25 Jan 2018 David Squire · Prevention of Future Deaths report Black Country
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Concerns raised 1
Failure of smoke-free hospital guidance to permit staged Section 17 leave for smoking patients refusing nicotine replacement medication View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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David Squire · Prevention of Future Deaths report
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Report summary
David Squire, a detained patient at The Priory Lakeside View Care Home, took his own life by hanging in Fibbersley Nature Reserve on 25 July 2018 after leaving escorted off-ground leave for a cigarette and not returning. Concerns were raised that smoke-free hospital guidance required smoking patients who refused nicotine replacement to begin leave off grounds, without the staged observation process used for non-smoking patients, and that the guidance did not adequately account for risks in mental health hospitals.
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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 of smoke-free hospital guidance to permit staged Section 17 leave for smoking patients refusing nicotine replacement medication
Wider context from the report “1. This guidance does not permit the proper use of Section 17 leave. The Priory is a smoke free hospital in accordance with NHS England guidance and cannot have a smoking area on the hospital grounds. To allow patients to smoke, Section 17 leave is utilised outside of The Priory’s grounds. Section 17 leave should be used for many purposes, including patent observation and interaction and to assess whether they are a risk of absconding. Given that purpose, the process of leave is staged. Patients start with escorted leave within the grounds, then unescorted, then escorted leave off grounds and then unescorted. Patients, who refuse nicotine replacement medication, and continue to smoke, must start the staged leave at escorted “off grounds.” This is so The Priory can comply with the NHS England guidance. Smoking patients therefore start leave at “off grounds” without the staged process and level of observation that non-smoking patients would be offered.
” Source location David Squire · Prevention of Future Deaths report
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How this respondent action was interpreted
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PFD Monitor interpretation Raise the complexity of smoking and section 17 leave with the Department of Health and Social Care through the government-led Mental Health Act review response.
Verbatim wording from the response “In response to your request for further consideration I can confirm NHS England will raise the complexity of this issue with the Department of Health & Social Care as part of its contributions to the government-led response to the Independent Review of the Mental Health Act that reported to the Prime Minister in December 2018. The government has signalled its intention to legislate in response to the review, and NHS England will suggest that the issue of smoking and use of section 17 leave should also be considered as part of future revisions to the Code of Practice.” Source location 2019-0062-Response-by-NHS-England
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PFD Monitor interpretation Suggest that smoking and section 17 leave be considered in future revisions to the Mental Health Act Code of Practice.
Verbatim wording from the response “In response to your request for further consideration I can confirm NHS England will raise the complexity of this issue with the Department of Health & Social Care as part of its contributions to the government-led response to the Independent Review of the Mental Health Act that reported to the Prime Minister in December 2018. The government has signalled its intention to legislate in response to the review, and NHS England will suggest that the issue of smoking and use of section 17 leave should also be considered as part of future revisions to the Code of Practice.” Source location 2019-0062-Response-by-NHS-England
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24 Jul 2017 Khuong Lam · Prevention of Future Deaths report South Wales Central
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Concerns raised 2
Failure to determine the number of escorts required for Section 17 leave View source Failure to review Section 17 leave on transfer View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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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.
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Khuong Lam · Prevention of Future Deaths report
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Report summary
Khuong Lam, a 42-year-old man with schizophrenia, died after absconding while on Section 17 leave, following a struggle involving pressure to the neck. The concerns included the lack of review or revocation of Section 17 leave when he was transferred to the Psychiatric Intensive Care Ward, the arrangements for escorts during leave, and the need to share related learning across Wales.
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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 determine the number of escorts required for Section 17 leave
Wider context from the report “(2) The inquest heard evidence that two escorts can provide a deterrent effect against absconsion, and are better able to deal with absconsions . Cardiff and Vale Health Board have now concluded a two month study of the efficacy of having two escorts to a patient on Section 17 leave and the lessons of this study should be applied across Wales .
” Source location Khuong Lam · Prevention of Future Deaths report
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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 review Section 17 leave on transfer
Wider context from the report “(3) ████████ the RC told the inquest that if he had been made aware of Khuong Lam’s transfer to PICU he could have reviewed him and decided whether Section 17 leave was still appropriate . The Coroner is concerned that the good practice now adopted by Cardiff Health Board should be replicated across Wales i.e. that the RC be informed of any transfer between wards; that Section 17 leave is reviewed on a transfer (and especially to PICU) ; and to consider further the number of escorts required for any Section 17 leave.
” Source location Khuong Lam · Prevention of Future Deaths report
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21 Feb 2017 JACK OLIVER PORTLAND · Prevention of Future Deaths report Buckinghamshire
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Concerns raised 4
Failure to establish and communicate a clear AWOL and leave authorisation procedure View source Failure to complete leave observation charts contemporaneously and consistently View source Failure to maintain an accurate and reliable leave tracking system View source
Failure to provide S17 leave records to required recipients View source See 1 more concern
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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JACK OLIVER PORTLAND · Prevention of Future Deaths report
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Report summary
Jack Oliver Portland was a prisoner who was diagnosed with substance-induced psychosis and later detained under the Mental Health Act. He died on 27 December 2015 at Wycombe Hospital while on unescorted leave from the Whiteleaf Centre; the medical cause of death was morphine and ethanol toxicity. Concerns included the management and communication of ACCT documents, family communication, discharge planning for a vulnerable and homeless prisoner, and the coordination of coronial disclosure.
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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 establish and communicate a clear AWOL and leave authorisation procedure
Wider context from the report “(3) The implementation of the AWOL procedure and checklist, including the application of 10-minute buffer time immediately at the end of scheduled leave was not clearly understood by witnesses in person and there appeared to be no proper overarching leave policy including proper recording of who assessed a patient prior to leave and who authorised a particular leave . There was no proper contemporaneous record of all the steps actually taken in connection of Mr Portland’s AWOL.
” Source location JACK OLIVER PORTLAND · Prevention of Future Deaths report
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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 complete leave observation charts contemporaneously and consistently
Wider context from the report “(3) The manually-completed observation charts, forming the third element of an effective leave management process, were acknowledged to be filled out sometimes retrospectively, sometimes prospectively, sometimes by reference to the whiteboard (and evidence suggested amended later) rather than always being completed in the ward round. There was scope for human error and discrepancies between the various records of leave .
” Source location JACK OLIVER PORTLAND · Prevention of Future Deaths report
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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 maintain an accurate and reliable leave tracking system
Wider context from the report “(2) A specific request for leave from the patient would be actioned by a nursing-level assessment, authorisation of the specific leave by the nurse in charge and implementation of the leave by a staff member. A Record of Leave of Absence would be completed and signed by the patient and the staff member and that staff member would usually then write up that patient’s name and the times out and due back on a whiteboard in the office. Evidence from witnesses confirmed that there was no particular order to the whiteboard . In the case of Mr Portland, his final leave had not been written on the whiteboard correctly and his absence was not identified until well over an hour after he was due back . The evidence indicated that the whiteboard is still used in the same way , notwithstanding that it was acknowledged that there was scope for human error and that addressing the issue was a matter of urgency.
” Source location JACK OLIVER PORTLAND · Prevention of Future Deaths report
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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 S17 leave records to required recipients
Wider context from the report “(1) The practical implementation of S17 leave involved, firstly, the grant of leave by the consultant psychiatrist and it was mandatory to provide copies of those Records of Grant not only to the patient, but also to the family of a patient along with the Inpatient clinical team and the MHA administrator . The Care Co-ordinator and GP were also optional recipients. No copies of any of Mr Portland’s S17 Records of Grant of Leave appeared to have been provided to anyone other than the patient . The family were unaware of changes to leave and were unable to participate in the leave process or assist Whiteleaf with regard to any heightened risks.
” Source location JACK OLIVER PORTLAND · Prevention of Future Deaths report
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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 governance approval and implement the amended section 17 leave form, including recording whether copies should be provided and to whom.
Verbatim wording from the response “The provision of copies of leave forms is not in fact mandatory under either the Mental Health Act Code of Practice or Trust policy (the Trust’s current granting of leave form, which suggests that this is the case, is misleading). Nevertheless, it is acknowledged that in many cases patients and their families find it useful to have a copy of the form in addition to being involved in discussions around the granting of any leave and conditions. The section 17 leave form has been amended and is currently going through the Trust’s governance processes for approval. It is anticipated that use of the new form will be implemented no later than 28th April 2017. The newly designed form allows the consultant to indicate, following discussions with patients and families, if copies should be provided and, if so, to whom.” Source location 2017-0049-Response-by-Oxford-Health-NHS-Trust
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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 Test the new leave-management SOP on Sapphire ward, review it, and expand implementation across all adult wards.
Verbatim wording from the response “In addition, a new standard operating procedure (SOP) for managing leave (appendix 1) includes the need for staff to have a discussion with the family, where appropriate consent is given by the patient, regarding the patient’s leave from the ward and to do this every time there is a change to the leave agreed.” Source location 2017-0049-Response-by-Oxford-Health-NHS-Trust
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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 Communicate AWOL procedures to staff and provide guidance and Missing Patient Action Checklists on all acute inpatient wards.
Verbatim wording from the response “The responsibility for ensuring that patients are back from leave now clearly rests with the person allocated to carry out general observations. That staff member is also responsible for informing the shift co-ordinator, who will co-ordinate the implementation of the AWOL policy, if a patient does not return on time (appendix 3). The shift co-ordinator is always a qualified nurse.” Source location 2017-0049-Response-by-Oxford-Health-NHS-Trust
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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 hourly physical handover of observation charts, with both allocated staff checking that records are complete and accurate.
Verbatim wording from the response “The new SOP referred to above is being tested on Sapphire ward. It clarifies and simplifies the management of leave on the ward. It gives clear instruction as to how leave is granted, the nursing level assessment, and simplifies the recording of leave on one collective ward document (appendix 2).” Source location 2017-0049-Response-by-Oxford-Health-NHS-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 Monitor observation-recording practice through the Matron and make the prohibition on prospective or retrospective entries explicit in the revised Observation Policy.
Verbatim wording from the response “Staff have been strongly reminded that it is not appropriate to fill in observations paperwork prospectively or retrospectively. This is now monitored by the Matron. We are in the process of reviewing the Trust’s Observation Policy, and will ensure that this is also made very explicit within the new version. This policy review will be complete by the end of April 2017.” Source location 2017-0049-Response-by-Oxford-Health-NHS-Trust
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How this respondent action was interpreted
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PFD Monitor interpretation Require shift coordinators to sign off relevant observation and leave-record sheets before handover.
Verbatim wording from the response “An existing SOP which covers shift co-ordination has had a new action added, which is that the shift co-ordinator signs off all relevant sheets, including observation charts, to ensure that all staff have fully completed the required paperwork, including the leave record form, and it is in order before handing over to the next shift.” Source location 2017-0049-Response-by-Oxford-Health-NHS-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 Replace multiple leave-recording locations and the whiteboard with one central ward document.
Verbatim wording from the response “The new SOP referred to above is being tested on Sapphire ward. It clarifies and simplifies the management of leave on the ward. It gives clear instruction as to how leave is granted, the nursing level assessment, and simplifies the recording of leave on one collective ward document (appendix 2).” Source location 2017-0049-Response-by-Oxford-Health-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 Providing patients or families copies of leave forms is not mandatory under the Mental Health Act Code of Practice or Trust policy.
Verbatim wording from the response “The provision of copies of leave forms is not in fact mandatory under either the Mental Health Act Code of Practice or Trust policy (the Trust’s current granting of leave form, which suggests that this is the case, is misleading). Nevertheless, it is acknowledged that in many cases patients and their families find it useful to have a copy of the form in addition to being involved in discussions around the granting of any leave and conditions. The section 17 leave form has been amended and is currently going through the Trust’s governance processes for approval. It is anticipated that use of the new form will be implemented no later than 28th April 2017. The newly designed form allows the consultant to indicate, following discussions with patients and families, if copies should be provided and, if so, to whom.” Source location 2017-0049-Response-by-Oxford-Health-NHS-Trust
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Concerns raised 3
Failure to notify local community and home treatment teams of S17 leave View source Absence of a risk mitigation plan before S17 leave View source Limited risk assessments before S17 leave View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
David Knight · 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
David Knight, who was detained under the Mental Health Act for chronic mental health issues, died on 23 May 2015 after walking onto a railway track in front of an oncoming train while on Section 17 leave. Concerns included a limited risk assessment before leave, no notification to local community and home treatment teams, and the difficulties associated with his out-of-county placement, including reduced family involvement and communication challenges.
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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 notify local community and home treatment teams of S17 leave
Wider context from the report “S17 leave is prescribed by the Responsible Medical Officer as part of the treatment to the hospitalised patient in order facilitate them re-integrating back into the community in a structured, safe and supported way. Typically this would start off with escorted leave in the grounds of the hospital and hospital locality, moving to unescorted leave and then to home leave. Latterly the community mental health services and Home Treatment Team are involved to ensure a smooth transition of the patient back to community living.
When Mr Knight's mental health deteriorated whilst on leave, there were concerns that a limited risk assessment was carried out by Cygnet Hospital prior to S17 leave on 21st May 2015 and there was no communication with the local community mental health team and Home Treatment Team in Cornwall notifying them of the leave . This meant that when Mr Knight's mental health deteriorated while on leave, there was no method of reducing the risk of self-harm or harm to others, as no mitigation plan had been put in place in advance of the leave and the Cornwall Community Mental Health Team and the Home Treatment Team were unaware he was on S17 leave in their area . The expert psychiatrists considered that although misjudgement about leave could occur in any hospital setting, the fact that Mr Knight was being treated out of County would have increased the risk of poor communication with the community treatment teams as the hospital would not be familiar with local service and it was very likely that this had a bearing on Mr Knight's death (████████).
” Source location David Knight · Prevention of Future Deaths report
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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 Absence of a risk mitigation plan before S17 leave
Wider context from the report “S17 leave is prescribed by the Responsible Medical Officer as part of the treatment to the hospitalised patient in order facilitate them re-integrating back into the community in a structured, safe and supported way. Typically this would start off with escorted leave in the grounds of the hospital and hospital locality, moving to unescorted leave and then to home leave. Latterly the community mental health services and Home Treatment Team are involved to ensure a smooth transition of the patient back to community living.
When Mr Knight's mental health deteriorated whilst on leave, there were concerns that a limited risk assessment was carried out by Cygnet Hospital prior to S17 leave on 21st May 2015 and there was no communication with the local community mental health team and Home Treatment Team in Cornwall notifying them of the leave. This meant that when Mr Knight's mental health deteriorated while on leave, there was no method of reducing the risk of self-harm or harm to others , as no mitigation plan had been put in place in advance of the leave and the Cornwall Community Mental Health Team and the Home Treatment Team were unaware he was on S17 leave in their area. The expert psychiatrists considered that although misjudgement about leave could occur in any hospital setting, the fact that Mr Knight was being treated out of County would have increased the risk of poor communication with the community treatment teams as the hospital would not be familiar with local service and it was very likely that this had a bearing on Mr Knight's death (████████).
” Source location David Knight · Prevention of Future Deaths report
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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 Limited risk assessments before S17 leave
Wider context from the report “S17 leave is prescribed by the Responsible Medical Officer as part of the treatment to the hospitalised patient in order facilitate them re-integrating back into the community in a structured, safe and supported way. Typically this would start off with escorted leave in the grounds of the hospital and hospital locality, moving to unescorted leave and then to home leave. Latterly the community mental health services and Home Treatment Team are involved to ensure a smooth transition of the patient back to community living.
When Mr Knight's mental health deteriorated whilst on leave, there were concerns that a limited risk assessment was carried out by Cygnet Hospital prior to S17 leave on 21st May 2015 and there was no communication with the local community mental health team and Home Treatment Team in Cornwall notifying them of the leave. This meant that when Mr Knight's mental health deteriorated while on leave, there was no method of reducing the risk of self-harm or harm to others, as no mitigation plan had been put in place in advance of the leave and the Cornwall Community Mental Health Team and the Home Treatment Team were unaware he was on S17 leave in their area. The expert psychiatrists considered that although misjudgement about leave could occur in any hospital setting, the fact that Mr Knight was being treated out of County would have increased the risk of poor communication with the community treatment teams as the hospital would not be familiar with local service and it was very likely that this had a bearing on Mr Knight's death (████████).
” Source location David Knight · 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 Publish and apply a revised Mental Health Act Code of Practice strengthening family involvement and robust risk assessment, including for leave of absence.
Verbatim wording from the response “You have raised concerns about the quality of the risk assessment that was undertaken and the limited contact with Mr Knight’s family by the mental health provider to support Mr Knight’s leave in the community. These matters are the responsibility of the local health services. However, you may be aware that the Department published a revised Mental Health Act 1983 Code of Practice in 2015 which strengthened the guiding principles of the Code.” Source location 2016-0414-Response-by-Department-of-Health
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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 Local health services are responsible for the quality of risk assessments and family contact supporting patients’ community leave.
Verbatim wording from the response “You have raised concerns about the quality of the risk assessment that was undertaken and the limited contact with Mr Knight’s family by the mental health provider to support Mr Knight’s leave in the community. These matters are the responsibility of the local health services. However, you may be aware that the Department published a revised Mental Health Act 1983 Code of Practice in 2015 which strengthened the guiding principles of the Code.” Source location 2016-0414-Response-by-Department-of-Health
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Concerns raised 3
Delays in responding to a patient’s absence from leave View source Failure to ensure that leave arrangements are understood by patients and communicated to relatives View source Lack of staff knowledge of leave and missing-patient policies View source
This report raised 4 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.
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AI-generated summary
Michael Peter McMonigle · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael Peter McMonigle was admitted as an informal patient to Farnham Ward at Lanchester Road Hospital and was assessed as being at significant risk of self-harm. On 11 August 2015 he left the hospital during accompanied leave, was later found suspended by a ligature, and was declared dead on 12 August. The principal concerns included failures to update and communicate risk information and leave arrangements, inadequate handover and policy implementation, and delays and omissions in responding to his absence.
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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 Delays in responding to a patient’s absence from leave
Wider context from the report “(1) The lack of knowledge of the policy for leave for informal patients amongst ward staff and the Consultant Psychiatrist in particular.
(2) The failure to follow the policy in terms of conducting an assessment prior to the handover.
(3) The failure to apply the policy in terms of ensuring that leave arrangements are clearly understood by the patient and communicated to relatives. See paragraphs 6.7 and 6.8, the policy of Leave from Hospital and Leave of Absence under Section 17 Mental Health Act 1973, policy no CLIN00025.
(4) The Face risk assessment, PARIS case notes and intervention plan were not updated with assessment of risk of self-harm or suicide and details of conditions for escorted leave following the formulation meeting on 10th August 2015. Instead, it fell to staff to verbally convey this information to colleagues who had not attended at the formulation meeting and to members of the family.
(5) Failure to respond to Michael’s absence until well after 19:20 hrs, when it was admitted by ward staff in evidence that interventions could have been commenced, alternatively at 21:00hrs when it was conceded that the alarm could have been raised given that was the normal time for return from leave.
(6) The response to Michael’s absence did not conform with paragraphs 7.3 of the Missing Patients Procedure, ref. CLIN-0006-V4 in that there was no search of the hospital internally, a search of the grounds, enquiry with other staff users, check of CCTV footage.
(6) The following responses were undertaken after 19.20 and 21.00 when in conclusion of the jury the alarm could have been raised: enquiry with friends or relatives from 22:30hrs at earliest, an attempt to telephone Michael from 22:40 hrs at earliest, contact with relatives from 22:30 hrs at the earliest (Michael’s mother said 23.15), Police at 23:45hrs at the earliest, other hospital staff at 00:15hr on 12th August at the earliest, the medical staff at 12:20hrs at the earliest. Staff knowledge of the Leave policy and Missing Patients Procedure was inadequate.
” Source location Michael Peter McMonigle · Prevention of Future Deaths report
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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 ensure that leave arrangements are understood by patients and communicated to relatives
Wider context from the report “(1) The lack of knowledge of the policy for leave for informal patients amongst ward staff and the Consultant Psychiatrist in particular.
(2) The failure to follow the policy in terms of conducting an assessment prior to the handover.
(3) The failure to apply the policy in terms of ensuring that leave arrangements are clearly understood by the patient and communicated to relatives. See paragraphs 6.7 and 6.8, the policy of Leave from Hospital and Leave of Absence under Section 17 Mental Health Act 1973, policy no CLIN00025.
(4) The Face risk assessment, PARIS case notes and intervention plan were not updated with assessment of risk of self-harm or suicide and details of conditions for escorted leave following the formulation meeting on 10th August 2015. Instead, it fell to staff to verbally convey this information to colleagues who had not attended at the formulation meeting and to members of the family.
(5) Failure to respond to Michael’s absence until well after 19:20 hrs, when it was admitted by ward staff in evidence that interventions could have been commenced, alternatively at 21:00hrs when it was conceded that the alarm could have been raised given that was the normal time for return from leave.
(6) The response to Michael’s absence did not conform with paragraphs 7.3 of the Missing Patients Procedure, ref. CLIN-0006-V4 in that there was no search of the hospital internally, a search of the grounds, enquiry with other staff users, check of CCTV footage.
(6) The following responses were undertaken after 19.20 and 21.00 when in conclusion of the jury the alarm could have been raised: enquiry with friends or relatives from 22:30hrs at earliest, an attempt to telephone Michael from 22:40 hrs at earliest, contact with relatives from 22:30 hrs at the earliest (Michael’s mother said 23.15), Police at 23:45hrs at the earliest, other hospital staff at 00:15hr on 12th August at the earliest, the medical staff at 12:20hrs at the earliest. Staff knowledge of the Leave policy and Missing Patients Procedure was inadequate.
” Source location Michael Peter McMonigle · Prevention of Future Deaths report
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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 Lack of staff knowledge of leave and missing-patient policies
Wider context from the report “(1) The lack of knowledge of the policy for leave for informal patients amongst ward staff and the Consultant Psychiatrist in particular.
(2) The failure to follow the policy in terms of conducting an assessment prior to the handover.
(3) The failure to apply the policy in terms of ensuring that leave arrangements are clearly understood by the patient and communicated to relatives. See paragraphs 6.7 and 6.8, the policy of Leave from Hospital and Leave of Absence under Section 17 Mental Health Act 1973, policy no CLIN00025.
(4) The Face risk assessment, PARIS case notes and intervention plan were not updated with assessment of risk of self-harm or suicide and details of conditions for escorted leave following the formulation meeting on 10th August 2015. Instead, it fell to staff to verbally convey this information to colleagues who had not attended at the formulation meeting and to members of the family.
(5) Failure to respond to Michael’s absence until well after 19:20 hrs, when it was admitted by ward staff in evidence that interventions could have been commenced, alternatively at 21:00hrs when it was conceded that the alarm could have been raised given that was the normal time for return from leave.
(6) The response to Michael’s absence did not conform with paragraphs 7.3 of the Missing Patients Procedure, ref. CLIN-0006-V4 in that there was no search of the hospital internally, a search of the grounds, enquiry with other staff users, check of CCTV footage.
(6) The following responses were undertaken after 19.20 and 21.00 when in conclusion of the jury the alarm could have been raised: enquiry with friends or relatives from 22:30hrs at earliest, an attempt to telephone Michael from 22:40 hrs at earliest, contact with relatives from 22:30 hrs at the earliest (Michael’s mother said 23.15), Police at 23:45hrs at the earliest, other hospital staff at 00:15hr on 12th August at the earliest, the medical staff at 12:20hrs at the earliest. Staff knowledge of the Leave policy and Missing Patients Procedure was inadequate.
” Source location Michael Peter McMonigle · Prevention of Future Deaths report
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19 Feb 2016 Brenda Elizabeth MORRIS · Prevention of Future Deaths report Inner North London
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Concerns raised 3
Failure to communicate the basis for weekend leave to the supervising partner View source Substandard nursing-record documentation of risk assessments before weekend leave View source Failure to routinely obtain required medical authorisation for unplanned leave of informal patients View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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Brenda Elizabeth MORRIS · 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
Brenda Elizabeth Morris, aged 66, died by drowning herself in the bath at home after being admitted to Larch Lodge as an informal patient and granted weekend leave. Concerns included inadequate communication with her partner about the basis for leave, limited routine feedback from family after leave, confusion about authorisation of unplanned leave, and substandard nursing documentation affecting the recording of risk assessments.
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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 communicate the basis for weekend leave to the supervising partner
Wider context from the report “1. Brenda Morris was allowed weekend leave on the basis that her partner was at home to keep an eye on her, but no member of staff told him this . This was not a situation where she needed 24 hour supervision. Nevertheless, it would have been helpful for him to know the basis for the leave, because he would then have modified his own behaviour accordingly.
” Source location Brenda Elizabeth MORRIS · 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 Substandard nursing-record documentation of risk assessments before weekend leave
Wider context from the report “4. Substandard documentation in the nursing records had already been identified before the inquest by your serious incident review. Without improvement in the records, it is not possible to determine whether and if so by whom a necessary risk assessment is undertaken , e.g. immediately before weekend leave is taken.
” Source location Brenda Elizabeth MORRIS · 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 routinely obtain required medical authorisation for unplanned leave of informal patients
Wider context from the report “3. There appears to be confusion about whether a doctor is needed to authorise unplanned leave of an informal patient (not relevant in this case because the leave had already been authorised). Your serious incident review of this matter indicates that this is necessary, but I heard evidence that such medical authorisation is not routinely sought .
” Source location Brenda Elizabeth MORRIS · 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 Implement and roll out the Informal patient leave agreement documenting doctor-approved leave, conditions, contingency plans, and signatures.
Verbatim wording from the response “However, in light of the importance of this issue the Trust has taken the decision to implement the use of template documentation to ensure that any leave has been appropriately agreed by a doctor. A new ‘Informal patient leave agreement’ has been developed. This document details the agreement of leave following assessment by a doctor. The template includes a box detailing any leave conditions along with any expectations from staff, patients, relatives and carers. A separate box deals with contingency plans. The agreement is then signed by the doctor, the patient and the relative. This document is expected to be in place before a patient goes on leave.” Source location 2016-0065-Response-by-East-London-NHS-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 Implement and roll out the inpatient leave checklist requiring risk assessment, family discussions, contingency plans, return feedback, and RIO documentation.
Verbatim wording from the response “In addition to the above an ‘In-patient leave checklist for informal and detained patients’ has been developed. It is also a requirement for this checklist to be completed for all leave. The checklist requires staff to assess risk prior to any period of leave, discuss with family or friends issues of risk and provide relatives/carers with a copy of an individualised contingency care plan. On return from leave staff will need to confirm that they have obtained feedback from family on the patient’s return from leave. The detail of all assessments and discussions will be fully documented on RIO.” Source location 2016-0065-Response-by-East-London-NHS-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 Conduct quarterly audits of leave forms and corresponding RIO entries from July 2016 through January 2017.
Verbatim wording from the response “Both forms are currently being piloted on one of our Mental Health Care for Older Persons wards with the aim of full introduction across all of our Older Persons wards by the end of this month. Use of the forms and the corresponding RIO entries will be the subject to quarterly audits starting from the end of July 2016 until January 2017 and will be subject to further review thereafter if necessary.” Source location 2016-0065-Response-by-East-London-NHS-Trust
Open published response
22 Oct 2015 Glenda Day · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 7
Lack of clear written home leave requirements View source Lack of defined recency requirements for risk assessment review before home leave View source Lack of defined recency requirements for doctor review before home leave View source
Failure to ensure doctor review before granting home leave View source Failure to review risk assessments before granting home leave View source Failure to communicate home leave requirements to relevant staff across the trust View source Failure to establish home leave requirements trustwide View source See 4 more concerns
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.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Glenda Day · 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
Glenda Day, who had a history of mental health problems, was admitted following an overdose and later took a fatal overdose after being granted home leave on 12 March 2015. She died on 13 March 2015; the inquest recorded opiate toxicity as the cause of death and suicide as the conclusion. The principal concerns were that home leave was granted without an adequate contemporaneous medical review and updated risk assessment, and that requirements for home leave were not clearly established, communicated, and monitored across the trust.
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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 Lack of clear written home leave requirements
Wider context from the report “3. I remain concerned however for patients across the wider trust and indeed for this ward when new staff are taken on, who may not be familiar with this tragic case. It seems to me very important to have these requirements enshrined in written policies . I understand that some work has already gone into this.
4. I was advised that a Home Leave Policy does exist for the Ward B2, but neither the ward manager ████████ nor the most senior nurse ████████ was able to tell me with any certainty whether these were in fact new requirements, or requirements that were already contained with the existing policy, which had been overlooked .
” Source location Glenda Day · 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 defined recency requirements for risk assessment review before home leave
Wider context from the report “7. It is also concerning that there appears to be no timescale for the two requirements referred to above – ie how contemporary does a doctor review and risk assessment review need to be before the patient can be granted home leave ?
” Source location Glenda Day · 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 defined recency requirements for doctor review before home leave
Wider context from the report “7. It is also concerning that there appears to be no timescale for the two requirements referred to above – ie how contemporary does a doctor review and risk assessment review need to be before the patient can be granted home leave ?
” Source location Glenda Day · 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 ensure doctor review before granting home leave
Wider context from the report “1. It would appear that ████████ twice granted Glenda home leave by telephone, without seeing the patient himself . On the first occasion (5 March), he did ask a trainee to see her first. On the second (12 March), he appears simply to have repeated his view of 9 March (when he last saw Glenda) without seeing her first, or asking a colleague to see her , despite the significant events which had occurred between 9 and 12 March. Her risk assessment had also not been updated since her overdose on 10 March.
” Source location Glenda Day · 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 review risk assessments before granting home leave
Wider context from the report “1. It would appear that ████████ twice granted Glenda home leave by telephone, without seeing the patient himself. On the first occasion (5 March), he did ask a trainee to see her first. On the second (12 March), he appears simply to have repeated his view of 9 March (when he last saw Glenda) without seeing her first, or asking a colleague to see her, despite the significant events which had occurred between 9 and 12 March. Her risk assessment had also not been updated since her overdose on 10 March.
” Source location Glenda Day · 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 communicate home leave requirements to relevant staff across the trust
Wider context from the report “5. I was also concerned that the focus was very much on this ward, rather than the trust as a whole. Whilst I was advised that a trustwide review is ongoing (dealing with involuntary patients as well), no witness could tell me whether these requirements are likely to be included in a trustwide policy, and when this review will be completed.
6. I remain concerned that the focus of this investigation has been too narrow. It is clearly important that these requirements are included in the written Home Leave Policy, and communicated to all relevant staff, across the trust .
” Source location Glenda Day · 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 establish home leave requirements trustwide
Wider context from the report “5. I was also concerned that the focus was very much on this ward, rather than the trust as a whole . Whilst I was advised that a trustwide review is ongoing (dealing with involuntary patients as well), no witness could tell me whether these requirements are likely to be included in a trustwide policy , and when this review will be completed.
6. I remain concerned that the focus of this investigation has been too narrow. It is clearly important that these requirements are included in the written Home Leave Policy, and communicated to all relevant staff, across the trust.
” Source location Glenda Day · Prevention of Future Deaths report
Open source report
11 Mar 2015 LEAH LEVINE · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2
Failure to clearly define temporary hospital leave conditions, supervision responsibilities and observation requirements View source Failure to document and provide temporary hospital leave arrangements to those taking the patient from hospital View source
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
LEAH LEVINE · 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
Leah Levine died on 5 October 2014 after getting through a window onto the roof of a house and either jumping or falling. Concerns were raised that the conditions of her temporary leave from hospital, including responsibility for supervision and any observation regime, had not been clearly agreed, documented, or consistently understood by staff.
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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 clearly define temporary hospital leave conditions, supervision responsibilities and observation requirements
Wider context from the report “When it was negotiated by the family and friends, with the NHS Trust employees, that she could have temporary leave from the hospital, it was never clearly set out as to what the conditions of that leave should be: who should be responsible for supervising her: What the level and frequency of such supervision should be: what, if any, observation regime should be put in place : and nothing was reduced to writing and given to those taking her from the hospital.
Consequent on the above, there was conflicting evidence from different members of the medical and nursing staff as to what exactly was expected and put forward as required .
” Source location LEAH LEVINE · 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 document and provide temporary hospital leave arrangements to those taking the patient from hospital
Wider context from the report “When it was negotiated by the family and friends, with the NHS Trust employees, that she could have temporary leave from the hospital, it was never clearly set out as to what the conditions of that leave should be: who should be responsible for supervising her: What the level and frequency of such supervision should be: what, if any, observation regime should be put in place: and nothing was reduced to writing and given to those taking her from the hospital .
Consequent on the above, there was conflicting evidence from different members of the medical and nursing staff as to what exactly was expected and put forward as required.
” Source location LEAH LEVINE · 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 Develop a procedure governing informal patients’ leave with family and friends, including medication, supervision, crisis planning and home-based treatment support considerations.
Verbatim wording from the response “I will therefore outline the action taken by the Trust to address the concern you have raised within your regulation 28. The Salford Directorate has developed a procedure that should be followed when Informal Patients are granted leave with family and friends. This procedure outlines the considerations by the Multidisciplinary team that need to be taken whilst granting leave for a service user in our care. These include medication management, supervision, crisis plan, home based treatment support if applicable. I enclose a copy of the procedure for your information. In order to share the learning from Ms Levine’s death and following the concerns raised during your inquest, the Directorate will inform all Inpatient Nursing and Medical of the procedure which will be implemented by the 31st May 2015.” Source location 2015-0093-Response-by-Greater-Manchester-West-NHS
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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 Implement the procedure for informal patients’ leave with family and friends by 31 May 2015.
Verbatim wording from the response “I will therefore outline the action taken by the Trust to address the concern you have raised within your regulation 28. The Salford Directorate has developed a procedure that should be followed when Informal Patients are granted leave with family and friends. This procedure outlines the considerations by the Multidisciplinary team that need to be taken whilst granting leave for a service user in our care. These include medication management, supervision, crisis plan, home based treatment support if applicable. I enclose a copy of the procedure for your information. In order to share the learning from Ms Levine’s death and following the concerns raised during your inquest, the Directorate will inform all Inpatient Nursing and Medical of the procedure which will be implemented by the 31st May 2015.” Source location 2015-0093-Response-by-Greater-Manchester-West-NHS
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 Inform all inpatient nursing and medical staff about the procedure by 31 May 2015.
Verbatim wording from the response “I will therefore outline the action taken by the Trust to address the concern you have raised within your regulation 28. The Salford Directorate has developed a procedure that should be followed when Informal Patients are granted leave with family and friends. This procedure outlines the considerations by the Multidisciplinary team that need to be taken whilst granting leave for a service user in our care. These include medication management, supervision, crisis plan, home based treatment support if applicable. I enclose a copy of the procedure for your information. In order to share the learning from Ms Levine’s death and following the concerns raised during your inquest, the Directorate will inform all Inpatient Nursing and Medical of the procedure which will be implemented by the 31st May 2015.” Source location 2015-0093-Response-by-Greater-Manchester-West-NHS
Open published response
12 Feb 2015 Jane Marie Clark and Isobel Griffin · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 1
Failure to set boundaries for patient leave View source
This report raised 7 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.
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AI-generated summary
Jane Marie Clark and Isobel Griffin · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jane Marie Clark died by suicide after leaving Berrywood Hospital on 22 August 2013 with an inadequate risk assessment, following recent suicide-related concerns and possession of a ligature. Isobel Griffin died after hanging herself on the ward on 17 August 2013, with death pronounced on 21 August 2013. The principal concerns included inadequate handover and risk assessments, failures to review relevant clinical information and treatment, and insufficient measures to minimise ligature risk.
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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 set boundaries for patient leave
Wider context from the report “Re Jane Marie Clark
1. The very challenging events of the previous evening and that morning do not appear to have been handed over and the nurse in charge did not read the notes before granting leave. Her risk assessment then was ill informed. It was not discussed with anyone nor properly documented.
2. She did not place any boundaries on the leave for example providing a time by which Jane was to return .
3. Risk assessment documentation generally was poor and appeared perfunctory.
Re Isobel Griffin
1. Mrs Griffin was admitted on 1 August and was not allocated a key worker until 8th August. The key worker did not read the notes so was not aware of the events of the 7th.
2. The risk assessment was not updated with the events of the 7th.
3. Mrs Griffin’s responsible clinician saw her on only one occasion on 14 August 2013 at which time he did not read the notes so he was unaware of events on the 7th when she handed in a belt and scissors and said she had 3-4 times tried to hang herself using a ligature.
4. A planned review of medication, diagnosis and treatment never took place despite a number of references in the notes to it from 6 August 2013. Mrs Griffin had been substantially unmedicated for most of the admission despite concerns expressed by her family.
5. On 11 August Mrs Griffin started to express thoughts to harm others. These thoughts distressed her. She did not intend to act on them but they were something new and a measure of her distress. These thoughts and their significance were not included in any risk assessment.
6. A risk assessment concluded on the 18th, the day after she had hanged herself on the ward, purports to be made with her agreement. It was evidence that risk assessment documentation is cut and pasted rather than reflecting the true circumstances.
7. The doors do not appear to be ligature proof and little was made available by way of evidence as to what measures would now be taken to minimise this risk.
” Source location Jane Marie Clark and Isobel Griffin · Prevention of Future Deaths report
Open source report
28 Jan 2015 Katherine Liana Bonaventura · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 3
Failure to record the outcome of mental state assessments after inpatient leave View source Lack of a system for sufficiently thorough private consultation with family members or carers after inpatient leave View source Lack of a system ensuring sufficient mental state assessment of patients returning from inpatient leave View source
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.
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AI-generated summary
Katherine Liana Bonaventura · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Katherine Liana Bonaventura, a patient detained under the Mental Health Act, returned to the Abraham Cowley Unit on 7 December 2012 after overnight leave with a concealed knife and fatally stabbed herself a few hours later. The principal concerns were that relevant information about her leave was not elicited from her family member, her mental state was not assessed sufficiently and immediately on return, and there was no system to ensure thorough consultation and assessment or recording of the assessment outcome.
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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 record the outcome of mental state assessments after inpatient leave
Wider context from the report “It was clear from the evidence that the Trust had and has in place Guidelines entitled “Working Age Adults Inpatient Leave of Absence Guidelines for Detained Patients” dated November 2011 and reviewed in July 2012. Those guidelines state, “Upon return from leave, an assessment of the patient should occur and the family member, carer should be consulted to ensure any issues arising during leave are noted. The outcome of this discussion should be documented in the patient’s clinical record. ”
It was apparent from the evidence that (i) the consultation with the family member / carer may consist of no more than an exchange of a few words in the presence of the patient, (ii) it is sometimes difficult for a family member / carer to provide all relevant information to staff in those circumstances and (iii) if staff are not immediately aware of any issues arising, their “assessment of the patient” may consist of no more than an exchange of a few words in the reception area.
It is, therefore, of great importance that staff elicit as much information as possible about the leave and any concerns arising, at the point of the patient’s return.
It is of concern that there is no system in place to ensure that a sufficiently thorough consultation takes place with the family member / carer, which is designed to elicit as much information as possible as soon as possible. One nurse stated in evidence that it is now his personal habit to escort the family member / carer off the Unit so that he can conduct a further, private, consultation, but that not all nurses do so. It is also of concern that there is no system in place to ensure that a sufficient mental state assessment of the patient is conducted, and its outcome is recorded , at the time of arrival back on the Unit.
” Source location Katherine Liana Bonaventura · Prevention of Future Deaths report
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 system for sufficiently thorough private consultation with family members or carers after inpatient leave
Wider context from the report “It was clear from the evidence that the Trust had and has in place Guidelines entitled “Working Age Adults Inpatient Leave of Absence Guidelines for Detained Patients” dated November 2011 and reviewed in July 2012. Those guidelines state, “Upon return from leave, an assessment of the patient should occur and the family member, carer should be consulted to ensure any issues arising during leave are noted. The outcome of this discussion should be documented in the patient’s clinical record.”
It was apparent from the evidence that (i) the consultation with the family member / carer may consist of no more than an exchange of a few words in the presence of the patient , (ii) it is sometimes difficult for a family member / carer to provide all relevant information to staff in those circumstances and (iii) if staff are not immediately aware of any issues arising, their “assessment of the patient” may consist of no more than an exchange of a few words in the reception area.
It is, therefore, of great importance that staff elicit as much information as possible about the leave and any concerns arising, at the point of the patient’s return.
It is of concern that there is no system in place to ensure that a sufficiently thorough consultation takes place with the family member / carer, which is designed to elicit as much information as possible as soon as possible . One nurse stated in evidence that it is now his personal habit to escort the family member / carer off the Unit so that he can conduct a further, private, consultation, but that not all nurses do so . It is also of concern that there is no system in place to ensure that a sufficient mental state assessment of the patient is conducted, and its outcome is recorded, at the time of arrival back on the Unit.
” Source location Katherine Liana Bonaventura · Prevention of Future Deaths report
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 system ensuring sufficient mental state assessment of patients returning from inpatient leave
Wider context from the report “It was clear from the evidence that the Trust had and has in place Guidelines entitled “Working Age Adults Inpatient Leave of Absence Guidelines for Detained Patients” dated November 2011 and reviewed in July 2012. Those guidelines state, “Upon return from leave, an assessment of the patient should occur and the family member, carer should be consulted to ensure any issues arising during leave are noted. The outcome of this discussion should be documented in the patient’s clinical record.”
It was apparent from the evidence that (i) the consultation with the family member / carer may consist of no more than an exchange of a few words in the presence of the patient, (ii) it is sometimes difficult for a family member / carer to provide all relevant information to staff in those circumstances and (iii) if staff are not immediately aware of any issues arising, their “assessment of the patient” may consist of no more than an exchange of a few words in the reception area .
It is, therefore, of great importance that staff elicit as much information as possible about the leave and any concerns arising, at the point of the patient’s return.
It is of concern that there is no system in place to ensure that a sufficiently thorough consultation takes place with the family member / carer, which is designed to elicit as much information as possible as soon as possible. One nurse stated in evidence that it is now his personal habit to escort the family member / carer off the Unit so that he can conduct a further, private, consultation, but that not all nurses do so. It is also of concern that there is no system in place to ensure that a sufficient mental state assessment of the patient is conducted , and its outcome is recorded, at the time of arrival back on the Unit.
” Source location Katherine Liana Bonaventura · Prevention of Future Deaths report
Open source report
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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.
