First reported 14 Oct 2013•Latest report 1 Jun 2026
Definition
What this concern includes
Includes planned or unescorted leave, return from leave, failure to return and absence without leave when a dedicated leave or absence control is deficient.
Not included
Excludes discharge and ordinary movement within a ward.
Excludes generic risk assessment, communication or police escalation not directly tied to inpatient leave or absence.
Reports
55
Distinct published reports
Individual concerns
119
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
134
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Department of Health and Social Care8
Sussex Partnership NHS Foundation Trust6
Essex Partnership University NHS Foundation Trust5
Greater Manchester Mental Health NHS Foundation Trust4
NHS England4
Surrey and Borders Partnership NHS Foundation Trust4
Lancashire & South Cumbria NHS Foundation Trust3
Tees, Esk and Wear Valleys NHS Foundation Trust3
Central and North West London NHS Foundation Trust2
Coventry and Warwickshire Partnership NHS Trust2
East London NHS Foundation Trust2
Metropolitan Police Service2
Nottinghamshire Healthcare NHS Foundation Trust2
Oxford Health NHS Foundation Trust2
South London and Maudsley NHS Foundation Trust2
NHS trust47
Ministerial department8
Police force5
Executive non-departmental public body4
Healthcare site2
Clinical commissioning group1
Company limited by guarantee1
Coronial office1
Devolved government1
English county council1
Health and care professional regulator1
Integrated care board1
Local health board1
National policing body1
Prison or young offender institution1
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
Manchester North
Concerns raised1
Failure to separately record post-leave assessment completion and outcomes
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Implement and share an inpatient leave care bundle covering safe community leave, return, and pre- and post-leave assessments.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 February 2023.
Action
Audit pre- and post-leave assessments and related documentation.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 22 February 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Inpatient Leave Care Bundle sets clear expectations for undertaking and recording pre- and post-leave assessments.
Stated by Greater Manchester Mental Health NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Essex
Concerns raised1
Lack of understanding of the distinction between an unauthorised absence after section 17 leave and an escape from a detained ward patient
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Create and disseminate an SBARD aide-mémoire guiding staff escalation to police for patients absent from authorised leave or absconded, including Mental Health Act status and risk information.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 February 2023.
Inner South London
Concerns raised2
Delays in alerting police when psychiatric patients fail to return from leave
Poor contemporaneous documentation of unescorted leave
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Action
Update the Missing Informal Patient Policy with a risk-assessment checklist and flow chart for managing patients who fail to return from leave.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 October 2022.
Action
Establish hourly ward accounting of patients during each shift, with responsibility allocated to the nurse in charge.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 October 2022.
Action
Review Datix recording of police contact during AWOL incidents to monitor reporting timeliness and escalate unnecessary delays.
Stated by Central and North West London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 25 October 2022.
Action
Update the Missing Informal Patient Policy to specify police-contact information required in SystmOne and Datix records.
Stated by Central and North West London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 25 October 2022.
Action
Develop Quick Reference Guides supporting staff use of the electronic clinical record system and care-planning templates.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 October 2022.
Action
Record each informal-leave episode on a paper form and upload it to the clinical record.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 October 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Police reporting after voluntary-leave failures need not be immediate or automatic; individualized risk assessment and ward-team discussion determine the response.
Stated by Central and North West London NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
West London
Concerns raised2
Failure to consider and approve or refuse patients' escorted leave requests
Blurring of the boundaries between escorted leave intentions and ward staff's ability to facilitate therapeutic leave
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Review the section 17 leave form and guidance to capture escort staffing stipulations.
Stated by South West London and St George'S Mental Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 24 February 2023.
Action
Facilitate escorted leave according to documented staffing stipulations and address non-compliance with applicable staff.
Stated by South West London and St George'S Mental Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 24 February 2023.
Action
Share learning from the Inquest across the service line.
Stated by South West London and St George'S Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 24 February 2023.
Norfolk
Concerns raised1
Failure to recover and check restricted items when patients return to the ward
This report raised 18 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.
Surrey
Concerns raised2
Lack of a missing-person plan with timeframes and escalation steps for leave
Failure to record risk assessments prior to leave
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.
West Sussex
Concerns raised2
Mismatch between AWOL and missing-person risk assessment grading criteria
Failure to require early provision of current risk assessments and completed AWOL forms
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.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Embed the completed Missing Persons Template, protocol and joint action plan into the revised multi-agency AWOL policy and practice.
Stated by Sussex PoliceStated plannedThe respondent said that this action was planned when they made their response on 3 February 2022.
Action
Revise the multi-agency AWOL Policy and embed the missing persons template, protocol and action plan into policy and practice.
Stated by Sussex Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 February 2022.
Action
Co-develop a Missing Persons Template and accompanying action plan to improve information sharing and joint risk assessment.
Stated by Sussex PoliceStated in progressThe respondent said that this action was in progress when they made their response on 3 February 2022.
Action
Co-develop a missing persons template and accompanying protocol for timely information-sharing and joint risk assessment.
Stated by Sussex Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 February 2022.
Lancashire and Blackburn with Darwen
Concerns raised3
Lack of a written policy specifying the circumstances for group leave and responsibility for granting it
Failure to require and define mandatory risk assessments before group leave
Lack of defined staff-to-patient ratios and criteria for group leave
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Implement and disseminate a written group-leave procedure covering approval circumstances, mandatory risk assessment, MDT agreement, observation eligibility, cancellation safeguards and staffing requirements.
Stated by Lancashire & South Cumbria NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 10 January 2022.
West Yorkshire Eastern
Concerns raised5
Failure to review wound-dressing materials before ground leave
Lack of documented ground-leave approval criteria and staff-grade requirements
Lack of dynamic risk-assessment discretion for escorts responding to absconding
Failure to determine sufficient escort numbers for ground leave
Failure to define permissible physical interventions during escorted leave
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Action
Scope alternative wound-covering options and contact other mental health trusts to capture and share relevant practice.
Stated by Leeds and York Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 October 2021.
Action
Undertake same-day leave risk assessments, decide whether leave should be altered, and document the decision, rationale and discussion in care records.
Stated by Leeds and York Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 18 October 2021.
Action
Undertake a tabletop review of patients granted time off the ward to check that leave discussions occurred and were appropriately documented.
Stated by Leeds and York Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 18 October 2021.
Action
Develop and incorporate scenario-based escorting and leave-risk decision-making training into initial and updated PMVA training for all staff, including bank staff.
Stated by Leeds and York Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 October 2021.
Action
Communicate case learning through procedures and provide staff with clear guidance on actions when escorted leave breaks down or a patient leaves the escort.
Stated by Leeds and York Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 18 October 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Physical touch was considered likely to increase distress and emotional dysregulation, so alternative support strategies were preferred.
Stated by Leeds and York Partnership NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Coventry
Concerns raised2
Failure to verify escort identity and presence for escorted leave
Insufficient handover arrangements for escorted leave
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.
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.7
Action
Require identified carers to collect and return patients on Section 17 leave rather than allowing unaccompanied departure to meet them.
Stated by Coventry and Warwickshire Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 6 January 2021.
Action
Amend and approve the Trust-wide Section 17 Leave Policy, including defined leave categories, revised safety forms, accompanied-leave checks, return-time escalation and shift monitoring.
Stated by Coventry and Warwickshire Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 6 January 2021.
Action
Develop and apply a Standard Operating Procedure to standardise clinical handover content and processes across clinical handover situations.
Stated by Coventry and Warwickshire Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 6 January 2021.
Action
Adopt SBAR as the communication tool for all identified clinical handover situations.
Stated by Coventry and Warwickshire Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 6 January 2021.
Action
Embed revised handover arrangements through staff engagement events and disseminated briefings.
Stated by Coventry and Warwickshire Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 6 January 2021.
Action
Include revised handover responsibilities in future local induction and preceptorship for new staff.
Stated by Coventry and Warwickshire Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 6 January 2021.
Action
Review rosters and supporting processes, consult staff-side representatives, and establish a consistent longer protected handover timeframe.
Stated by Coventry and Warwickshire Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 6 January 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The Trust cannot change handover shift patterns until a robust consultation with unions and staff representatives is completed.
Stated by Coventry and Warwickshire Partnership NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The Trust considers handovers currently more effective because of work already undertaken, while a consistent timeframe is established after consultation.
Stated by Coventry and Warwickshire Partnership NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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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.
