure that a copy is always available prior to any leave. The leave/time away from the ward monitoring form, has been” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust
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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 deliver targeted Section 17 leave training to Associate Directors of Nursing and Quality.
Verbatim wording from the response “The Associate Director of Nursing and Quality has developed and delivered targeted training to all Associate Directors of Nurses (ADONs) around Section 17 leave, including the changes to policy and procedures and the need to ensure that processes are being followed and documented. This training is currently being disseminated across the relevant parts of the Trust with oversight of the ADONs. Within the last three weeks, 957 (70%) of substantive ward staff within the Trust have been trained in the new Section 17 leave policy. In addition to this, Section 17 leave/time away from the ward training has been delivered to temporary workers, community staff, corporate services, and professional groups to ensure they are aware of the changes. Compliance with training continues to be closely monitored by the ADONs to ensure the Trust captures all relevant staff.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust
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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 Use Section 17 leave folders, flowcharts, templates and contact cards to give staff, patients and accompanying persons accessible leave requirements and contact information.
Verbatim wording from the response “In order to further assist staff with the requirements of Section 17 leave, staff have been provided with leave folder templates and contact cards, which are now in use across the relevant parts of the Trust. At the front of the leave folders a flowchart that has been produced to remind staff of the requirements of Section 17 leave. The leave folder also contains a copy of the most recent Section 17 leave form and the leave/time away from the ward monitoring form to enable easy access. Contact cards are now also given to the patient and the accompanying person, which have details of the ward contact details, any conditions of leave, a check that a copy of the section 17 leave form has been provided and details of time and date which patient is due to return.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust
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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 Continue auditing clinical records to assess compliance with Section 17 leave procedures.
Verbatim wording from the response “The Trust continue to audit the clinical records to assess the Trust compliance with Section 17 leave procedures and an assessment will be made to determine the impact of the Section 17 leave policy changes, which was approved on 10 September 2024 by the Trust's Executive Team.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust
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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 Assess the impact of the amended Section 17 leave policy changes.
Verbatim wording from the response “The Trust continue to audit the clinical records to assess the Trust compliance with Section 17 leave procedures and an assessment will be made to determine the impact of the Section 17 leave policy changes, which was approved on 10 September 2024 by the Trust's Executive Team.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Section 17 leave and monitoring forms will remain in paper format rather than being converted to electronic forms.
Verbatim wording from the response “The Section 17 leave policy has now been reviewed, amended and rolled out across the Trust, with a decision made that the Section 17 leave form and leave/time away from the ward monitoring form will remain in paper format, rather than going electronic. Section 17 leave forms are required to be signed by both the patient and accompanying person, to ensure they are aware of the conditions of leave and each person is provided with a copy, with a copy now also kept within a leave folder on the ward to ensure that a copy is always available prior to any leave. The leave/time away from the ward monitoring form, has been” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust
Open published response
29 May 2024 Hayley Jayne Cowan · Prevention of Future Deaths report Manchester North
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Concerns raised 3
Capacity-shaped local policies for Section 17 leave View source Lack of consistency in definitions of accompanied and escorted leave View source Inconsistent guidance on whether patients should remain within eyeline or at a reasonable distance during leave View source
This report raised 1 other concern. 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.
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AI-generated summary
Hayley Jayne Cowan · 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
Hayley Jayne Cowan was detained under Section 3 of the Mental Health Act and absconded during accompanied leave to a local shop on 3 June 2022. She was found deceased the following day after using drugs; concerns included inconsistent definitions and guidance for accompanied and escorted leave, including what staff should do if they needed to use the bathroom while accompanying a patient.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Capacity-shaped local policies for Section 17 leave
Wider context from the report “The court heard evidence as to the lack of consistency and clarity for Mental Health trusts in understanding and defining how Section 17 leave should be conducted . This issue was highlighted in the paper published in December 2022 ████████, “NHS mental health services policies on leave for detained patients in England and Wales: A national audit.” Journal Psychiatric Mental Health Nursing 2023; 30: 719-730.
- Local policies appear to be shaped as a result of capacity
- There is a lack of consistency as to how “accompanied leave” and “escorted leave” are defined.
- Guidance as to whether a patient should remain in “eye-line” or at a “reasonable distance” is inconsistent and does not assist trusts in considering how trusts should work.
The Mental Health Act Codes of Practice, Guidance from the MOJ to Forensic providers and Trust policy are inconsistent. This is particularly the case in considering whether a patient needs to be within “eyeline” or a “reasonable distance” when on leave. There is also no guidance as to how trusts instruct staff on practical matters such as what to do if the staff member needs the bathroom whilst out with a patient.
” Source location Hayley Jayne Cowan · Prevention of Future Deaths report
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 Lack of consistency in definitions of accompanied and escorted leave
Wider context from the report “The court heard evidence as to the lack of consistency and clarity for Mental Health trusts in understanding and defining how Section 17 leave should be conducted. This issue was highlighted in the paper published in December 2022 ████████, “NHS mental health services policies on leave for detained patients in England and Wales: A national audit.” Journal Psychiatric Mental Health Nursing 2023; 30: 719-730.
- Local policies appear to be shaped as a result of capacity
- There is a lack of consistency as to how “accompanied leave” and “escorted leave” are defined.
- Guidance as to whether a patient should remain in “eye-line” or at a “reasonable distance” is inconsistent and does not assist trusts in considering how trusts should work.
The Mental Health Act Codes of Practice, Guidance from the MOJ to Forensic providers and Trust policy are inconsistent. This is particularly the case in considering whether a patient needs to be within “eyeline” or a “reasonable distance” when on leave. There is also no guidance as to how trusts instruct staff on practical matters such as what to do if the staff member needs the bathroom whilst out with a patient.
” Source location Hayley Jayne Cowan · Prevention of Future Deaths report
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 Inconsistent guidance on whether patients should remain within eyeline or at a reasonable distance during leave
Wider context from the report “The court heard evidence as to the lack of consistency and clarity for Mental Health trusts in understanding and defining how Section 17 leave should be conducted. This issue was highlighted in the paper published in December 2022 ████████, “NHS mental health services policies on leave for detained patients in England and Wales: A national audit.” Journal Psychiatric Mental Health Nursing 2023; 30: 719-730.
- Local policies appear to be shaped as a result of capacity
- There is a lack of consistency as to how “accompanied leave” and “escorted leave” are defined.
- Guidance as to whether a patient should remain in “eye-line” or at a “reasonable distance” is inconsistent and does not assist trusts in considering how trusts should work.
The Mental Health Act Codes of Practice, Guidance from the MOJ to Forensic providers and Trust policy are inconsistent. This is particularly the case in considering whether a patient needs to be within “eyeline” or a “reasonable distance” when on leave. There is also no guidance as to how trusts instruct staff on practical matters such as what to do if the staff member needs the bathroom whilst out with a patient.
” Source location Hayley Jayne Cowan · Prevention of Future Deaths report
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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 Revise the Mental Health Act Code of Practice after introducing the reform legislation.
Verbatim wording from the response “Regarding your comments on the inconsistencies between the Mental Health Act Code of Practice, guidance from the Ministry of Justice, and local Trust policy, this Government has announced we will be bringing forward legislation to reform the Mental Health Act in this Parliamentary Session. We will subsequently be revising the Code of Practice, and will be considering where further changes can be made to strengthen statutory guidance. We will consider the issues you have raised as part of that work.” Source location Response from DHSC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider the reported inconsistencies and identify further changes to strengthen statutory guidance.
Verbatim wording from the response “Regarding your comments on the inconsistencies between the Mental Health Act Code of Practice, guidance from the Ministry of Justice, and local Trust policy, this Government has announced we will be bringing forward legislation to reform the Mental Health Act in this Parliamentary Session. We will subsequently be revising the Code of Practice, and will be considering where further changes can be made to strengthen statutory guidance. We will consider the issues you have raised as part of that work.” Source location Response from DHSC
Open published response
5 Feb 2024 Georgia Dehaney-Perkins · Prevention of Future Deaths report Essex
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Concerns raised 1
Incomplete recording of alcohol consumption incidents after leave View source
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 concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Georgia Dehaney-Perkins · 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
Georgia Dehaney-Perkins was found deceased on 6 September 2022 on Latton Common, Harlow, after a history of mental health difficulties, self-harm and suicidal ideation. The medical cause of death was recorded as combined alcohol and drug toxicity. Concerns included the suitability and safety of her ward bathroom, incomplete risk assessment and incident recording, insufficient documentation and communication about medication and alcohol risks, and a lack of action after family raised concerns about her leaving home with medication.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Incomplete recording of alcohol consumption incidents after leave
Wider context from the report “(2) Medication was appropriately withheld on 28 August when Ms Dehaney-Perkins returned to the ward intoxicated due to potential interaction with alcohol that can cause increased sedation,
(3) arrhythmia and fatality.
a. This risk of consuming alcohol with her specific medication was not discussed with the Ms Dehaney-Perkins or family.
b. Not all incidents of consumption of alcohol on return from leave were recorded and risk assessments were not updated.
c. Ms Dehaney-Perkins had agreed to mitigations of medication management by her family that were not recorded on the care plan on discharge on 2 September. Ms Dehaney-Perkins demanded control of her medication on 4 September against concerns of her family who were forced to return medication.
” Source location Georgia Dehaney-Perkins · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete leave risk assessments, offer post-leave engagement, record incidents through Datix, update risk assessments, and share relevant information with involved professionals.
Verbatim wording from the response “A risk assessment is completed prior to a patient going on leave. Upon the patient returning from leave one to one engagement is offered to the patient, if any incident has occurred whilst the patient has been on leave this is reported via Datix and the risk assessment is updated accordingly. The incident is also documented within the patients’ notes and information is shared with all health professionals involved in the care of the patient during handover, Multidisciplinary Team meetings and ward reviews.” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
19 Dec 2023 MORGAN-ROSE HART · Prevention of Future Deaths report Essex
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Concerns raised 1
Failure to escalate changes in leave risk View source
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.
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AI-generated summary
MORGAN-ROSE HART · 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
Morgan-Rose Hart, who was detained on a female mental health ward, died on 12 July 2022 after being found unresponsive with a ligature around her neck. The report identified concerns about missed and falsified observations, failures to complete physical welfare checks after bathroom alerts, inadequate escalation of risk, shortcomings in investigation and record keeping, and insufficient suitable placements for people with autism and mental health and self-harm risks in Essex.
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× 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 escalate changes in leave risk
Wider context from the report “(3) Escalation of risk – Morgan-Rose attempted to secure unescorted leave on the morning of her death, her Responsible Clinician had only authorised escorted leave. This was not escalated to the nurse in charge and the Responsible Clinician was not informed .
” Source location MORGAN-ROSE HART · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement an inpatient care framework with named-nurse responsibilities and personalised leave plans reviewed by clinical teams.
Verbatim wording from the response “EPUT are adopting and implementing an evidence based framework within inpatient services to support engagement, care planning and therapeutic intervention. This is an internationally recognised framework which will support a positive cultural change across all our ward environments around therapeutic engagement, holistic care planning (including leave plans), whilst considering the context of care. This will include re-establishing the ‘named nurse’ function and responsibilities.” Source location Response from Essex Partnership University NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review multidisciplinary safety huddles and improve handovers through a nurse-in-charge checklist and task allocation.
Verbatim wording from the response “Communication will be improved within the multi - disciplinary team by reviewing the impact of the multi-disciplinary team safety huddles through a Qi methodology. As well as implementing improvements in the handover process with the introduction of the nurse in charge checklist and task allocation.” Source location Response from Essex Partnership University NHS Foundation Trust
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Concerns raised 1
Failure to integrate risk assessment tool outcomes into absconding-risk policies and operational requirements View source
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.
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AI-generated summary
Jack FARRINGTON · 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 Farrington, who had a long history of mental health difficulties and was detained under section 2 of the Mental Health Act, died on 2 January 2020 after running from an emergency department and falling from a road bridge. The report raised concerns about fragmented access to medical records, inadequate handovers and record keeping, insufficient flagging and assessment of absconding and self-harm risks, and the implementation of measures intended to keep him safe.
Read the report on judiciary.uk
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to integrate risk assessment tool outcomes into absconding-risk policies and operational requirements
Wider context from the report “A ‘Mental Health Primary Disturbance Survey’ tool was used to assess Jack on his arrival at ED. This indicated that his risk level was ‘level 5+ black’ and this in turn set out a requirement of the mandatory presence of security guards. However when Jack absconded there was evidence that no security guards were present. There was evidence that clinicians made risk based decisions that such guards were not necessary.
However I heard evidence that the hospital board were not aware of this tool mandating a security presence and that the tool outcomes were not reflected in trust policies about the risk of absconding . The Acting Medical Director has stated that this tool requires assessment as to whether it is fit for purpose.
” Source location Jack FARRINGTON · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Mental Health Primary Disturbance Survey to reflect current guidance and enhanced-observation escalation requirements.
Verbatim wording from the response “We can confirm that the Trust has undertaken a full review of the Mental Health Primary Disturbance Survey in accordance with Acute Psychiatric Emergency guidance (APEx) and the Royal College of Emergency Clinicians Mental Health in Emergency Departments guidance (2023) updating the tool to reflect best practice guidance for enhanced observation requirement. The tool includes a clear guidance for escalation of concerns to senior nursing staff for support, this includes night-time and out of hours available support.” Source location Response from Portsmouth Hospitals University NHS Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Security personnel are not universally required; allocation remains situation- and case-specific, based on clinical risk assessment and mental-health-team input.
Verbatim wording from the response “The allocation of security personnel to support the care of mental health patients is situation and case specific and may vary dynamically for any given individual patient. This is assessed by the local clinical team with support from the Mental Health Liaison team and regular review in the Mental Health huddle. As was discussed at the inquest, the presence of security staff can at times be provocative for Mental Health patients and cause an escalation in their distress and resultant behaviours. A collaborative approach is necessary whereby security staff work closely with mental health professionals and clinical staff to ensure a coordinated and appropriate response to patient needs, supported by risk assessments to ensure their safety and the safety of staff.” Source location Response from Portsmouth Hospitals University NHS Trust
Open published response
4 Aug 2023 Gerard Murray · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 1
Inadequate door board system for monitoring patient returns after unescorted leave View source
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.
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AI-generated summary
Gerard Murray · 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
Gerard Murray died on 16 July 2022 after leaving the mental health ward at Bassetlaw Hospital on unescorted leave and being found deceased later that day. The report identifies concerns about limited risk assessment and management, inadequate monitoring of patients returning from leave, limited family and carer involvement, and staff awareness of the ligature risk reduction pathway.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequate door board system for monitoring patient returns after unescorted leave
Wider context from the report “2. There was an inadequate door board system for monitoring the return of
patients after unescorted leave on ward B2. The same arrangements
remain currently, despite the ward move to Beech ward on new premises
” Source location Gerard Murray · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen adherence to the door board process across Beech Ward and the wider site.
Verbatim wording from the response “Historically the system of monitoring who leaves and returns to the wards, (locally known as the Door Board) was poorly adhered to in some areas. Significant work has been completed with the team on Beech (and across the site) to strengthen their adherence to the process which has seen a significant improvement in practice.” Source location Response from Nottingham Heathcare
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assign ward staff to verify leave parameters, record departures and expected returns, and manage associated safety and property checks.
Verbatim wording from the response “Each ward has a dedicated member of staff responsible for assessing individual mental state, checking leave parameters, and reiterating these to the patient prior to leave, confirming legality and permission issues with the nurse in charge, and managing those possessions a patient may take on or return with from leave, IE Cigarette Lighters and items bought at the local shops etc.” Source location Response from Nottingham Heathcare
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Procure and pilot an electronic leave-alarm system, then consider wider rollout based on pilot feedback.
Verbatim wording from the response “The staff member maintains a running log of when patients leave the ward, and are due back, their clothing, and a brief description to aid searching if a patient chooses not to return. Given the frequent use of leave from patients across the site, the Care Group has sought ways to enhance this monitoring. As such, an electronic device is being procured which will allow multiple alarms to be set for each person’s leave, ensuring an audible alarm will sound when a patient is due back on the ward. This will be trialled and rolled out based on the feedback of this pilot. We will share with you the output of this in due course.” Source location Response from Nottingham Heathcare
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct daily senior-nurse spot checks of door board compliance, staff understanding, and escalation of late returns.
Verbatim wording from the response “To ensure there is consistent compliance with the door board system, a checking process has been incorporated in the Senior Nurse’s daily observation spot checks. This includes a band 6 nurse or above observing staff completing their observations rounds, and quality checking their understanding and performance within the role. The spot checks also test individual understanding of the door board process, their knowledge of who is on and off the ward, and discussions to ensure they understand clearly how to escalate concerns if a patient hasn’t returned.” Source location Response from Nottingham Heathcare
Open published response
8 Jun 2023 Hilary Clare (Billy) Guedalla · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3
Failure to consult medical notes and records during leave risk assessment View source Failure to prevent unescorted leave from a secure unit when prohibited by clinical risk assessment View source Lack of a proper system for identifying whether service users may leave the unit View source
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 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
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 TrustStated plannedThe respondent said that this action was planned when they made their response on 22 June 2023. View source
Action
Conduct daily multidisciplinary Safety Huddles on City and Hackney inpatient wards to share critical clinical, risk and leave information.
Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 June 2023. View source
Action
Document inpatient leave arrangements on ward nursing-office whiteboards, reassess them at handover, and require staff to check them before authorising leave.
Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 June 2023. View source
Action
Require junior staff to consult the shift coordinator before permitting patient leave.
Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 June 2023. View source
Action
Relocate and revise inpatient Sign In/Sign Out books to capture leave, return, documentation, belongings and search information.
Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 June 2023. View source
Action
Spot-check each Sign In/Sign Out book once per shift and develop a more robust audit system.
Stated by East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 June 2023. View source See 3 more actions
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AI-generated summary
Hilary Clare (Billy) Guedalla · 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
Hilary Clare (Billy) Guedalla died by suicide after leaving Gardener Ward, Homerton Hospital, unaccompanied on 29 October 2021 and was found on 30 October 2021. The report identifies concerns including failures to communicate the decision restricting unescorted leave and information about suicide risk, inadequate risk assessment, delays and failures in contacting emergency services and family, non-compliance with missing-patient procedures, and inadequate staffing.
Read the report on judiciary.uk
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to consult medical notes and records during leave risk assessment
Wider context from the report “6. The member of staff who allowed the deceased to leave the unit made a brief risk assessment of them before deciding whether they should be allowed to leave. That person did not consult any medical notes or records about the deceased when making that assessment . Had that member of staff consulted the deceased’s medical notes and records, the serious suicide risk which they posed would have been evident .
” Source location Hilary Clare (Billy) Guedalla · Prevention of Future Deaths report
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 prevent unescorted leave from a secure unit when prohibited by clinical risk assessment
Wider context from the report “1. The deceased was allowed to leave Gardener Ward (“the unit”) which was part of a secure facility of the hospital, alone , when a clinical decision had been taken that they should not be allowed to leave the unit unaccompanied by staff , because they posed a serious risk of suicide.
” Source location Hilary Clare (Billy) Guedalla · Prevention of Future Deaths report
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 Lack of a proper system for identifying whether service users may leave the unit
Wider context from the report “5. There was no proper system for identifying whether a service user should be permitted to leave the unit .
” Source location Hilary Clare (Billy) Guedalla · Prevention of Future Deaths report
Open source report
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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 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.
Verbatim wording from the response “In order to ensure that this does not occur again, at the next Gardner Ward away day on 23 August 2023 all staff will be reminded again of the importance of properly recording clinical decisions (whether made by themselves or in Ward Management Meetings or Ward Rounds). As well as reviewing the RIO notes prior to making important clinical decisions. This same discussion will be repeated at the next away days for all City and Hackney inpatient wards. Considerations about the differences in recording such information between formal and informal service users will be discussed. A memo has been sent out to all ward staff on 27 July 2023 by the Clinical Director reinforcing these expectations too.” Source location Response from East London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct daily multidisciplinary Safety Huddles on City and Hackney inpatient wards to share critical clinical, risk and leave information.
Verbatim wording from the response “In order to provide an additional safety net to ensure that appropriate information sharing occurs, a daily Safety Huddle comprised of the entire multi-disciplinary team now takes place on all City and Hackney inpatient wards each morning. Critical clinical information about all service users is shared during the Safety Huddles. Important clinical decisions and risk information discussed at the Safety Huddles are expected to be documented on RIO (this expectation will also be further reinforced at the away day and junior doctor induction).” Source location Response from East London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Document inpatient leave arrangements on ward nursing-office whiteboards, reassess them at handover, and require staff to check them before authorising leave.
Verbatim wording from the response “Additionally, all inpatient leave arrangements (for both formal and informal service users) are now documented on the relevant nursing office whiteboard in each City and Hackney inpatient ward. The leave arrangements are reassessed at every shift handover and the whiteboard is updated accordingly. It is expected that all staff members check the whiteboard before allowing leave of any type.” Source location Response from East London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require junior staff to consult the shift coordinator before permitting patient leave.
Verbatim wording from the response “Further, junior staff members are now required to speak to the shift co-ordinator (the most senior staff member) prior to allowing patient leave.” Source location Response from East London NHS Foundation Trust
Open published response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Relocate and revise inpatient Sign In/Sign Out books to capture leave, return, documentation, belongings and search information.
Verbatim wording from the response “I have been provided with assurances that the process for managing the Sign In/Sign Out book (the “book”) on all inpatient units in City and Hackney has been improved. The book is now located at the nursing office to enhance completion. It has been revised to include the following information: service user name, whether leave is escorted (and by whom) or not, location of planned leave, time left and time returned, the validity of Section 17 leave papers for detained patients, description of items taken, and whether search on return was completed.” Source location Response from East London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Spot-check each Sign In/Sign Out book once per shift and develop a more robust audit system.
Verbatim wording from the response “Presently, either the nurse in charge or the shift coordinator spot checks the book to ensure completion one time per shift. However, work is being done to develop a more robust audit system.” Source location Response from East London NHS Foundation Trust
Open published response
Concerns raised 2
Failure to provide the family with the Section 17 leave form View source Lack of senior officer knowledge of leave and clinical risk management policies View source
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 concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Caroline Victoria Forte · 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
Caroline Victoria Forte had been receiving inpatient mental health treatment and was granted Section 17 weekend leave to stay at her parents' address. She was found hanging on 20 February 2022. Concerns included inadequate communication within the ward and with her family, the absence of an overarching care plan or risk assessment before leave, failure to follow the Section 17 leave policy, and difficulties sharing information from her private psychiatrist with NHS services.
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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 the family with the Section 17 leave form
Wider context from the report “The Jury in their findings found the following matter contributed to the death of Caroline namely 1. Inadequate communication within Amberley Ward. 2. Inadequate communication between Amberley ward and Caroline's family. 3. No evidence of an overnight care plan or risk assessment prior to leaving the ward. 4. Failure to follow the section 17 leave of Absence policy.
During the course of the evidence we heard that:-
a) The daily care log was not completed so it was not possible to ascertain who was the last person to see Caroline leave the ward.
b) There was no record to show which nurse carried out a risk assessment before she left.
c) There was no overnight care plan.
d) The “My care and safety plan” had not been updated with regards to “My family will do” section.
e) The family were not provided with a copy of the Section 17 leave form
f) At the time of this leave the family were unaware that Caroline had self-harmed in the hospital by tying a ligature. Therefore, the family told the Inquest that they therefore had no strategies in place to minimise the risks of such an event. Similarly there was no communication with the hospital as to how to minimise Caroline’s risk.
f) Senior Officers from the ward showed a lack of knowledge of the Trust’s own Section 17 leave policy and Safe and Effective Assessment & Management of Clinical risk: Risk Management Police and Procedure.
” Source location Caroline Victoria Forte · Prevention of Future Deaths report
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 Lack of senior officer knowledge of leave and clinical risk management policies
Wider context from the report “The Jury in their findings found the following matter contributed to the death of Caroline namely 1. Inadequate communication within Amberley Ward. 2. Inadequate communication between Amberley ward and Caroline's family. 3. No evidence of an overnight care plan or risk assessment prior to leaving the ward. 4. Failure to follow the section 17 leave of Absence policy.
During the course of the evidence we heard that:-
a) The daily care log was not completed so it was not possible to ascertain who was the last person to see Caroline leave the ward.
b) There was no record to show which nurse carried out a risk assessment before she left.
c) There was no overnight care plan.
d) The “My care and safety plan” had not been updated with regards to “My family will do” section.
e) The family were not provided with a copy of the Section 17 leave form
f) At the time of this leave the family were unaware that Caroline had self-harmed in the hospital by tying a ligature. Therefore, the family told the Inquest that they therefore had no strategies in place to minimise the risks of such an event. Similarly there was no communication with the hospital as to how to minimise Caroline’s risk.
f) Senior Officers from the ward showed a lack of knowledge of the Trust’s own Section 17 leave policy and Safe and Effective Assessment & Management of Clinical risk: Risk Management Police and Procedure.
” Source location Caroline Victoria Forte · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce the new Record of Patient Leaving Ward document across Trust wards and provide local staff training on its consistent use.
Verbatim wording from the response “During the aforementioned improvement works, it was recognised that the existing 'log' did not sufficiently enable staff to be prompted to capture all relevant information, and needed improving in a number of areas. So, new documentation has now been created, in the form of a new 'Record of patient leaving ward' document, a copy of which I attach. This will be introduced on the Trust's wards from 1 July, with local training being provided to staff to ensure the importance of its consistent use is fully understood. As with any new documentation there will then be a review of the new documentation's efficacy; this will be done in 3 months' time and the findings reported through the Trust's Acute Care Forum.” Source location Response from Sussex Partnership Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the Section 17 leave learning briefing with Regulation 28 Working Group regional representatives for dissemination across NHS regions.
Verbatim wording from the response “The Trust has also shared with us a helpful learning briefing on Section 17 leave from inpatient wards. This will be shared with the national Regulation 28 Working Group regional representatives for dissemination across the seven NHS regions, to raise awareness of the issue with their Trusts and to encourage best practice.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Section 17 leave policy to incorporate the new form and other specified modifications.
Verbatim wording from the response “The s.17 leave policy is being updated, so that it incorporates the new form, as well as some other modifications. Once ratified, there will be corresponding training which is delivered by the Trust's Mental Health Act team which is overseen by the Trust's Legal Director. Regarding the ward's understanding of the Safe and Effective Assessment & Management of Clinical risk: Risk Management policy, I understand that this specifically centred on the aforementioned assessment of risk prior to s.17 leave and corresponding sharing of information within the ward and with the family.” Source location Response from Sussex Partnership Foundation Trust
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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.
