Recurring concern

Unsafe management of inpatient leave and absence

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First reported 14 Oct 2013•Latest report 1 Jun 2026

Definition

What this concern includes

Includes planned or unescorted leave, return from leave, failure to return and absence without leave when a dedicated leave or absence control is deficient.

Not included

Excludes discharge and ordinary movement within a ward.
Excludes generic risk assessment, communication or police escalation not directly tied to inpatient leave or absence.

Reports: 55
Individual concerns: 119
Date range: 2013–2026
Stated actions: 134

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care8

Sussex Partnership NHS Foundation Trust6

Essex Partnership University NHS Foundation Trust5

Greater Manchester Mental Health NHS Foundation Trust4

NHS England4

Surrey and Borders Partnership NHS Foundation Trust4

Lancashire & South Cumbria NHS Foundation Trust3

Tees, Esk and Wear Valleys NHS Foundation Trust3

Central and North West London NHS Foundation Trust2

Coventry and Warwickshire Partnership NHS Trust2

East London NHS Foundation Trust2

Metropolitan Police Service2

Nottinghamshire Healthcare NHS Foundation Trust2

Oxford Health NHS Foundation Trust2

South London and Maudsley NHS Foundation Trust2

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

3 Apr2014
Brighton and Hove
Concerns raised2
1. Failure to allocate an appropriately familiar escort for informal patient leave
2. Failure to document leave reasons, risk assessments and decisions
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.
Respondent positions 1
1. Position
  The shortcomings identified were unlikely to have prevented the tragic outcome.
  Stated by Sussex Partnership NHS Foundation TrustDisputes the concern
AI-generated summary

DANUTA Bronislawa CORBETT · 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

Danuta Bronislawa Corbett jumped from the window of her eighth-floor flat during escorted leave on 4 November 2013 and died. The report raises concerns that decisions about her leave were not documented in accordance with policy and that the agency escort was not given important information about her distress, her home, or her stated threat to kill herself by jumping from it.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to allocate an appropriately familiar escort for informal patient leave
Wider context from the report
“(1) The report concerns the leave policy so far as it relates to Informal Patients. (Copy enclosed – refer to S. 4.5 and then S. 43). (2) Leave was considered first on 1.11.2013 when Mrs. Corbett was on 15 minute observations. The Ward Review documents that she wants leave to go to her home to collect some papers over the next 2 – 3 days- Escorted leave agreed. No Leave occurred on 1st, 2nd or 3rd November, 2013 but no reason for this is documented. On the 4th she has another Ward Review. She remained on 15 minute observations. As to leave, none of the matters referred to in the Policy at S.4.3 are documented in the Progress Note or in the Clinical Review or in the Electronic Note of the ward review on 4th November. In the afternoon of 4th November, Mrs. Corbett repeated her request to the Charge Nurse to go home. She was apparently Risk Assessed again and an escort was allocated. The escort was an agency health care worker who had never met the patient and had never worked on this ward before. No note by the risk assessment, or the decision to allow escorted leave was made in accordance with S.4.3 of the Policy. The patient’s details and details of the reasons for her admission were not handed over to the escort, in particular neither the fact that her flat/home was central to her distress or the fact that she had threatened to kill herself by jumping from it were known to the escort. Thus none of the decisions regarding her Leave on the 4th November are documented. This patient jumped out of her 8th floor flat window at home during this escorted leave. ”
Source location
DANUTA Bronislawa CORBETT · Prevention of Future Deaths report
Page 1 · concerns
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 leave reasons, risk assessments and decisions
Wider context from the report
“(1) The report concerns the leave policy so far as it relates to Informal Patients. (Copy enclosed – refer to S. 4.5 and then S. 43). (2) Leave was considered first on 1.11.2013 when Mrs. Corbett was on 15 minute observations. The Ward Review documents that she wants leave to go to her home to collect some papers over the next 2 – 3 days- Escorted leave agreed. No Leave occurred on 1st, 2nd or 3rd November, 2013 but no reason for this is documented. On the 4th she has another Ward Review. She remained on 15 minute observations. As to leave, none of the matters referred to in the Policy at S.4.3 are documented in the Progress Note or in the Clinical Review or in the Electronic Note of the ward review on 4th November. In the afternoon of 4th November, Mrs. Corbett repeated her request to the Charge Nurse to go home. She was apparently Risk Assessed again and an escort was allocated. The escort was an agency health care worker who had never met the patient and had never worked on this ward before. No note by the risk assessment, or the decision to allow escorted leave was made in accordance with S.4.3 of the Policy. The patient’s details and details of the reasons for her admission were not handed over to the escort, in particular neither the fact that her flat/home was central to her distress or the fact that she had threatened to kill herself by jumping from it were known to the escort. Thus none of the decisions regarding her Leave on the 4th November are documented. This patient jumped out of her 8th floor flat window at home during this escorted leave. ”
Source location
DANUTA Bronislawa CORBETT · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The shortcomings identified were unlikely to have prevented the tragic outcome.

Verbatim wording from the response
“It seems unlikely that any of the shortcomings highlighted by this very sad case would have prevented the tragic outcome. However, all the staff involved in Danuta’s care have carefully reflected on what happened and used the learning to improve their practice.”

Source location
2014-0150-Response-by-Sussex-Partnership-NHS-Trust
Page 2 · response
Published 3 April 2014
Open published response
31 Jan2014
West Sussex
Concerns raised2
1. Failure to carry out the required assessment when patients leave the ward
2. Unclear application of the leave policy to patients attending activities within hospital grounds
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.
AI-generated summary

Ryan Chapman · 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

Ryan Chapman was admitted to a mental health ward and, while being accompanied to an activity, left the hospital and ran into the path of an articulated lorry. He died from his injuries on 22 May 2013. Concerns included staff misunderstanding and inconsistent application of the Trust’s leave policy, uncertainty about the role of peer support workers as escorts, delays in completing his risk assessment and care plan, limited information for his family, and inconsistent ward visitor security.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to carry out the required assessment when patients leave the ward
Wider context from the report
“2. Staff seemed unclear as whether or not this policy should be applied when patients left the ward to attend activities within the hospital grounds. It if was to be applied then it was not strictly adhered to in Ryan’s case. The Nurse in Charge did not carry out an assessment, as required under Para 4.5., of Ryan at the time he left the ward. ”
Source location
Ryan Chapman · Prevention of Future Deaths report
Page 1 · concerns
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
Unclear application of the leave policy to patients attending activities within hospital grounds
Wider context from the report
“2. Staff seemed unclear as whether or not this policy should be applied when patients left the ward to attend activities within the hospital grounds. It if was to be applied then it was not strictly adhered to in Ryan’s case. The Nurse in Charge did not carry out an assessment, as required under Para 4.5., of Ryan at the time he left the ward. ”
Source location
Ryan Chapman · Prevention of Future Deaths report
Page 1 · concerns
Open source report
22 Oct2013
North and East Cambridgeshire
Concerns raised1
1. Lack of clear policy on staff-to-patient ratios for escorted leave from psychiatric wards
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.
AI-generated summary

Christopher James MORGAN · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

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

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of clear policy on staff-to-patient ratios for escorted leave from psychiatric wards
Wider context from the report
“The Trust should ensure that a clear practice and policy is adopted in relation to the ratio of staff to patient as to staff that should accompany patients on escorted leave from psychiatric wards ”
Source location
Christopher James MORGAN · Prevention of Future Deaths report
Page 1 · concerns
Open source report
21 Oct2013
North London
Concerns raised1
1. Failure to identify difficulties experienced by patients on Section 17 leave
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Review the Code of Practice on section 17 leave of absence and care planning, informed by this case.
  Stated by Department of Health and Social CareStated in progress
AI-generated summary

Daniel Maurice McMahon · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

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

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to identify difficulties experienced by patients on Section 17 leave
Wider context from the report
“(2) Department of Health:- Consideration to be given to using a feedback form, where a patient is on S17 of the MHA 1983 leave, to be completed by those caring for the patient in the community and the professional staff at the hospital to ensure that any difficulties that a patient has while on leave are picked up ”
Source location
Daniel Maurice McMahon · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

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

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

Source location
2013-0271-Response
Page 2 · response
Published 19 December 2013
Open published response
14 Oct2013
Liverpool
Concerns raised2
1. Failure to review and update the informal-patient leave policy
2. Failure to document informal-patient leave start and expected return times before leave
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Review and update Trust policies so they reflect national best practice.
  Stated by Mersey Care NHS Foundation TrustStated in progress
2. Action
  Complete the fundamental reviews of the three remaining out-of-date policies by 31 March 2014.
  Stated by Mersey Care NHS Foundation TrustStated planned
3. Action
  Review and update the policy identified as a concern at the inquest.
  Stated by Mersey Care NHS Foundation TrustStated completed
AI-generated summary

Yousef SHOKRI-GHARAB · 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

Yousef SHOKRI-GHARAB, an asylum seeker receiving inpatient treatment for mental illness, was found collapsed in a disused car park on 20 June 2013 and died at the Royal Liverpool University Hospital after attempts at resuscitation. The inquest concluded that he died from morphine (heroin) toxicity. Concerns included an outdated Mersey Care policy on leave for informal patients, which did not reflect practice, and leave permissions being authorised without regard to the Responsible Medical Officer's opinion.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to review and update the informal-patient leave policy
Wider context from the report
“The Mersey Care Policy and Procedure for leave for an informal patient was ratified in October 2006 and was due for review in October 2007. It has not been reviewed. The policy does not reflect practice. The policy needs to be updated immediately to protect patients and to be fair to employees of Mersey Care. To reflect current practice the policy should reflect amongst other matters that leave is permitted when observations are reduced to level 1 and there has been a multidisciplinary team consensus that a regime of leave is appropriate having consideration to (i) the deceased's vulnerability, (ii) the fact that the hospital had assumed responsibility for the patient's welfare and safety, including by the exercise of control, and (iii) the nature of the risk and whether it was "exceptional" rather than "ordinary" The policy should include stressing the importance of documenting before leave the time of taking leave and when the patient is due back. The operation of the policy should be audited to ensure compliance. ”
Source location
Yousef SHOKRI-GHARAB · Prevention of Future Deaths report
Page 2 · concerns
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 informal-patient leave start and expected return times before leave
Wider context from the report
“The Mersey Care Policy and Procedure for leave for an informal patient was ratified in October 2006 and was due for review in October 2007. It has not been reviewed. The policy does not reflect practice. The policy needs to be updated immediately to protect patients and to be fair to employees of Mersey Care. To reflect current practice the policy should reflect amongst other matters that leave is permitted when observations are reduced to level 1 and there has been a multidisciplinary team consensus that a regime of leave is appropriate having consideration to (i) the deceased's vulnerability, (ii) the fact that the hospital had assumed responsibility for the patient's welfare and safety, including by the exercise of control, and (iii) the nature of the risk and whether it was "exceptional" rather than "ordinary" The policy should include stressing the importance of documenting before leave the time of taking leave and when the patient is due back. The operation of the policy should be audited to ensure compliance. ”
Source location
Yousef SHOKRI-GHARAB · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review and update Trust policies so they reflect national best practice.

Verbatim wording from the response
“I can confirm that the Corporate Governance Team have been tasked with ensuring that all policies are received and updated to ensure that they reflect national best practice. Of the 120 Corporate Policies and Procedures currently in place, 117 are now in date. Three policies are subject to a fundamental review; this process will be completed by 31st March 2014. Between November 2013 and 12th February 2014, 50 policies have been reviewed and updated.”

Source location
2013-0259-Response-by-Mersey-Care-NHS
Page 1 · response
Published 26 January 2014
Open published response
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
Complete the fundamental reviews of the three remaining out-of-date policies by 31 March 2014.

Verbatim wording from the response
“I can confirm that the Corporate Governance Team have been tasked with ensuring that all policies are received and updated to ensure that they reflect national best practice. Of the 120 Corporate Policies and Procedures currently in place, 117 are now in date. Three policies are subject to a fundamental review; this process will be completed by 31st March 2014. Between November 2013 and 12th February 2014, 50 policies have been reviewed and updated.”

Source location
2013-0259-Response-by-Mersey-Care-NHS
Page 1 · response
Published 26 January 2014
Open published response
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 and update the policy identified as a concern at the inquest.

Verbatim wording from the response
“I can confirm that the policy that provided you with concern at the Inquest on 11th October 2013 was one of the first to be reviewed and updated.”

Source location
2013-0259-Response-by-Mersey-Care-NHS
Page 1 · response
Published 26 January 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Failure to allocate an appropriately familiar escort for informal patient leave

Failure to document leave reasons, risk assessments and decisions

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised2

Failure to carry out the required assessment when patients leave the ward

Unclear application of the leave policy to patients attending activities within hospital grounds

Concerns raised1

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

Concerns raised1

Failure to identify difficulties experienced by patients on Section 17 leave

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised2

Failure to review and update the informal-patient leave policy

Failure to document informal-patient leave start and expected return times before leave

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Respondent positions 1

Actions described in response 1

Actions described in response 3