Recurring concern

Unsafe management of inpatient leave and absence

First to latest report 14 Oct 2013 — 1 Jun 2026

Reports that mention this concern
55
Times this concern has been raised
119
Stated actions linked to this concern
134

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.

What is 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 and published responses 55 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Brighton and Hove

    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

  2. West Sussex

    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

  3. North and East Cambridgeshire

    AI-generated summary

    Christopher James MORGAN · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

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

    Wider context from the report

    “The Trust should ensure that a clear practice and policy is adopted in relation to the ratio of staff to patient as to staff that should accompany patients on escorted leave from psychiatric wards ”

    Source location

    Christopher James MORGAN · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. North London

    AI-generated summary

    Daniel Maurice McMahon · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to identify difficulties experienced by patients on Section 17 leave

    Wider context from the report

    “(2) Department of Health:- Consideration to be given to using a feedback form, where a patient is on S17 of the MHA 1983 leave, to be completed by those caring for the patient in the community and the professional staff at the hospital to ensure that any difficulties that a patient has while on leave are picked up ”

    Source location

    Daniel Maurice McMahon · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

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

    Verbatim wording from the response

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

    Source location

    2013-0271-Response
    Page 2 · response
    Published 19 December 2013

    Open published response

  5. Liverpool

    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

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026