9 Dec 2020 Kimberley Smith · Prevention of Future Deaths report Surrey
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Concerns raised 8
Lack of written processes for managing informal patients assessed as too high risk to leave the unit View source Lack of written procedures addressing intermittent observations when informal patients request to leave the unit View source Lack of written risk-assessment procedures for informal patients requesting to leave the unit View source
Lack of a written timeframe for reporting informal patients missing when they fail to return at the agreed time View source Alcohol detoxification protocols lacking management of leave requests during treatment View source Lack of written procedures for recording assessments and decisions on informal patients’ requests to leave the unit View source Lack of a written timeframe for reporting detained patients missing when they fail to return at the agreed time View source Lack of written risk-management plans for informal patients leaving the unit View source See 5 more concerns
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.
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Kimberley Smith · 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
Kimberley Smith, who had a history of mental health conditions, alcohol dependency and self-harm, died by suicide after leaving an inpatient psychiatric unit while on unescorted leave and being found with a plastic bag over her head. The concerns included inadequate risk assessment and management of alcohol use and leave, failures in observation and missing-person procedures, and the absence of clear written policies for informal and detained patients leaving the unit.
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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 written processes for managing informal patients assessed as too high risk to leave the unit
Wider context from the report “1. There is no clear written policy/procedure on the following:
- The carrying out of risk assessments when informal patients request to leave the unit;
- The relevance of an informal patient being on intermittent observations when they request to leave the unit;
- The processes to follow if informal patients are risk assessed as too high risk to themselves to leave the unit;
- The risk management plans to put in place when informal patients do leave the unit;
- The recording of assessments and decisions relation to requests made by informal patients to leave the unit;
- The timeframe for reporting informal patients to the police as missing persons if they fail to return at the agreed time.
” Source location Kimberley Smith · 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 written procedures addressing intermittent observations when informal patients request to leave the unit
Wider context from the report “1. There is no clear written policy/procedure on the following:
- The carrying out of risk assessments when informal patients request to leave the unit;
- The relevance of an informal patient being on intermittent observations when they request to leave the unit;
- The processes to follow if informal patients are risk assessed as too high risk to themselves to leave the unit;
- The risk management plans to put in place when informal patients do leave the unit;
- The recording of assessments and decisions relation to requests made by informal patients to leave the unit;
- The timeframe for reporting informal patients to the police as missing persons if they fail to return at the agreed time.
” Source location Kimberley Smith · 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 written risk-assessment procedures for informal patients requesting to leave the unit
Wider context from the report “1. There is no clear written policy/procedure on the following:
- The carrying out of risk assessments when informal patients request to leave the unit;
- The relevance of an informal patient being on intermittent observations when they request to leave the unit;
- The processes to follow if informal patients are risk assessed as too high risk to themselves to leave the unit;
- The risk management plans to put in place when informal patients do leave the unit;
- The recording of assessments and decisions relation to requests made by informal patients to leave the unit;
- The timeframe for reporting informal patients to the police as missing persons if they fail to return at the agreed time.
” Source location Kimberley Smith · 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 written timeframe for reporting informal patients missing when they fail to return at the agreed time
Wider context from the report “1. There is no clear written policy/procedure on the following:
- The carrying out of risk assessments when informal patients request to leave the unit;
- The relevance of an informal patient being on intermittent observations when they request to leave the unit;
- The processes to follow if informal patients are risk assessed as too high risk to themselves to leave the unit;
- The risk management plans to put in place when informal patients do leave the unit;
- The recording of assessments and decisions relation to requests made by informal patients to leave the unit;
- The timeframe for reporting informal patients to the police as missing persons if they fail to return at the agreed time.
” Source location Kimberley Smith · 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 Alcohol detoxification protocols lacking management of leave requests during treatment
Wider context from the report “During the course of the inquest the court also heard that following Miss Smith’s death SABP carried out a Serious Incident investigation which resulted in the following recommendation,
‘To develop a protocol for managing alcohol detoxification on mental health wards, including specific care plans, minimum monitoring and how to manage leave requests during treatment.’
The court heard that a protocol has been developed to manage the medical aspects of alcohol detoxification but does not cover care plans, minimum monitoring or the management of leave request during treatment.
It is of concern that these aspects of the recommendation remain outstanding and consideration should be given to implementing them as a matter of urgency.
” Source location Kimberley Smith · 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 written procedures for recording assessments and decisions on informal patients’ requests to leave the unit
Wider context from the report “1. There is no clear written policy/procedure on the following:
- The carrying out of risk assessments when informal patients request to leave the unit;
- The relevance of an informal patient being on intermittent observations when they request to leave the unit;
- The processes to follow if informal patients are risk assessed as too high risk to themselves to leave the unit;
- The risk management plans to put in place when informal patients do leave the unit;
- The recording of assessments and decisions relation to requests made by informal patients to leave the unit;
- The timeframe for reporting informal patients to the police as missing persons if they fail to return at the agreed time.
” Source location Kimberley Smith · 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 written timeframe for reporting detained patients missing when they fail to return at the agreed time
Wider context from the report “2. There is no clear written policy/procedure on the following:
- The timeframe for reporting detained patients to the police as missing persons if they fail to return at the agreed time.
” Source location Kimberley Smith · 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 written risk-management plans for informal patients leaving the unit
Wider context from the report “1. There is no clear written policy/procedure on the following:
- The carrying out of risk assessments when informal patients request to leave the unit;
- The relevance of an informal patient being on intermittent observations when they request to leave the unit;
- The processes to follow if informal patients are risk assessed as too high risk to themselves to leave the unit;
- The risk management plans to put in place when informal patients do leave the unit;
- The recording of assessments and decisions relation to requests made by informal patients to leave the unit;
- The timeframe for reporting informal patients to the police as missing persons if they fail to return at the agreed time.
” Source location Kimberley Smith · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a standalone written policy governing informal-patient leave, including risk assessment, leave decisions, risk management, recording and missing-person reporting.
Verbatim wording from the response “Our response:
Guidance in relation to leave for informal patients is currently set out in the Trust’s Section 17 Leave Policy. The Trust has decided to build and strengthen upon this by developing a separate, standalone written policy regarding leave for informal patients. The policy will aim to ensure that the right balance is struck between respecting the rights of informal patients and the need to protect people who may be vulnerable and at risk of harm to themselves. The policy will also require all leave for informal patients to be supported by the patient’s risk assessment and care plan. I have had sight of the new draft policy and am confident that it will cover all the issues that you have highlighted (as outlined above).” Source location 2020-0279-Response-from-Surrey-and-Borders-Partnership-NHS-Foundation-Trust-Redacted
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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 Roll out a competency framework to train staff on the new and updated leave policies and their practical application.
Verbatim wording from the response “Once the new and updated policies have been finalised and approved, a structured roll out of a competency framework will begin, to support our staff in understanding the new policy and the updated policies and how to put them into practice.” Source location 2020-0279-Response-from-Surrey-and-Borders-Partnership-NHS-Foundation-Trust-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Section 17 Leave Policy and Absent Without Leave Policy with guidance on reporting patients missing after agreed leave.
Verbatim wording from the response “2. Policy/procedure on reporting patients as missing
In the PFD, you identified that there is no clear written policy/procedure on the timeframe for reporting patients to the police as missing persons if they fail to return at the agreed time.” Source location 2020-0279-Response-from-Surrey-and-Borders-Partnership-NHS-Foundation-Trust-Redacted
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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 guidance on alcohol detoxification for people admitted to inpatient wards.
Verbatim wording from the response “Our response:
The Trust has now completed its guidance regarding “Alcohol detoxification for people admitted to inpatient wards”.” Source location 2020-0279-Response-from-Surrey-and-Borders-Partnership-NHS-Foundation-Trust-Redacted
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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 Develop guidelines for managing people with alcohol use disorders on mental health wards, covering withdrawal monitoring, leave, risk assessments and care planning.
Verbatim wording from the response “We are also developing new guidelines for “Management of People with Alcohol Use Disorders (AuDs) Admitted to Mental Health Wards”. The new guidelines cover the following: monitoring of patients during withdrawal and detoxification (both physical and mental health), leave, risk assessments and care planning.” Source location 2020-0279-Response-from-Surrey-and-Borders-Partnership-NHS-Foundation-Trust-Redacted
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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 Train and support inpatient staff to implement the alcohol-use-disorder guidelines through collaboration between detoxification nurses and inpatient Advanced Clinical Practitioners.
Verbatim wording from the response “Once complete, i-access detoxification nurses will work with the inpatient Advanced Clinical Practitioners to train and support inpatient staff to put the guidelines into practice.” Source location 2020-0279-Response-from-Surrey-and-Borders-Partnership-NHS-Foundation-Trust-Redacted
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Concerns raised 1
Failure to complete leave documentation fully and use correct forms 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.
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David Clark · 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 Clark was detained at Orchard Hospital under section 3 of the Mental Health Act and left on escorted leave on 26 June 2019. He was found in the Lancaster canal the following morning; the reported concerns included incomplete leave documentation, failure to follow the AWOL procedure, inadequate handover and training, and an outstanding action plan.
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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 documentation fully and use correct forms
Wider context from the report “(1) That documentation in relation to leave was not completed fully and incorrect forms used
” Source location David Clark · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Section 17 leave audit and report compliance monthly through the Senior Leadership Team.
Verbatim wording from the response “o Section 17 leave - An inpatient safety matrix which will audit this practice at ward level includes a section of Section 17 Leave. The audit tool has been developed and agreed with Ward Managers (attachment 4). However implementation has been paused due to COVID 19 (new target date September 2020) once implemented compliance will be reported on a monthly basis through the Senior Leadership Team.” Source location 2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
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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 Use the pre- and post-leave assessment form in the RiO electronic care record across Secure Services.
Verbatim wording from the response “o Work has been undertaken to the new electronic care record RiO which now includes a pre and post leave assessment form. This is in place in Secure Services and is to be rolled out across the Trust by March 2021.” Source location 2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
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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 Roll out the RiO pre- and post-leave assessment form across the Trust.
Verbatim wording from the response “o Work has been undertaken to the new electronic care record RiO which now includes a pre and post leave assessment form. This is in place in Secure Services and is to be rolled out across the Trust by March 2021.” Source location 2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
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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 Implementation of the Section 17 leave audit and Safety and Security role review was paused because of COVID-19.
Verbatim wording from the response “o Section 17 leave - An inpatient safety matrix which will audit this practice at ward level includes a section of Section 17 Leave. The audit tool has been developed and agreed with Ward Managers (attachment 4). However implementation has been paused due to COVID 19 (new target date September 2020) once implemented compliance will be reported on a monthly basis through the Senior Leadership Team.” Source location 2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
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15 Jan 2020 Daniel Jeffrey Moran · Prevention of Future Deaths report Manchester West
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Concerns raised 1
Failure to clarify ward staff and ward doctors' roles and responsibilities for managing patient risk and authorising leave View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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
Daniel Jeffrey Moran · 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 Jeffrey Moran was pronounced dead at home on 14 July 2019 after using a rope as a ligature to partially suspend himself from a window. He had a history of depression, alcohol misuse and multiple recent suicide attempts, and had self-discharged from hospital after being assessed as not meeting the criteria for detention under the Mental Health Act. Concerns included staff understanding of confidentiality, patient-flow prioritisation, roles and responsibilities in managing risk, documentation, and decisions about self-discharge and detention.
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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 clarify ward staff and ward doctors' roles and responsibilities for managing patient risk and authorising leave
Wider context from the report “3. Ward staff and ward doctors need to have a greater understanding of each other’s roles and responsibilities in relation to managing patient risk and whose responsibility it is to authorise leave and ensuring contemporaneous documentation are kept in relation to the decision making rationale (documenting any changes in risk and capacity).
” Source location Daniel Jeffrey Moran · Prevention of Future Deaths report
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24 Jul 2019 Hannah Dolly Kaur Bharaj · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to communicate the change in risk level when patients leave a secure environment View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Hannah Dolly Kaur Bharaj · 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
Hannah Dolly Kaur Bharaj had anorexia, depression and fluctuating suicidal ideation, and died at Salford Royal Hospital on 13 July 2018 from injuries sustained after jumping from a first-floor café. Concerns included inadequate communication and discharge planning, unsuitable placement and care coordination, incomplete sharing of clinical information, and the safety of the café balustrade and adjacent table.
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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 change in risk level when patients leave a secure environment
Wider context from the report “6. Understanding and communication by the Priory about the change in risk level when Hannah moved from a secure environment to periods of time outside the unit in the care of her family;
” Source location Hannah Dolly Kaur Bharaj · Prevention of Future Deaths report
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23 May 2019 Sasha Sabrina FORSTER · Prevention of Future Deaths report Central Hampshire
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Concerns raised 4
Failure to agree and update a common action plan for revoked s.17 leave View source Failure to collect and return patients to the ward when s.17 leave is revoked View source Failure to finalise the formal revocation of s.17 leave View source
Lack of shared awareness of powers and responsibilities when s.17 leave is revoked View source See 1 more concern
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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Sasha Sabrina FORSTER · 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
Sasha Sabrina FORSTER, a 20-year-old woman with a lengthy history of mental health disorders, self-harm and overdoses, died by suicide following deliberate ingestion of a fatal overdose of Propranolol tablets. The inquest identified concerns that hospitals and police forces were not always aware of their powers and responsibilities when her section 17 leave was revoked, or had not agreed and updated a common plan, resulting in inconsistent actions and an increased risk to Sasha.
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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 agree and update a common action plan for revoked s.17 leave
Wider context from the report “Evidence received at the inquest suggested that the various hospitals and police forces which had regular dealings with Sasha were not always aware of their powers and responsibilities towards her in circumstances when her s.17 leave was being revoked, or else had not agreed and, where required, updated a common plan of action to be followed in those circumstances .
As a result, there was inconsistency in the actions taken when her s.17 leave had been revoked, which led to an increased risk that Sasha might act in such a way which would result in her death, whether intentionally or not.
” Source location Sasha Sabrina FORSTER · 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 collect and return patients to the ward when s.17 leave is revoked
Wider context from the report “(1) Evidence was given during the inquest by SBP staff on the ward concerned, that the reason SBP staff did not arrange to collect Sasha and return her to the ward when her s.17 leave had been revoked , was that they did not have the resources to allow them to do this , despite it being their legal responsibility so to do .
(2) Sasha’s mother gave evidence that SBP’s reliance on her bringing Sasha back to the ward when s.17 leave had been revoked , placed an unfair and intolerable burden on her, in circumstances when she and the rest of the family were struggling to keep Sasha safe. Knowing that SBP would not send someone out to collect Sasha made her feel that she had no choice but to agree to their request.
(3) The last such occasion when SBP staff on the ward decided that Sasha’s s.17 leave should be revoked was on the afternoon of her death on 31.3.17. Although formal revocation of leave was never finalised, Sasha’s mother was given to believe that it would be, and again reluctantly agreed to bring Sasha back to the ward. Whilst with her mother, Sasha was able to run off and take the substantial Propranolol overdose which proved to be fatal.
” Source location Sasha Sabrina FORSTER · 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 finalise the formal revocation of s.17 leave
Wider context from the report “(1) Evidence was given during the inquest by SBP staff on the ward concerned, that the reason SBP staff did not arrange to collect Sasha and return her to the ward when her s.17 leave had been revoked, was that they did not have the resources to allow them to do this, despite it being their legal responsibility so to do.
(2) Sasha’s mother gave evidence that SBP’s reliance on her bringing Sasha back to the ward when s.17 leave had been revoked, placed an unfair and intolerable burden on her, in circumstances when she and the rest of the family were struggling to keep Sasha safe. Knowing that SBP would not send someone out to collect Sasha made her feel that she had no choice but to agree to their request.
(3) The last such occasion when SBP staff on the ward decided that Sasha’s s.17 leave should be revoked was on the afternoon of her death on 31.3.17. Although formal revocation of leave was never finalised , Sasha’s mother was given to believe that it would be , and again reluctantly agreed to bring Sasha back to the ward. Whilst with her mother, Sasha was able to run off and take the substantial Propranolol overdose which proved to be fatal.
” Source location Sasha Sabrina FORSTER · 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 shared awareness of powers and responsibilities when s.17 leave is revoked
Wider context from the report “Evidence received at the inquest suggested that the various hospitals and police forces which had regular dealings with Sasha were not always aware of their powers and responsibilities towards her in circumstances when her s.17 leave was being revoked , or else had not agreed and, where required, updated a common plan of action to be followed in those circumstances.
As a result, there was inconsistency in the actions taken when her s.17 leave had been revoked, which led to an increased risk that Sasha might act in such a way which would result in her death, whether intentionally or not.
” Source location Sasha Sabrina FORSTER · 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 Draft a shared systemwide protocol for managing complex AWOL cases and work towards its finalisation.
Verbatim wording from the response “The PFD stated that clarification was required as to the actions that would be taken to achieve the goals set out in a letter dated 22 May 2019 from the Deputy Chief Executive of Surrey and Borders Partnership NHS Foundation Trust (SABP). This letter committed to the development of joint working protocols across the system for the management of complex absent without leave (AWOL) cases (cases where section 17 has been revoked and a person is AWOL).” Source location Sasha-Forster-R2019-01692
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold a further stakeholder meeting to review achievements and identify additional actions or training needs, including dissemination of learning.
Verbatim wording from the response “To respond to the PFD, a meeting was held on the 01 July 2019 between a number of the key stakeholders named in the PFD. Below is a summary of the discussions and actions that were agreed moving forwards. A further meeting will be held to discuss and evidence dissemination of learning and training.” Source location Sasha-Forster-R2019-01692
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the AWOL Policy with a clear risk-escalation process map, then share it with staff and add it to the section 17 competency framework.
Verbatim wording from the response “This Inquest has highlighted that not all staff are aware that the above risk escalation process should be followed in the event that a person is AWOL and needs to be returned to the ward. We take full responsibility and we will therefore update our AWOL Policy with a clear process map that outlines how concerns about a person who is AWOL should be escalated by September 2019. Thereafter, this will be shared with staff and added to the section 17 competency framework to ensure awareness of the process.” Source location Sasha-Forster-R2019-01693
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue providing local-induction training so staff understand the AWOL policy and the process to follow when a person is absent without leave.
Verbatim wording from the response “I hope that the above reassures you that there is a process in place to facilitate the return of AWOL inpatients to the ward and that the Trust is committed on an ongoing basis to provide training through local induction to our staff and ensuring they are aware of the policy and process they should follow when a person is AWOL.” Source location Sasha-Forster-R2019-01693
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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 Include a written-authority template in the AWOL policy, update the policy with PFD learning, and present it to the Policy Assurance Group by September 2019.
Verbatim wording from the response “If the person is known to frequent emergency departments, frequently call the emergency services, or frequent another place where professionals are present, early consideration should be given to providing those services with written authority to take the person into custody and return them to the ward (they should be supported by SABP, the Police, and ambulance services (NHS or private / secure), in doing this as appropriate).” Source location Sasha-Forster-R2019-01692
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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 Develop and include a section 17 leave revocation template in the Trust’s section 17 leave policy.
Verbatim wording from the response “If the decision is made to revoke the person’s leave this should be documented in the person’s notes before the SABP section 18 form or any other paperwork is completed (this means it will be visible to others accessing the record on SystmOne). It is preferable for this to be documented by the clinician who makes the decision to revoke the leave.” Source location Sasha-Forster-R2019-01692
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review mental health training for emergency services, emergency departments, police and Trust staff to include proportionate coverage of Mental Health Act sections 17 and 18.
Verbatim wording from the response “The mental health training provided to emergency services, emergency department, police and SABP staff will be reviewed to include an overview of section 17 and 18 of the MHA. This should be proportionate to the frequency that each organisation is expected to come across these cases and this will be determined by each organisation.” Source location Sasha-Forster-R2019-01692
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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 Care providers have no legal responsibility to arrange return of patients whose section 17 leave is revoked.
Verbatim wording from the response “In relation to leave of absence from hospital, you may wish to note that the Department does not agree that care providers have a legal responsibility to arrange for the return to hospital of patients whose section 17 leave has been revoked.” Source location Sasha-Forster-R2019-0169
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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 Care providers decide how to facilitate returns after revoked section 17 leave, using resources available to them.
Verbatim wording from the response “Section 18 of the Mental Health Act gives hospitals the power to take a patient into custody for return to the hospital or place of treatment. However, it does not place a legal responsibility on hospitals to arrange this. As such, it is for care providers to decide on the best way to facilitate such returns from within the resources available to them.” Source location Sasha-Forster-R2019-0169
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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 Existing risk assessment, staffing allocation and escalation arrangements are considered sufficient to return known AWOL patients safely.
Verbatim wording from the response “known, and they are not posing a risk to themselves or others, we agree that it is the Trust’s responsibility to arrange for them to be returned to the ward by SABP staff; in line with our Absent Without Leave Missing Persons Policy. Staff have access to the hospital pool car, taxi services, or secure / NHS ambulance transport in order to facilitate the return of a person who is AWOL to the ward, depending on what is considered to be most appropriate in the circumstances, following a risk assessment.” Source location Sasha-Forster-R2019-01693
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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 Maintaining additional staffing on every ward for AWOL returns is considered impractical because such incidents are uncommon and wards meet safe staffing standards.
Verbatim wording from the response “It would be impractical for SABP to have extra staffing on each ward on a shift by shift basis for the purpose of being available to return people who are AWOL and whose whereabouts are known, particularly as this is an uncommon occurrence. All our Wards comply with National Safe Staffing standards.” Source location Sasha-Forster-R2019-01693
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12 Apr 2019 Emma Felicity BUTLER · Prevention of Future Deaths report Buckinghamshire
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Concerns raised 1
Unclear understanding and compliance with leave conditions relevant to searches View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Emma Felicity BUTLER · 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
Emma Butler was an inpatient at Ruby Ward who died at Stoke Mandeville Hospital from blood loss after incised wounds inflicted outside the Whiteleaf Centre while she was on unescorted leave. The report raised concerns about access to means of self-harm on and outside the ward, hourly observations, urgent access to ward support, and planning for discharge.
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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 Unclear understanding and compliance with leave conditions relevant to searches
Wider context from the report “(2) Access to means of self-harm from outside the ward. The processes for searching and seizing potential self-harm material after return from unescorted leave did not prevent items being brought in from the outside at risk to the particular patient, other patients and staff and the evidence regarding the extent of strip or other searches from staff members was variable. The risk of items being brought onto the ward from outside for use by that patient or others remains where the system for searching and the nature and extent of that search has not prevented the introduction of such items. The understanding of and compliance with specific conditions of leave in the context of searches was unclear.
” Source location Emma Felicity BUTLER · Prevention of Future Deaths report
Open source report
8 Mar 2019 John Peter RICHARDSON · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 1
Lack of a specific leave policy for voluntary patients 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
John Peter RICHARDSON · 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
John Peter Richardson was admitted as a voluntary patient to Meadowfields Hospital with suicidal thoughts and went missing after leaving the hospital grounds on 3 February 2018. His body was found in woodlands on 4 February 2018, and death was confirmed at the scene. The report identified concerns including the absence of a further risk assessment and care plan, poor communication and record keeping, and confusion about his leave arrangements.
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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 a specific leave policy for voluntary patients
Wider context from the report “(2) However the death of Mr Richardson appears to have occurred when there was some confusion amongst staff with regards to Mr Richardson’s leave status . This was identified by the Jury in their conclusion. Whilst some guidance is provided to staff, with regards to voluntary patients taking leave, there is no specific Leave Policy for Voluntary Patients in the same way as there is one for those patients sectioned under the Mental Health Act.
” Source location John Peter RICHARDSON · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include guidance on voluntary patients leaving wards in the new Acute Care Operational Policy.
Verbatim wording from the response “Following receipt of your letter, we have given considerable further thought as to how best we might improve our staff’s understanding of the principles to be followed when voluntary patients leave the wards. The decision we have taken is to include guidance in our new Acute Care Operational Policy. I have enclosed a copy of that guidance for your information. As you will see, it covers both s.17 leave as well as the principles that need to be applied to voluntary patients. Presenting the guidance in this way was considered to be preferable to any further stand-alone policy. It is hoped that this will be highly accessible and provide immediate access to the key principles, coupled with signposting to other documents if more information is required.” Source location 2019-0084-Response-by-Sussex-Partnership-NHS-Trust
Open published response
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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 No further standalone policy is considered necessary because the principles are incorporated into the new Acute Care Operational Policy.
Verbatim wording from the response “Following receipt of your letter, we have given considerable further thought as to how best we might improve our staff’s understanding of the principles to be followed when voluntary patients leave the wards. The decision we have taken is to include guidance in our new Acute Care Operational Policy. I have enclosed a copy of that guidance for your information. As you will see, it covers both s.17 leave as well as the principles that need to be applied to voluntary patients. Presenting the guidance in this way was considered to be preferable to any further stand-alone policy. It is hoped that this will be highly accessible and provide immediate access to the key principles, coupled with signposting to other documents if more information is required.” Source location 2019-0084-Response-by-Sussex-Partnership-NHS-Trust
Open published response
26 Feb 2019 Mr Keith Heatley · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 2
Lack of policy or procedure for reviewing and assessing voluntarily admitted patients before home leave View source Insufficient procedures for liaising with family and CPN to assess preparedness and support before patient leave View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Keith Heatley · 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
Mr Keith Heatley was admitted voluntarily to hospital on 1 May 2018 and transferred to Ward 14, later leaving the family home during home leave on 18 May and being found in the water; the medical cause of death was drowning and the inquest reached an open conclusion. Concerns included the absence in Wales of a policy for reviewing and assessing voluntarily admitted patients before home leave, insufficient guidance for staff, and insufficient procedures for liaising with the family and community psychiatric nurse about preparedness and support.
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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 policy or procedure for reviewing and assessing voluntarily admitted patients before home leave
Wider context from the report “(1) The evidence of a Consultant Psychiatrist who was a Clinical Advisor to a Significant Incident Review stated that there was a policy in England for reviewing and assessing patients who are voluntarily admitted to hospitals before they go on home leave. There is no such policy or procedure in Wales.
” Source location Mr Keith Heatley · 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 Insufficient procedures for liaising with family and CPN to assess preparedness and support before patient leave
Wider context from the report “(3) There were no insufficient procedures in place for hospital staff to liaise with the patient’s family and CPN when leave is considered to examine the preparedness of the family and whether there were systems of support in place.
” Source location Mr Keith Heatley · Prevention of Future Deaths report
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 Implement a checklist requiring multidisciplinary staff, the Community Mental Health Team and family to review and express views before informal patients take ward leave.
Verbatim wording from the response “The Regulation 28 Report related to the fact that there was no policy or procedure in place in Wales to review and assess informal patients prior to them going on leave from the Ward. The Health Board accepts that Mr Heatley’s leave should have been managed better and has implemented a checklist to ensure multi-disciplinary team members including the Community Mental Health Team and the patient’s family are aware and able to express their views on the leave, prior to the patient going on leave away from the Ward.” Source location 2019-0478-Response-from-Swansea-Bay-Health-Board-Redacted
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 Develop a policy addressing leave arrangements for informal patients in compliance with Welsh legislation.
Verbatim wording from the response “Furthermore, the Health Board is taking advice on the policies in place in England in terms of ensuring the Welsh legislation is complied with, Mental Health Measure 2012, which is not applicable in England. Consideration will also be given to balancing the fact that they are voluntary patients and we cannot deprive these patients of their liberties. Once the Health Board has developed a policy then it will be shared on an all Wales basis to ensure learning from this case is shared across NHS Wales.” Source location 2019-0478-Response-from-Swansea-Bay-Health-Board-Redacted
Open published response
×
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 Voluntary patients’ liberty rights constrain the Health Board’s ability to restrict their leave while developing a compliant policy.
Verbatim wording from the response “Furthermore, the Health Board is taking advice on the policies in place in England in terms of ensuring the Welsh legislation is complied with, Mental Health Measure 2012, which is not applicable in England. Consideration will also be given to balancing the fact that they are voluntary patients and we cannot deprive these patients of their liberties. Once the Health Board has developed a policy then it will be shared on an all Wales basis to ensure learning from this case is shared across NHS Wales.” Source location 2019-0478-Response-from-Swansea-Bay-Health-Board-Redacted
Open published response
12 Jul 2018 Adam James Carter · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 2
Failure to retain leave authorisation documentation in accordance with section 17 leave guidance View source Failure to record nursing assessment of clinical state immediately before escorted ground leave View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Adam James Carter · 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
Adam James Carter died on 10 September 2017 after absconding from The Harbour mental health facility during escorted leave and falling from the fifth floor of a car park. The principal concern was inadequate record keeping about Adam’s risks, leave arrangements, leave authorisation and assessment before leave, which could affect staff decisions about patient safety.
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 retain leave authorisation documentation in accordance with section 17 leave guidance
Wider context from the report “The concern relates to record keeping.
During his independent review of this matter, a Consultant Psychiatrist identified some discrepancies within the medical records including the following:
• Although he felt that the therapeutic team had an understanding of the extent to which Adam posed a risk of:
- aggression and violence;
- self harm;
- suicidal behaviour;
- absconding;
He did not feel that these risks were documented or clearly formulated in the medical notes.
• He stated that there was very little detail in the documentation as regards Adam’s use of leave nor of care planning of his leave. The rationale for leave having been granted was not recorded nor were the benefits and risks associated with leave.
• He was unable to find a record of an assessment of Adam’s clinical state by nursing staff immediately before the period of escorted ground leave on 10th September 2017 as required by trust policy (although he did not feel that this would have any bearing on the decision to afford Adam leave on this occasion).
• He could not find a copy of the Leave Authorisation that granted Adam leave and felt that documentation of leave fell short of the guidance laid out in the Trust policy for the authorisation of section 17 leave of absence .
Clearly the quality of record keeping is important in the context of a detained mental health patient. Adam had spent some time in a Psychiatric Intensive Care Unit and then a number of days on an acute inpatient ward prior to the events of 10th September 2017.
The level of risk such a patient poses as regards issues such as the risk of self harm and absconding are fundamental to the care provided. Plans were being made for Adam to be discharged and into the community rather than back to his parents’ home and he was being afforded the opportunity to build towards that discharge by granting him leave which was an important step in progressing towards that goal. However, such decisions need to be made appropriately and informed by how the risk a patient poses is viewed at that time. It is vital that the basis for such decisions is clear from the records.
If this does not happen then I have a concern that future deaths may result – inevitably patients such as Adam are cared for by a team consisting of different staff performing different shifts. Staff taking over the care of a patient such as Adam ought not to have to rely on the verbal information provided to them and handover of that patient’s care but need to have the opportunity to read the records and to remind themselves how the risk their patient poses is viewed by for example the relevant Consultant Psychiatrist, and why he or she has been granted leave.
The court heard that escorted grounds leave was granted to Adam but that nursing staff had discretion as regards whether that leave went ahead and they may exercise such discretion subject to how Adam presented, his behaviour on the ward etc. If they cannot access accurate and informative records, such staff may make decisions that are not in the interests of their patients. Leave may proceed on a basis not felt to be safe. Leave may be declined because the staff member – unable to access the relevant information – decides to err on the side of caution and declines leave to the detriment of that patient’s progress and the condition of his / her mental health.
It seems to me that if an independent consultant psychiatrist has conducted a review and identified these issues in relation to records it should inevitably prompt a concern on my part that unless I write a report such as this one future deaths may result.
I therefore raise the concern. I cannot be prescriptive about what action should be taken and I make no recommendations but simply raise the issue.
At the conclusion of the inquest, I indicated to the Properly Interested Persons that I proposed to write to the Department of Health by way of a report in accordance with the provisions of paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009.
” Source location Adam James Carter · 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 record nursing assessment of clinical state immediately before escorted ground leave
Wider context from the report “The concern relates to record keeping.
During his independent review of this matter, a Consultant Psychiatrist identified some discrepancies within the medical records including the following:
• Although he felt that the therapeutic team had an understanding of the extent to which Adam posed a risk of:
- aggression and violence;
- self harm;
- suicidal behaviour;
- absconding;
He did not feel that these risks were documented or clearly formulated in the medical notes.
• He stated that there was very little detail in the documentation as regards Adam’s use of leave nor of care planning of his leave. The rationale for leave having been granted was not recorded nor were the benefits and risks associated with leave.
• He was unable to find a record of an assessment of Adam’s clinical state by nursing staff immediately before the period of escorted ground leave on 10th September 2017 as required by trust policy (although he did not feel that this would have any bearing on the decision to afford Adam leave on this occasion).
• He could not find a copy of the Leave Authorisation that granted Adam leave and felt that documentation of leave fell short of the guidance laid out in the Trust policy for the authorisation of section 17 leave of absence.
Clearly the quality of record keeping is important in the context of a detained mental health patient. Adam had spent some time in a Psychiatric Intensive Care Unit and then a number of days on an acute inpatient ward prior to the events of 10th September 2017.
The level of risk such a patient poses as regards issues such as the risk of self harm and absconding are fundamental to the care provided. Plans were being made for Adam to be discharged and into the community rather than back to his parents’ home and he was being afforded the opportunity to build towards that discharge by granting him leave which was an important step in progressing towards that goal. However, such decisions need to be made appropriately and informed by how the risk a patient poses is viewed at that time. It is vital that the basis for such decisions is clear from the records.
If this does not happen then I have a concern that future deaths may result – inevitably patients such as Adam are cared for by a team consisting of different staff performing different shifts. Staff taking over the care of a patient such as Adam ought not to have to rely on the verbal information provided to them and handover of that patient’s care but need to have the opportunity to read the records and to remind themselves how the risk their patient poses is viewed by for example the relevant Consultant Psychiatrist, and why he or she has been granted leave.
The court heard that escorted grounds leave was granted to Adam but that nursing staff had discretion as regards whether that leave went ahead and they may exercise such discretion subject to how Adam presented, his behaviour on the ward etc. If they cannot access accurate and informative records, such staff may make decisions that are not in the interests of their patients. Leave may proceed on a basis not felt to be safe. Leave may be declined because the staff member – unable to access the relevant information – decides to err on the side of caution and declines leave to the detriment of that patient’s progress and the condition of his / her mental health.
It seems to me that if an independent consultant psychiatrist has conducted a review and identified these issues in relation to records it should inevitably prompt a concern on my part that unless I write a report such as this one future deaths may result.
I therefore raise the concern. I cannot be prescriptive about what action should be taken and I make no recommendations but simply raise the issue.
At the conclusion of the inquest, I indicated to the Properly Interested Persons that I proposed to write to the Department of Health by way of a report in accordance with the provisions of paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009.
” Source location Adam James Carter · Prevention of Future Deaths report
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 Include the actions’ impact in a clinical audit, then review findings and provide feedback through team clinical supervision.
Verbatim wording from the response “The impact of the above actions will be included in a clinical audit in January 2019. Matrons and ward managers will then review the findings from these audits and feed the results back during clinical supervision with their teams.” Source location 2018-0226-Response-by-Lancashire-Care-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prompt nursing teams to reassess patients’ risks and mental state immediately before leave and document the decision in clinical records.
Verbatim wording from the response “Once leave has been agreed by the Multi Disciplinary Team, the nursing team on each ward will be prompted to fully consider the patients risks and state of mind immediately prior to the patient taking this leave, and reminded to document their up to date decision in the clinical record.” Source location 2018-0226-Response-by-Lancashire-Care-NHS-Trust
Open published response
6 Mar 2018 Rastislav Petrisko · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 3
Delays in notifying police when patients fail to return from leave View source Lack of recorded drug-screening results on return from leave View source Failure to use a consistent risk-assessment method for vulnerable patients granted 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.
×
AI-generated summary
Rastislav Petrisko · 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
Rastislav Petrisko, who had a history of suicide attempts, drug and alcohol misuse, and mental health admissions, took a fatal overdose after being granted unescorted leave from a mental health ward. The concerns included an apparently unsuitable low-risk assessment, inappropriate unescorted leave, delayed notification of police when he failed to return, and differing approaches to risk assessment.
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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 Delays in notifying police when patients fail to return from leave
Wider context from the report “The responsible clinician (RC) assessed the patient as low risk on granting an hour’s unescorted leave in the local area from 13th. He said that he was not mentally unstable, which would trigger an escort. He was no longer expressing suicidal thoughts. The RC did not consider that Mr Petrisko was an immediate risk to himself, although the past medical history established a higher long term risk. He had already taken leave several times without self-harming (although unknown to the doctor he had returned drunk on 8th whilst in another unit).
Although there was reference to recent or pending drug testing there was no record of the result of any drug screening on return from leave in this admission. A nurse indicated that being high risk made no difference to the likelihood of drug screening and the RC indicated that he may still be given leave if he was high risk. However a mental health nurse on the ward said that he was given leave as he was low risk. The risk assessments were guided by the statutory guidance of the Mental Health Act and were not subject to further local guidance. In retrospect the RC did not change his risk assessment.
A missing persons form was completed by the ward. His risk was described as concern he would take large amount of drugs and alcohol, which would affect his mental state and that it was not out of character. In answer to the question whether he was likely to commit suicide, was written: “Was admitted with overdose cocaine and medication with suicidal intent”. The police were called at 21.56 and attended at 23.30, by which time emergency services were already in attendance to him in the car park, following a 999 call.
As he was low risk the local policy on handling patients who had absconded at the time indicated that he could be given a period of grace before the police were notified, if he did not return at the allotted time . This was given as he had a history of being late back from leave. The ward notified the police 1 hour 49 minutes after he was due back, a period of time acknowledged to be too long . The policy in place made clear that a high risk patient should be reported immediately. The revised Trust policy continues that requirement, removes the period of grace but leaves it to the discretion of the clinicians when to call the police, if the patient is deemed not to be high risk .
The DI from the Metropolitan Police Service indicated on reviewing the case, that he would be classed as medium risk, not low risk. High risk is an immediate risk to life, when a DI is deployed immediately to investigate and search. Medium Risk is that the risk to life is not immediate, but is a concern. An investigation and search is begun within the hour. Low risk is where there are no immediate concerns. The investigation may not begin straight away but take a few days.
She further said that an immediate action would be to identify the places from which he had been admitted before. The medical records indicated that of the last three admissions he had been brought in from the Calderwood Street Car Park on two occasions (13.12.16 and 05.01.17). That was the site where he took the final fatal overdose.
Thus if the police had been rung immediately, and assuming they took no action for the whole of the first hour, they would have had at least 49 minutes to find him in this site, which on the facts of the present case would enable an inference to be drawn that his life would have been saved. Thus the risk assessment by the police would seem to enable some deaths to be prevented, which would not necessarily on application of the assessment of the responsible physician, as immediate reporting only occurs if the patient is high risk. It is of concern that there are two different methods of assessing the risk when a vulnerable patient is granted leave, both in operation, one with greater potential of saving his life than the other.
” Source location Rastislav Petrisko · 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 recorded drug-screening results on return from leave
Wider context from the report “The responsible clinician (RC) assessed the patient as low risk on granting an hour’s unescorted leave in the local area from 13th. He said that he was not mentally unstable, which would trigger an escort. He was no longer expressing suicidal thoughts. The RC did not consider that Mr Petrisko was an immediate risk to himself, although the past medical history established a higher long term risk. He had already taken leave several times without self-harming (although unknown to the doctor he had returned drunk on 8th whilst in another unit).
Although there was reference to recent or pending drug testing there was no record of the result of any drug screening on return from leave in this admission . A nurse indicated that being high risk made no difference to the likelihood of drug screening and the RC indicated that he may still be given leave if he was high risk. However a mental health nurse on the ward said that he was given leave as he was low risk. The risk assessments were guided by the statutory guidance of the Mental Health Act and were not subject to further local guidance. In retrospect the RC did not change his risk assessment.
A missing persons form was completed by the ward. His risk was described as concern he would take large amount of drugs and alcohol, which would affect his mental state and that it was not out of character. In answer to the question whether he was likely to commit suicide, was written: “Was admitted with overdose cocaine and medication with suicidal intent”. The police were called at 21.56 and attended at 23.30, by which time emergency services were already in attendance to him in the car park, following a 999 call.
As he was low risk the local policy on handling patients who had absconded at the time indicated that he could be given a period of grace before the police were notified, if he did not return at the allotted time. This was given as he had a history of being late back from leave. The ward notified the police 1 hour 49 minutes after he was due back, a period of time acknowledged to be too long. The policy in place made clear that a high risk patient should be reported immediately. The revised Trust policy continues that requirement, removes the period of grace but leaves it to the discretion of the clinicians when to call the police, if the patient is deemed not to be high risk.
The DI from the Metropolitan Police Service indicated on reviewing the case, that he would be classed as medium risk, not low risk. High risk is an immediate risk to life, when a DI is deployed immediately to investigate and search. Medium Risk is that the risk to life is not immediate, but is a concern. An investigation and search is begun within the hour. Low risk is where there are no immediate concerns. The investigation may not begin straight away but take a few days.
She further said that an immediate action would be to identify the places from which he had been admitted before. The medical records indicated that of the last three admissions he had been brought in from the Calderwood Street Car Park on two occasions (13.12.16 and 05.01.17). That was the site where he took the final fatal overdose.
Thus if the police had been rung immediately, and assuming they took no action for the whole of the first hour, they would have had at least 49 minutes to find him in this site, which on the facts of the present case would enable an inference to be drawn that his life would have been saved. Thus the risk assessment by the police would seem to enable some deaths to be prevented, which would not necessarily on application of the assessment of the responsible physician, as immediate reporting only occurs if the patient is high risk. It is of concern that there are two different methods of assessing the risk when a vulnerable patient is granted leave, both in operation, one with greater potential of saving his life than the other.
” Source location Rastislav Petrisko · 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 use a consistent risk-assessment method for vulnerable patients granted leave
Wider context from the report “The responsible clinician (RC) assessed the patient as low risk on granting an hour’s unescorted leave in the local area from 13th. He said that he was not mentally unstable, which would trigger an escort. He was no longer expressing suicidal thoughts. The RC did not consider that Mr Petrisko was an immediate risk to himself, although the past medical history established a higher long term risk. He had already taken leave several times without self-harming (although unknown to the doctor he had returned drunk on 8th whilst in another unit).
Although there was reference to recent or pending drug testing there was no record of the result of any drug screening on return from leave in this admission. A nurse indicated that being high risk made no difference to the likelihood of drug screening and the RC indicated that he may still be given leave if he was high risk. However a mental health nurse on the ward said that he was given leave as he was low risk. The risk assessments were guided by the statutory guidance of the Mental Health Act and were not subject to further local guidance . In retrospect the RC did not change his risk assessment.
A missing persons form was completed by the ward. His risk was described as concern he would take large amount of drugs and alcohol, which would affect his mental state and that it was not out of character. In answer to the question whether he was likely to commit suicide, was written: “Was admitted with overdose cocaine and medication with suicidal intent”. The police were called at 21.56 and attended at 23.30, by which time emergency services were already in attendance to him in the car park, following a 999 call.
As he was low risk the local policy on handling patients who had absconded at the time indicated that he could be given a period of grace before the police were notified, if he did not return at the allotted time. This was given as he had a history of being late back from leave. The ward notified the police 1 hour 49 minutes after he was due back, a period of time acknowledged to be too long. The policy in place made clear that a high risk patient should be reported immediately. The revised Trust policy continues that requirement, removes the period of grace but leaves it to the discretion of the clinicians when to call the police, if the patient is deemed not to be high risk.
The DI from the Metropolitan Police Service indicated on reviewing the case, that he would be classed as medium risk, not low risk. High risk is an immediate risk to life, when a DI is deployed immediately to investigate and search. Medium Risk is that the risk to life is not immediate, but is a concern. An investigation and search is begun within the hour. Low risk is where there are no immediate concerns. The investigation may not begin straight away but take a few days.
She further said that an immediate action would be to identify the places from which he had been admitted before. The medical records indicated that of the last three admissions he had been brought in from the Calderwood Street Car Park on two occasions (13.12.16 and 05.01.17). That was the site where he took the final fatal overdose.
Thus if the police had been rung immediately, and assuming they took no action for the whole of the first hour, they would have had at least 49 minutes to find him in this site, which on the facts of the present case would enable an inference to be drawn that his life would have been saved. Thus the risk assessment by the police would seem to enable some deaths to be prevented, which would not necessarily on application of the assessment of the responsible physician, as immediate reporting only occurs if the patient is high risk. It is of concern that there are two different methods of assessing the risk when a vulnerable patient is granted leave, both in operation , one with greater potential of saving his life than the other.
” Source location Rastislav Petrisko · 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.
