First reported 21 Aug 2013•Latest report 19 May 2026
Definition
What this concern includes
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.
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.
Reports
45
Distinct published reports
Individual concerns
75
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
112
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.
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
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.
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.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The panel responsible for the funded care package, rather than the Trust, is responsible for developing risk assessments for prolonged absences from placements.
Stated by Dudley Integrated Health and Care NHS TrustRedirects 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.
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.8
Action
Review the Force Missing Person Policy with NHS partners to address missing-person responsibilities and communication issues.
Stated by Surrey PoliceStated in progressThe respondent said that this action was in progress when they made their response on 24 November 2014.
Action
Continue working with NHS and medical partners to establish effective communication channels and consistent responses to mental-health issues.
Stated by Surrey PoliceStated in progressThe respondent said that this action was in progress when they made their response on 24 November 2014.
Action
Develop and implement a flow chart directing staff through enquiries after a person goes missing.
Stated by Surrey and Borders Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 November 2014.
Action
Emphasise and disseminate the MISPER process to ward staff and managers.
Stated by Surrey and Borders Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 November 2014.
Action
Require staff to complete and upload MISPER Appendix A information to RiO for missing-person reports.
Stated by Surrey and Borders Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 November 2014.
Action
Arrange mandatory MISPER training for all unit staff, with completion required by the end of February 2015.
Stated by Surrey and Borders Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 24 November 2014.
Action
Implement training and a familiarisation programme for police and mental-health or medical staff after completing the policy review.
Stated by Surrey PoliceStated plannedThe respondent said that this action was planned when they made their response on 24 November 2014.
Action
Develop and enhance the Force training programme addressing missing-person procedures and mental-health risk assessment.
Stated by Surrey PoliceStated in progressThe respondent said that this action was in progress when they made their response on 24 November 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The communication failure concerned notification of an absent classification, not mental health issues in the wider context.
Stated by Surrey PoliceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The existing Missing Person Policy comprehensively provides risk assessment criteria and clearly allocates responsibility for enquiries.
Stated by Surrey PoliceExisting 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.
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
Review the response and existing measures against the inquest findings to ensure they address the identified issues and are embedded in current practice.
Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 28 August 2014.
Action
Complete the Metropolitan Police missing-person reporting form when a child arrives.
Stated by Ethelbert Childrens ServicesStated completedThe respondent said that this action was complete when they made their response on 28 August 2014.
Action
Complete and pass a vulnerability assessment to Kent Police for each child at placement.
Stated by Ethelbert Childrens ServicesStated completedThe respondent said that this action was complete when they made their response on 28 August 2014.
Action
Prepare risk assessment reports for missing looked-after children’s strategy meetings and pass them to police to inform search-risk and resource decisions.
Stated by London Borough of BexleyStated completedThe respondent said that this action was complete when they made their response on 28 August 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Implemented information-sharing arrangements, vulnerability assessments, reporting forms and telephone notifications address concerns about missing children’s information and risk assessment.
Stated by Ethelbert Childrens ServicesExisting 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.
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 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.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The AWOL policy was implemented appropriately, including searching and contacting police after the patient was found missing.
Stated by Sussex Partnership NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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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.
