Includes failures of controls dedicated to the missing-person response, such as staff understanding of the procedure, risk classification, communication of status, searches, escalation, agency coordination and family notification.
What is not included
Excludes generic delays in escalation or communication that are not explicitly connected to a missing-person response.
Excludes unrelated patient-deterioration, emergency-response or clinical-escalation failures.
Excludes general accessibility or communication deficiencies concerning visits, relatives or care unless they concern notification or coordination within a missing-person response.
Trends
Reports over time
Reports mentioning this concern, 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.
Metropolitan Police Service8
College of Policing7
Greater Manchester Police5
Department of Health and Social Care4
Surrey and Borders Partnership NHS Foundation Trust4
West Midlands Police4
East London NHS Foundation Trust3
Home Office3
National Police Chiefs’ Council3
Sussex Partnership NHS Foundation Trust3
Birmingham and Solihull Mental Health NHS Foundation Trust2
NHS England2
North London NHS Foundation Trust2
Sussex Police2
Association Of British Neurologists1
Police force28
NHS trust22
National policing body8
Ministerial department6
Integrated care board3
Executive non-departmental public body2
Registered charity2
Type not available2
Charitable incorporated organisation1
English county council1
English metropolitan district council1
English unitary authority1
External territorial police force1
London borough council1
Multi-service care provider1
Reports and published responses 45 reports
See individual reports that have raised this concern, and the actions taken in response
Staffordshire South
Concerns raised1
Failure to contact healthcare professionals during missing-person risk assessment
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Dudley Integrated Health and Care NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Dudley Integrated Health and Care NHS Trust
The panel responsible for the funded care package, rather than the Trust, is responsible for developing risk assessments for prolonged absences from placements.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Surrey
Concerns raised3
Failure of communication between police and hospital staff about missing-person status
Failure to make enquiries or investigations to ascertain a missing person’s whereabouts
Lack of adequate training for police and hospital staff on missing-person procedures, responsibilities and risk assessment
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Surrey and Borders Partnership NHS Foundation Trust
Surrey Police
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.8
Surrey Police
Review the Force Missing Person Policy with NHS partners to address missing-person responsibilities and communication issues.
Surrey Police
Continue working with NHS and medical partners to establish effective communication channels and consistent responses to mental-health issues.
Surrey and Borders Partnership NHS Foundation Trust
Develop and implement a flow chart directing staff through enquiries after a person goes missing.
Surrey and Borders Partnership NHS Foundation Trust
Emphasise and disseminate the MISPER process to ward staff and managers.
Surrey and Borders Partnership NHS Foundation Trust
Require staff to complete and upload MISPER Appendix A information to RiO for missing-person reports.
Surrey and Borders Partnership NHS Foundation Trust
Arrange mandatory MISPER training for all unit staff, with completion required by the end of February 2015.
Surrey Police
Implement training and a familiarisation programme for police and mental-health or medical staff after completing the policy review.
Surrey Police
Develop and enhance the Force training programme addressing missing-person procedures and mental-health risk assessment.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Surrey Police
The communication failure concerned notification of an absent classification, not mental health issues in the wider context.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Surrey Police
The existing Missing Person Policy comprehensively provides risk assessment criteria and clearly allocates responsibility for enquiries.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Inner South London
Concerns raised2
Failure to classify a missing person as high risk when warranted
Failure to carry out an effective search for a missing person
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Ethelbert Childrens Services
London Borough of Bexley
Metropolitan Police Service
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Metropolitan Police Service
Review the response and existing measures against the inquest findings to ensure they address the identified issues and are embedded in current practice.
Ethelbert Childrens Services
Complete the Metropolitan Police missing-person reporting form when a child arrives.
Ethelbert Childrens Services
Complete and pass a vulnerability assessment to Kent Police for each child at placement.
London Borough of Bexley
Prepare risk assessment reports for missing looked-after children’s strategy meetings and pass them to police to inform search-risk and resource decisions.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Ethelbert Childrens Services
Implemented information-sharing arrangements, vulnerability assessments, reporting forms and telephone notifications address concerns about missing children’s information and risk assessment.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Buckinghamshire
Concerns raised3
Failure to provide effective family liaison during missing person enquiries
Failure to apply the high-risk definition appropriately in missing person assessments
Lack of missing person coordinator coverage at weekends
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
West Sussex
Concerns raised1
Delays in declaring an AWOL patient missing and informing the police
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Sussex Partnership NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Sussex Partnership NHS Foundation Trust
The AWOL policy was implemented appropriately, including searching and contacting police after the patient was found missing.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.