18 Jun 2019 Alfred Sykes · Prevention of Future Deaths report Manchester South
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Concerns raised 2
Failure to adequately consider and act on missing-person sighting information View source Inadequate planning, staffing and coverage of searches for missing persons 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
Alfred Sykes · 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
Alfred Sykes became lost while travelling home by bus on 7 February 2018 and was found dead beneath undergrowth at St Georgian's Cricket Club on 11 February 2018. The principal concern was that information about his last sighting and direction of travel was not given adequate consideration, and that the subsequent police search of the sports fields was inadequate. The report states that a larger search on the morning of 8 February might have found him earlier, although he would not have been found alive in the circumstances described.
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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 adequately consider and act on missing-person sighting information
Wider context from the report “1. GMP were informed that Mr Sykes was missing at around 8.00pm on 7th February. He was treated as a high risk missing person from the outset;
2. At approximately 4.00am on 8th February a member of the public called in to report that he had seen and spoken to a gentleman of Alfred Sykes description at about 4pm on 7th February on Egerton Road asking for directions to Longmead Avenue. When the caller could not help him he then asked if there were any football fields nearby. The caller pointed him in the direction of the sports fields at Woodsmoor, at the end of Egerton Road, including St Georgian's Cricket Club. Alfred Sykes was seen by the caller speaking to other people further along Egerton Road, closer to the sports fields;
3. At about 8.00am two police officers, with no allocated tasks at that time, took it upon themselves to conduct a search of the sports fields. The above report had been mentioned at the morning briefing but there was no plan to carry out any search of the fields. It was apparently more than 300m from the spot where the caller spoke to Alfred Sykes. The two officers attended and walked a route around the fields which did not include all of the periphery. They reported a negative result. In my opinion that search was inadequate to report a negative result, as agreed by ████████ in her evidence;
4. On 11th February two members of the public (one of whom knew of Alfred Sykes) and who had heard he was missing also took it upon themselves to search the fields, finding him as above.
My concern is that the report from the member of the public at 4.00am on 8th February of Alfred Sykes’ last sighting was given any or any adequate consideration and action , seemingly because it was more than 300m radius from ████████ However the significance of the sighting and the information was not lost on two police officers who on their own initiative looked around the playing fields. In evidence, ████████ advised that just two police officers for such a large area was insufficient. I agree.
Had there been a greater number of officers deployed on the morning of 8th February to search the fields to which Alfred Sykes had been directed and was last seen walking towards, it is likely he would have been found that morning.
The evidence is that Alfred Sykes would not have been found alive, in combination his frailties and the weather but in different circumstance (particularly the weather) the outcome might have been different for him and for others in the future.
Further, earlier discovery would have;
1. lessened the anguish for the family;
2. saved resources in the continued search over the following 3 days.
” Source location Alfred Sykes · 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 Inadequate planning, staffing and coverage of searches for missing persons
Wider context from the report “1. GMP were informed that Mr Sykes was missing at around 8.00pm on 7th February. He was treated as a high risk missing person from the outset;
2. At approximately 4.00am on 8th February a member of the public called in to report that he had seen and spoken to a gentleman of Alfred Sykes description at about 4pm on 7th February on Egerton Road asking for directions to Longmead Avenue. When the caller could not help him he then asked if there were any football fields nearby. The caller pointed him in the direction of the sports fields at Woodsmoor, at the end of Egerton Road, including St Georgian's Cricket Club. Alfred Sykes was seen by the caller speaking to other people further along Egerton Road, closer to the sports fields;
3. At about 8.00am two police officers, with no allocated tasks at that time, took it upon themselves to conduct a search of the sports fields. The above report had been mentioned at the morning briefing but there was no plan to carry out any search of the fields . It was apparently more than 300m from the spot where the caller spoke to Alfred Sykes. The two officers attended and walked a route around the fields which did not include all of the periphery . They reported a negative result. In my opinion that search was inadequate to report a negative result , as agreed by ████████ in her evidence;
4. On 11th February two members of the public (one of whom knew of Alfred Sykes) and who had heard he was missing also took it upon themselves to search the fields, finding him as above.
My concern is that the report from the member of the public at 4.00am on 8th February of Alfred Sykes’ last sighting was given any or any adequate consideration and action, seemingly because it was more than 300m radius from ████████ However the significance of the sighting and the information was not lost on two police officers who on their own initiative looked around the playing fields. In evidence, ████████ advised that just two police officers for such a large area was insufficient . I agree.
Had there been a greater number of officers deployed on the morning of 8th February to search the fields to which Alfred Sykes had been directed and was last seen walking towards , it is likely he would have been found that morning.
The evidence is that Alfred Sykes would not have been found alive, in combination his frailties and the weather but in different circumstance (particularly the weather) the outcome might have been different for him and for others in the future.
Further, earlier discovery would have;
1. lessened the anguish for the family;
2. saved resources in the continued search over the following 3 days.
” Source location Alfred Sykes · 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 Review high-risk missing-person searches daily and notify the Force Search Coordinator promptly of the circumstances.
Verbatim wording from the response “As a result of this report, with immediate effect all high risk missing person searches being conducted by a PoISA from the Specialist Search Unit, will be reviewed by another officer on a daily basis and the PoISC (Force Search Coordinator) appraised of the circumstances at the earliest opportunity.” Source location 2019-0201-Response-from-Greater-Manchester-Police-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 Add an annual refresher exercise on missing-person searches to PoISA/Search Manager continuous professional development, using recent force or national incidents.
Verbatim wording from the response “As a result of this incident, the annual POISA/Search Manager CPD will now include refresher training by way of an exercise in respect of missing person search, using incidents that have occurred within the force or nationally over the previous twelve months. This will ensure that officers remain operationally competent and any training issues can be appropriately addressed.” Source location 2019-0201-Response-from-Greater-Manchester-Police-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 The 300-metre search radius and requirement for confirmed sightings were considered appropriate to avoid ad hoc searching while information remained unconfirmed.
Verbatim wording from the response “As guidance to a reasonable, realistic and proportionate size of search area, a 300 meters radius around the PLS is recommended and nationally recognised in order to achieve a high level of confidence. A radius of 300 metres equates to a total search area of 283,239 Square meters (or 69.9 acres). The 300 metre radius will always be a guide and natural boundaries should be used such as main roads, motorways, railway lines, fences etc.” Source location 2019-0201-Response-from-Greater-Manchester-Police-Redacted
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27 Feb 2019 Janie McFadyen · Prevention of Future Deaths report Manchester City
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Concerns raised 2
Lack of clarity about when and in what circumstances a person leaving the program should be reported as missing View source Inappropriate placement of missing-person reporting responsibility on family members View source
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. 2
Action
Implement safeguarding, missing-person, medication, eligibility, health, welfare, fire-safety, drug-testing and related operational policies and procedures.
Stated by Victory Outreach ManchesterStated completedThe respondent said that this action was complete when they made their response on 27 February 2019. View source
Action
Review, amend and update residents’ records, including intake, support, risk, welfare, medical, medication, missing-person, departure and financial documentation.
Stated by Victory Outreach ManchesterStated completedThe respondent said that this action was complete when they made their response on 27 February 2019. View source
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AI-generated summary
Janie McFadyen · 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
Janie McFadyen left a drug rehabilitation facility in Manchester on 23 November 2017 and was found unconscious on derelict land on 25 November 2017. She died after suffering cardiac arrests; the inquest recorded hypothermia and the use of Diazepam, Zopiclone, Cocaine and Heroin, with a drug-related conclusion. The principal concerns included the lack of appropriate protocols and staff training, unclear arrangements for accessing health and police guidance, and the failure to clearly determine when a person leaving the facility should be reported missing.
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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 clarity about when and in what circumstances a person leaving the program should be reported as missing
Wider context from the report “1 The clear lack of the apparent existence of appropriate protocols, policies, processes or other guidance to deal with the large number of issues identified above
2. The lack of an apparent clear and cohesive set of arrangements for seeking help and guidance from primary or secondary NHS drug/alcohol and mental health services or seeking advice from the Police about a Missing Persons Policy
3 A complete lack of clarity about when and in what circumstances who leaves the program should be reported to the Police as being a missing person. It is suggested that the deceased would have fallen into the category of a High Risk Missing Person in all the circumstances and that there should be established procedures for dealing with such situations.
4. The inappropriateness of attempting to place the responsibility on members of a family to decide whether or not they wish to report an individual as a missing person to the Police
5 It is suggested that every person who works at either the male or female unit has appropriate and recognised training for their roles and this is regularly reviewed and updated
6. If other similar units run by Victory Outreach are operated in the same way elsewhere in England and Wales, a similar program of review identified in paragraphs 1-5 immediately above should be undertaken.
” Source location Janie McFadyen · 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 Inappropriate placement of missing-person reporting responsibility on family members
Wider context from the report “1 The clear lack of the apparent existence of appropriate protocols, policies, processes or other guidance to deal with the large number of issues identified above
2. The lack of an apparent clear and cohesive set of arrangements for seeking help and guidance from primary or secondary NHS drug/alcohol and mental health services or seeking advice from the Police about a Missing Persons Policy
3 A complete lack of clarity about when and in what circumstances who leaves the program should be reported to the Police as being a missing person. It is suggested that the deceased would have fallen into the category of a High Risk Missing Person in all the circumstances and that there should be established procedures for dealing with such situations.
4. The inappropriateness of attempting to place the responsibility on members of a family to decide whether or not they wish to report an individual as a missing person to the Police
5 It is suggested that every person who works at either the male or female unit has appropriate and recognised training for their roles and this is regularly reviewed and updated
6. If other similar units run by Victory Outreach are operated in the same way elsewhere in England and Wales, a similar program of review identified in paragraphs 1-5 immediately above should be undertaken.
” Source location Janie McFadyen · 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 Implement safeguarding, missing-person, medication, eligibility, health, welfare, fire-safety, drug-testing and related operational policies and procedures.
Verbatim wording from the response “1. Policies and Procedures as detailed in the table below and copies of these can be found in the Victory Homes Supporting Document File content list number 2.” Source location Response from Victory Outreach
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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, amend and update residents’ records, including intake, support, risk, welfare, medical, medication, missing-person, departure and financial documentation.
Verbatim wording from the response “2. Residents Files have been reviewed, amended and updated as detailed in the table below. Copies of these can be found in the Victory Homes Supporting Document File content list number 3.” Source location Response from Victory Outreach
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15 Jan 2019 Ms Catherine Anne Horton · Prevention of Future Deaths report London (South)
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Concerns raised 2
Failure to complete a Safe and Well check before closing a missing person investigation View source Insufficient staffing capacity for missing person enquiries 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
Ms Catherine Anne Horton · 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
Ms Catherine Anne Horton, a patient with paranoid schizophrenia detained under section 3 of the Mental Health Act 1983, died by hanging in July 2017, with the death occurring sometime between 16 and 24 July. The report identified failures in ward observation, recording and risk assessment, leadership, the police information pack, and the execution of a section 135(2) warrant. It also raised concerns about a missing-person investigation being incorrectly closed before a Safe and Well check, in the context of staff shortages and pressure of work.
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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 a Safe and Well check before closing a missing person investigation
Wider context from the report “There were multiple failures in the days leading up to Ms Horton’s death. During the evidence it was made clear that a mistake was made in relation to closing a missing person investigation relating to the deceased (before a Safe and Well check had been undertaken) . This occurred at a time when staffing was low and the expectations of the Officer or Officers working on particular days was well above what was achievable. Particularly, on the day the investigation was incorrectly closed was one where the unit was dealing with 28 missing person enquiries.
I strongly suspect that resources are stretched in every department of the MPS. However, the missing persons’ unit may not be seen as readily as other departments as a life-saving department. Of course it is because of the vulnerable nature of the persons missing and I am told that Croydon has the highest figures of missing persons in Europe. At the time of Ms Horton’s death, an error was made that coincided with staff being re-located elsewhere and the senior officer giving evidence said that the error was made due to pressure of work.
I have sufficient concern about a wider issue which warrants the writing of this Prevent Future Death Report (CJA 2009, Schedule 5, Paragraph 7; Regulation 28 Coroners (Investigations) Regulations 2013) to be sent more centrally.
” Source location Ms Catherine Anne Horton · 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 Insufficient staffing capacity for missing person enquiries
Wider context from the report “There were multiple failures in the days leading up to Ms Horton’s death. During the evidence it was made clear that a mistake was made in relation to closing a missing person investigation relating to the deceased (before a Safe and Well check had been undertaken). This occurred at a time when staffing was low and the expectations of the Officer or Officers working on particular days was well above what was achievable . Particularly, on the day the investigation was incorrectly closed was one where the unit was dealing with 28 missing person enquiries .
I strongly suspect that resources are stretched in every department of the MPS . However, the missing persons’ unit may not be seen as readily as other departments as a life-saving department. Of course it is because of the vulnerable nature of the persons missing and I am told that Croydon has the highest figures of missing persons in Europe. At the time of Ms Horton’s death, an error was made that coincided with staff being re-located elsewhere and the senior officer giving evidence said that the error was made due to pressure of work .
I have sufficient concern about a wider issue which warrants the writing of this Prevent Future Death Report (CJA 2009, Schedule 5, Paragraph 7; Regulation 28 Coroners (Investigations) Regulations 2013) to be sent more centrally.
” Source location Ms Catherine Anne Horton · 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 Review and update policies and standard operating procedures for missing-person risk assessments, investigations and interviews with returned missing people.
Verbatim wording from the response “The MPS has reviewed and updated its policies and standard operating procedures for on-going risk-assessments, investigations and interviews with returning missing people. Interviews with returned or found missing people are aimed at prevention of further missing episodes. Information that could prevent the person going missing again, along with any other information affecting their welfare, is disseminated to our policing and partner agencies, which allows for early intervention.” Source location 2019-0143-Response-by-Metropolitan-Police
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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 BCU policing model, incorporating MPUs into twelve BCUs to provide greater resilience and consistency.
Verbatim wording from the response “The structure, working practices and resourcing of MPS Missing Persons Units (MPUs) have changed significantly since 2017. The MPS has now implemented a programme to incorporate thirty two boroughs into twelve Basic Command Units (BCUs), providing resilience and consistency across London to help the MPS meet its financial and operational challenges. The design of the new MPUs under this programme is intended to resolve some of the historic issues that have been raised which involves an investment of additional posts into MPUs across the MPS. Considering the financial constraints the MPS is operating within, we believe this to be a significant commitment to what is acknowledged as an area of risk.” Source location 2019-0143-Response-by-Metropolitan-Police
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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 Increase dedicated MPU staffing through additional safeguarding-focused police officer posts across the MPS.
Verbatim wording from the response “The structure, working practices and resourcing of MPS Missing Persons Units (MPUs) have changed significantly since 2017. The MPS has now implemented a programme to incorporate thirty two boroughs into twelve Basic Command Units (BCUs), providing resilience and consistency across London to help the MPS meet its financial and operational challenges. The design of the new MPUs under this programme is intended to resolve some of the historic issues that have been raised which involves an investment of additional posts into MPUs across the MPS. Considering the financial constraints the MPS is operating within, we believe this to be a significant commitment to what is acknowledged as an area of risk.” Source location 2019-0143-Response-by-Metropolitan-Police
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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 Establish BCU Safeguarding Hubs with senior safeguarding leadership and flexible deployment of officers to MPUs during periods of high demand.
Verbatim wording from the response “Under the delivery of this new policing model for London, each BCU has established an MPU that is resourced according to local demand. Each MPU works to a set of minimum standards of operational procedure, staffing levels, skills and supervision. The responsibility of implementing the model and operational delivery lies with local leadership teams, ultimately BCU Commanders. This does however involve balancing available resources at times against operational demand, and flexing resources to respond to peaks and critical issues. The BCU Commanders are best placed to make decisions where vacancies are held, taking into account all the risks being dealt with by the BCU as a whole and by Safeguarding the most vulnerable in particular.” Source location 2019-0143-Response-by-Metropolitan-Police
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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 Provide 24-hour staffing for safeguarding investigation teams through a corporate shift pattern.
Verbatim wording from the response “The MPS has invested significantly in safeguarding focused police officer posts as part of the new BCU model, which has resulted in an increase of dedicated MPU officers. The MPUs are now integrated with local command and control functions via a local operations room in each BCU that monitors live and incoming risk at all times. Any new missing person who comes to the notice of police will continue to be risk assessed and monitored by the emergency response team Duty Inspector. Any high-risk missing person will immediately be passed to the Safeguarding MPU under the direction of a Detective Inspector who will utilise all relevant and available resources to ensure priority actions are addressed. Safeguarding investigation teams across London are resourced 24 hours a day following the implementation of a corporate shift pattern.” Source location 2019-0143-Response-by-Metropolitan-Police
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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 Conduct three-month and full reviews of the BCU model and provide recommendations to address identified risks and improve the model.
Verbatim wording from the response “Following the implementation of BCUs, led by the Assistant Commissioner for Frontline Policing, the Deputy Assistant Commissioner for Local Policing will conduct a three month review of their progress; this provides the opportunity to check that all the elements of the BCU including MPUs are working effectively. This will be followed by a full review (June to September 2019) and recommendations will be provided on how to further improve the model taking into account pressures that have been experienced and address any risks or issues that have been identified.” Source location 2019-0143-Response-by-Metropolitan-Police
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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 Increase staffing in the South Area MPU and plan a further increase in staffing levels.
Verbatim wording from the response “South Area (SN) BCU incorporates the boroughs of Croydon, Sutton and Bromley. The South Area MPU has had an uplift of officers with a plan to increase staffing levels further in the near future. High risk missing person cases should attract a BCU response and a senior detective within the Safeguarding Hub will lead the investigation. There are currently some challenges regarding the investigation of low and medium graded missing person reports before they reach the MPU, however this is now being addressed as a matter of urgency.” Source location 2019-0143-Response-by-Metropolitan-Police
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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 Local BCU leadership, ultimately BCU Commanders, is responsible for implementing the policing model and making operational staffing decisions.
Verbatim wording from the response “Under the delivery of this new policing model for London, each BCU has established an MPU that is resourced according to local demand. Each MPU works to a set of minimum standards of operational procedure, staffing levels, skills and supervision. The responsibility of implementing the model and operational delivery lies with local leadership teams, ultimately BCU Commanders. This does however involve balancing available resources at times against operational demand, and flexing resources to respond to peaks and critical issues. The BCU Commanders are best placed to make decisions where vacancies are held, taking into account all the risks being dealt with by the BCU as a whole and by Safeguarding the most vulnerable in particular.” Source location 2019-0143-Response-by-Metropolitan-Police
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16 Nov 2018 Dawn Patricia GILL · Prevention of Future Deaths report Inner North London
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Concerns raised 3
Delays in alerting hospital security when an inpatient is missing View source Lack of clarity in the missing-person policy View source Failure to record communications about contacting security for missing patients 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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Dawn Patricia GILL · 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
Dawn Patricia Gill, a long-term drug user, died from a methadone overdose after taking illicit drugs while in the Royal London Hospital alongside prescribed medication. Concerns included the absence of a nursing care plan addressing her drug use, the loss of her drug chart, failures to detect her in her room during searches, and confusion about when to alert hospital security after she was thought to be missing.
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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 Delays in alerting hospital security when an inpatient is missing
Wider context from the report “4. Ms Gill was thought to have left the ward for a cigarette some time before 12.30am, though she was not actually seen leaving. She was wearing her night things. When her absence was discovered, hospital security personnel were not alerted . They could have viewed the CCTV. If they had done so, they would have realised that she had never left the ward. Hopefully, this would have prompted a redoubling of the search effort of the ward.
There was confusion about the circumstances when the missing person policy should be followed. I was told that the policy is not clear. The responsible nurse said it was in the back of her mind to contact security and she did not know why she had not. The sister in charge said that she would not contact security for the first two hours . The director of nursing said the contact should be immediate . The clinical site manager and the responsible nurse disagreed about the nature of the conversation between them regarding contacting security. Neither of them had made a note.
There seemed to be a lack of clarity.
” Source location Dawn Patricia GILL · 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 clarity in the missing-person policy
Wider context from the report “4. Ms Gill was thought to have left the ward for a cigarette some time before 12.30am, though she was not actually seen leaving. She was wearing her night things. When her absence was discovered, hospital security personnel were not alerted. They could have viewed the CCTV. If they had done so, they would have realised that she had never left the ward. Hopefully, this would have prompted a redoubling of the search effort of the ward.
There was confusion about the circumstances when the missing person policy should be followed . I was told that the policy is not clear . The responsible nurse said it was in the back of her mind to contact security and she did not know why she had not. The sister in charge said that she would not contact security for the first two hours. The director of nursing said the contact should be immediate. The clinical site manager and the responsible nurse disagreed about the nature of the conversation between them regarding contacting security. Neither of them had made a note.
There seemed to be a lack of clarity .
” Source location Dawn Patricia GILL · 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 communications about contacting security for missing patients
Wider context from the report “4. Ms Gill was thought to have left the ward for a cigarette some time before 12.30am, though she was not actually seen leaving. She was wearing her night things. When her absence was discovered, hospital security personnel were not alerted. They could have viewed the CCTV. If they had done so, they would have realised that she had never left the ward. Hopefully, this would have prompted a redoubling of the search effort of the ward.
There was confusion about the circumstances when the missing person policy should be followed. I was told that the policy is not clear. The responsible nurse said it was in the back of her mind to contact security and she did not know why she had not. The sister in charge said that she would not contact security for the first two hours. The director of nursing said the contact should be immediate. The clinical site manager and the responsible nurse disagreed about the nature of the conversation between them regarding contacting security. Neither of them had made a note.
There seemed to be a lack of clarity.
” Source location Dawn Patricia GILL · 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 Remind nursing teams about the risks of assuming that an absent patient is not on Trust premises.
Verbatim wording from the response “Ms Gill had been judged by the clinical team to have capacity to decide for herself whether she should leave the hospital or not under her own volition. The Barts Health Missing Person / Absconding Patient Policy is clear that this would not classify her absence as a “missing patient” but as a “self-absenting patient”. By this definition she was thought to have been a patient who had capacity, was not subject to legal detention, and who had left the hospital through her own choice, without clinical approval, with the intention of returning. In such circumstances the Trust policy states the Security team should not be called. However the policy recommends that if there is concern that the person may be missing “on Trust premises” then the Security team should be called. The problem here was that the staff did not suspect Ms Gill was on Trust premises, and they should have considered this.” Source location 2018-0354-Response-by-Barts-Health-NHS-Trust
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29 Oct 2018 Rosario CORDERO-SANZ · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Inadequate understanding of the missing person process among special police officers View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Rosario CORDERO-SANZ · 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
Rosario (known as Charo) Cordero-Sanz died after jumping in front of a train at Bethnal Green Underground Station on 14 July 2018. The concerns included gaps in special police officers’ access to information, understanding of missing-person and mental-health procedures, communication with a non-native English-speaking friend, and the failure to identify her as a high-risk missing person.
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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 Inadequate understanding of the missing person process among special police officers
Wider context from the report “2. In addition, the jury heard as follows.
- The three police officers did not appear to have an in depth understanding of the misper process .
- They did not (save for one who had attended such calls before) appear to have an in depth understanding of the s136 Mental Health Act / mental health potential issues.
- They did not consider using language line to assist them in obtaining information from the non native English speaking friend, with whom they spoke outside the building where Ms Cordero-Sanz was staying with a friend. Being able to speak in his native language might have facilitated the informant to give fuller details, such as the fact that Ms Cordero-Sanz was by now hearing voices.
- Having been told that she would be upset by their uniforms, they did not insist on seeing Ms Cordero-Sanz to assess her for themselves, or call for the assistance of a plain clothes colleague, or suggest that they speak to the friend who was sitting inside with her.
- Nobody thought of calling an ambulance that night, save for the CAD (computer aided despatch) operator who took the call in the first place, but he did not mention he had done so to anyone else.
I wonder whether this suggests a training need, and/or whether, given the difficulties in maintaining skills on only 15 hours a month, consideration could be given to teaming special officers with regulars?
” Source location Rosario CORDERO-SANZ · 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 Review support for Metropolitan Special Constabulary practical learning.
Verbatim wording from the response “• The three police officers did not appear to have an in depth understanding of the misper process.
On their initial foundation course, all MSC officers receive training on how to deal with a missing person and are expected to be conversant with changes in legislation and policy. The MPS is satisfied that the level of training provided is sufficient for MSC officers. If a MSC officer, or indeed any police officer, is unsure of how to deal with an incident they should seek supervisory advice at the scene. In light of this incident, all MSC coordinators who are experienced police constables supporting the MSC, have been tasked to review the support of MSC practical learning.” Source location 2018-0307-Response-by-Metropolitan-Police
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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 Disseminate learning from the report and review training for Metropolitan Special Constabulary and regular officers.
Verbatim wording from the response “The MPS has supported the dissemination of the learning opportunities presented by your report and is reviewing training in the context of both the MSC and the regular service. The MPS identifies that an aspiration to patrol MSC officers with regular officers on a regular basis would be unachievable due to competing demands, as well as MSC availability. As a direct result of this incident, CE BCU has put processes in place to ensure that MSC officers are briefed and debriefed at the start and end of their tours of duty and have supervisory support throughout. Commander Muskett, the lead for frontline policing, has directed that this process be implemented across all other BCUs.” Source location 2018-0307-Response-by-Metropolitan-Police
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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 foundation training is considered sufficient for special officers handling missing-person incidents.
Verbatim wording from the response “• The three police officers did not appear to have an in depth understanding of the misper process.
On their initial foundation course, all MSC officers receive training on how to deal with a missing person and are expected to be conversant with changes in legislation and policy. The MPS is satisfied that the level of training provided is sufficient for MSC officers. If a MSC officer, or indeed any police officer, is unsure of how to deal with an incident they should seek supervisory advice at the scene. In light of this incident, all MSC coordinators who are experienced police constables supporting the MSC, have been tasked to review the support of MSC practical learning.” Source location 2018-0307-Response-by-Metropolitan-Police
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18 Jan 2018 Paul Lawrence Hanton · Prevention of Future Deaths report West Sussex
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Concerns raised 3
Failure to make appropriate referrals to other police forces View source Unequal police response to high-risk informal and sectioned patients View source Lack of joint policy with the Adult Safeguarding Board View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Paul Lawrence Hanton · 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
Paul Hanton was an informal patient at Langley Green Mental Health Hospital when he absconded during an escorted walk on 18 April 2016. Eight days later, he jumped in front of a train at Kings Cross Underground Station and died from head injuries. The principal concerns included the information provided during the missing-person call, delays and gaps in police action, inaccessible hospital CCTV, and differing responses to informal and sectioned patients assessed as being at high risk of self-harm or suicide.
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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 make appropriate referrals to other police forces
Wider context from the report “4) Police to ensure the initial risk assessment is clearly endorsed in the CAD and timely actions are undertaken both locally and appropriate referrals are made to other Forces .
” Source location Paul Lawrence Hanton · 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 Unequal police response to high-risk informal and sectioned patients
Wider context from the report “6) Police to consider equal response to informal as well as sectioned patients if guided by clinical staff of high risk. I heard from senior staff at Langley Green that there is a discernibly different response from police when the missing person is an informal patient rather than under a MHA order . In the latter case, often a blue light police car is immediately dispatched to the hospital and a room/locality search takes place. This is not the case with an informal patient yet the same high risk of self-harm or suicide or risk of causing injuries to others may exist . In other words, there seems to be a general perception that informal patients are less unwell.
” Source location Paul Lawrence Hanton · 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 joint policy with the Adult Safeguarding Board
Wider context from the report “5) Police to consider joint policy with Adult Safeguarding Board .
” Source location Paul Lawrence Hanton · 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 Review the jointly agreed absent-without-leave and informal-missing-patients policy through partner-agency consultation, including seeking Safeguarding Board comments and considering coroner recommendations.
Verbatim wording from the response “Point five identifies the need to consider a joint policy with the Adult Safeguarding Board. Sussex Police and Sussex Partnership NHS Foundation have a jointly agreed policy relating to patients absent without leave / informal missing patients which applies to all patients including those detained under the Mental Health Act 1983, subject to Guardianship, Supervised Community Treatment Orders as well as those in hospital informally. The document provides guidance for managers and staff regarding duties, responsibilities and actions to be taken when a patient is absent without leave or provides the legal framework which sets out these duties and responsibilities. This Policy (a copy of which is attached) was due for review in November 2017 and is currently in the process of consultation with all partner agencies prior to the finalisation of any amendments and additions.” Source location 2018-0021-Response-by-Sussex-Police
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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 Sussex Partnership NHS Foundation Trust will respond directly to concerns one, two and three.
Verbatim wording from the response “Points one, two and three (as numbered in the report) will be responded to by Sussex Partnership NHS Foundation Trust directly to you.” Source location 2018-0021-Response-by-Sussex-Police
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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 Patient status does not determine response level; response is determined by assessed risk, regardless of whether the patient is informal or sectioned.
Verbatim wording from the response “Point six asks the police to consider whether there is an equal response to informal as well as sectioned patients if they are assessed by clinical staff as high risk. I can assure you that whether they were an informal or sectioned patient would be noted but would not determine the level of response. This is determined by the level of risk which is a combination of the likelihood of harm coming to the missing person or the wider public, and the potential seriousness of harm that might result.” Source location 2018-0021-Response-by-Sussex-Police
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13 Jan 2017 Natalie Gray · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 1
Unclear escalation procedures for people at medium risk of self harm View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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
Natalie Gray · 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
Natalie Gray died after leaving Priority House, where she was an informal patient, and jumping in front of a train at Barming railway station on 21 April 2015. The principal concerns included insufficient risk assessments, inadequate handovers and failures in procedures for informal patient leave, communication of risk, recording third-party information and reporting her absence to police.
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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 Unclear escalation procedures for people at medium risk of self harm
Wider context from the report “(3) Kent Police and Kent & Medway NHS & Social Care Partnership Trust have agreed a Missing Person Procedure implemented 1st December 2015. There is a concern about the terminology for use in the risk assessment that the Mental Health Trust is required to complete which may lead to an inaccurate risk assessments. There appears to be no explanation as to whether the risk is that formally documented, or the risk at the time the patient left the facility which may be less clear. Additionally the use of the term 'significant' is highly subjective, is it intended to mean a likely risk of self harm or something more. It is not clear how the Trust should deal with those likely to place themselves in danger and therefore at medium risk of self harm, in terms of the timescales involved and whether 999 should be used or not. By way of example, Natalie's documented risk was inaccurately recorded as low, when it should have been medium and on leaving the facility medium to high, this could lead to an underestimation of the risk of self harm depending on how the form is interpreted by staff.
” Source location Natalie Gray · Prevention of Future Deaths report
Open source report
8 Nov 2016 Ozeilivo Andrew AKERELE · Prevention of Future Deaths report Coventry
View report summary
Concerns raised 2
Failure of the search to locate a missing person despite an intensive search near the last confirmed sighting View source Failure of the search team to locate a missing person when searching a defined graveyard area 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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AI-generated summary
Ozeilivo Andrew AKERELE · 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
Ozeilivo Andrew Akerele disappeared, and his body was found 15 months later in a disused graveyard close to the last confirmed sighting of him. The concerns relate to failures to search the area adequately and promptly, failure to follow up a recommendation for a more thorough search, and gaps in communication with the Police Search Advisor. The inquest concluded with a finding of misadventure.
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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 of the search to locate a missing person despite an intensive search near the last confirmed sighting
Wider context from the report “(1) failure to find the body of Mr Akerele despite an intensive search when in fact his body was found very close to the last confirmed sighting of him .
” Source location Ozeilivo Andrew AKERELE · 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 of the search team to locate a missing person when searching a defined graveyard area
Wider context from the report “(2) failure of the search team to find Mr Akerele when they did eventually search the disused graveyard in approximately late February 2015 despite the graveyard being approximately 60m x 30m .
” Source location Ozeilivo Andrew AKERELE · 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 Refer the case to the National Missing Persons Operational Group to consider working with POLSA on amending search-coordination guidance.
Verbatim wording from the response “The case will now be referred to the National Missing Persons Operational Group to consider working with the Police Search Advisor (POLSA) to amend guidance around how a search is co-ordinated in similar cases; specifically providing clarity around the tasking of the search, what is being searched for and the accurate recording of search, completed with oversight by Senior Investigating Officer (SIO) and POLSA.” Source location 2017-0337-Response-by-West-Midland-Police
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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 The individual search decisions appeared reasonable, although a more comprehensive search strategy and recording process was needed.
Verbatim wording from the response “In relation to the searching, it does appear that a more comprehensive search strategy and updates could have been compiled, with absolute clarity around who had searched what area, to what extent and at what time. The individual decisions by ████████ and ████████ appear reasonable, but a more comprehensive effort would have ensured that the relevant information that ████████ had accessed the land that ████████ thought inaccessible, and the relative limitations of the search that ████████ had carried out, would have been more apparent at an earlier stage. It also appears that an earlier invitation to the POLSA may have assisted in the tasking and recording of searches at the earliest opportunity.” Source location 2017-0337-Response-by-West-Midland-Police
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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 The National Missing Persons Operational Group will consider amending guidance on coordinating, tasking and recording similar searches with POLSA involvement.
Verbatim wording from the response “The case will now be referred to the National Missing Persons Operational Group to consider working with the Police Search Advisor (POLSA) to amend guidance around how a search is co-ordinated in similar cases; specifically providing clarity around the tasking of the search, what is being searched for and the accurate recording of search, completed with oversight by Senior Investigating Officer (SIO) and POLSA.” Source location 2017-0337-Response-by-West-Midland-Police
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Concerns raised 4
Delays in escalating contact with relatives, police, hospital staff and medical staff after a patient’s absence View source Delays in responding to a patient’s absence from leave View source Failure to carry out required internal, grounds, staff and CCTV searches for a missing patient View source
Lack of staff knowledge of leave and missing-patient policies View source See 1 more concern
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.
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
Michael Peter McMonigle · 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
Michael Peter McMonigle was admitted as an informal patient to Farnham Ward at Lanchester Road Hospital and was assessed as being at significant risk of self-harm. On 11 August 2015 he left the hospital during accompanied leave, was later found suspended by a ligature, and was declared dead on 12 August. The principal concerns included failures to update and communicate risk information and leave arrangements, inadequate handover and policy implementation, and delays and omissions in responding to his absence.
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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 Delays in escalating contact with relatives, police, hospital staff and medical staff after a patient’s absence
Wider context from the report “(1) The lack of knowledge of the policy for leave for informal patients amongst ward staff and the Consultant Psychiatrist in particular.
(2) The failure to follow the policy in terms of conducting an assessment prior to the handover.
(3) The failure to apply the policy in terms of ensuring that leave arrangements are clearly understood by the patient and communicated to relatives. See paragraphs 6.7 and 6.8, the policy of Leave from Hospital and Leave of Absence under Section 17 Mental Health Act 1973, policy no CLIN00025.
(4) The Face risk assessment, PARIS case notes and intervention plan were not updated with assessment of risk of self-harm or suicide and details of conditions for escorted leave following the formulation meeting on 10th August 2015. Instead, it fell to staff to verbally convey this information to colleagues who had not attended at the formulation meeting and to members of the family.
(5) Failure to respond to Michael’s absence until well after 19:20 hrs, when it was admitted by ward staff in evidence that interventions could have been commenced, alternatively at 21:00hrs when it was conceded that the alarm could have been raised given that was the normal time for return from leave.
(6) The response to Michael’s absence did not conform with paragraphs 7.3 of the Missing Patients Procedure, ref. CLIN-0006-V4 in that there was no search of the hospital internally, a search of the grounds, enquiry with other staff users, check of CCTV footage.
(6) The following responses were undertaken after 19.20 and 21.00 when in conclusion of the jury the alarm could have been raised: enquiry with friends or relatives from 22:30hrs at earliest, an attempt to telephone Michael from 22:40 hrs at earliest, contact with relatives from 22:30 hrs at the earliest (Michael’s mother said 23.15), Police at 23:45hrs at the earliest, other hospital staff at 00:15hr on 12th August at the earliest, the medical staff at 12:20hrs at the earliest. Staff knowledge of the Leave policy and Missing Patients Procedure was inadequate.
” Source location Michael Peter McMonigle · 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 Delays in responding to a patient’s absence from leave
Wider context from the report “(1) The lack of knowledge of the policy for leave for informal patients amongst ward staff and the Consultant Psychiatrist in particular.
(2) The failure to follow the policy in terms of conducting an assessment prior to the handover.
(3) The failure to apply the policy in terms of ensuring that leave arrangements are clearly understood by the patient and communicated to relatives. See paragraphs 6.7 and 6.8, the policy of Leave from Hospital and Leave of Absence under Section 17 Mental Health Act 1973, policy no CLIN00025.
(4) The Face risk assessment, PARIS case notes and intervention plan were not updated with assessment of risk of self-harm or suicide and details of conditions for escorted leave following the formulation meeting on 10th August 2015. Instead, it fell to staff to verbally convey this information to colleagues who had not attended at the formulation meeting and to members of the family.
(5) Failure to respond to Michael’s absence until well after 19:20 hrs, when it was admitted by ward staff in evidence that interventions could have been commenced, alternatively at 21:00hrs when it was conceded that the alarm could have been raised given that was the normal time for return from leave.
(6) The response to Michael’s absence did not conform with paragraphs 7.3 of the Missing Patients Procedure, ref. CLIN-0006-V4 in that there was no search of the hospital internally, a search of the grounds, enquiry with other staff users, check of CCTV footage.
(6) The following responses were undertaken after 19.20 and 21.00 when in conclusion of the jury the alarm could have been raised: enquiry with friends or relatives from 22:30hrs at earliest, an attempt to telephone Michael from 22:40 hrs at earliest, contact with relatives from 22:30 hrs at the earliest (Michael’s mother said 23.15), Police at 23:45hrs at the earliest, other hospital staff at 00:15hr on 12th August at the earliest, the medical staff at 12:20hrs at the earliest. Staff knowledge of the Leave policy and Missing Patients Procedure was inadequate.
” Source location Michael Peter McMonigle · 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 carry out required internal, grounds, staff and CCTV searches for a missing patient
Wider context from the report “(1) The lack of knowledge of the policy for leave for informal patients amongst ward staff and the Consultant Psychiatrist in particular.
(2) The failure to follow the policy in terms of conducting an assessment prior to the handover.
(3) The failure to apply the policy in terms of ensuring that leave arrangements are clearly understood by the patient and communicated to relatives. See paragraphs 6.7 and 6.8, the policy of Leave from Hospital and Leave of Absence under Section 17 Mental Health Act 1973, policy no CLIN00025.
(4) The Face risk assessment, PARIS case notes and intervention plan were not updated with assessment of risk of self-harm or suicide and details of conditions for escorted leave following the formulation meeting on 10th August 2015. Instead, it fell to staff to verbally convey this information to colleagues who had not attended at the formulation meeting and to members of the family.
(5) Failure to respond to Michael’s absence until well after 19:20 hrs, when it was admitted by ward staff in evidence that interventions could have been commenced, alternatively at 21:00hrs when it was conceded that the alarm could have been raised given that was the normal time for return from leave.
(6) The response to Michael’s absence did not conform with paragraphs 7.3 of the Missing Patients Procedure, ref. CLIN-0006-V4 in that there was no search of the hospital internally, a search of the grounds, enquiry with other staff users, check of CCTV footage.
(6) The following responses were undertaken after 19.20 and 21.00 when in conclusion of the jury the alarm could have been raised: enquiry with friends or relatives from 22:30hrs at earliest, an attempt to telephone Michael from 22:40 hrs at earliest, contact with relatives from 22:30 hrs at the earliest (Michael’s mother said 23.15), Police at 23:45hrs at the earliest, other hospital staff at 00:15hr on 12th August at the earliest, the medical staff at 12:20hrs at the earliest. Staff knowledge of the Leave policy and Missing Patients Procedure was inadequate.
” Source location Michael Peter McMonigle · 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 staff knowledge of leave and missing-patient policies
Wider context from the report “(1) The lack of knowledge of the policy for leave for informal patients amongst ward staff and the Consultant Psychiatrist in particular.
(2) The failure to follow the policy in terms of conducting an assessment prior to the handover.
(3) The failure to apply the policy in terms of ensuring that leave arrangements are clearly understood by the patient and communicated to relatives. See paragraphs 6.7 and 6.8, the policy of Leave from Hospital and Leave of Absence under Section 17 Mental Health Act 1973, policy no CLIN00025.
(4) The Face risk assessment, PARIS case notes and intervention plan were not updated with assessment of risk of self-harm or suicide and details of conditions for escorted leave following the formulation meeting on 10th August 2015. Instead, it fell to staff to verbally convey this information to colleagues who had not attended at the formulation meeting and to members of the family.
(5) Failure to respond to Michael’s absence until well after 19:20 hrs, when it was admitted by ward staff in evidence that interventions could have been commenced, alternatively at 21:00hrs when it was conceded that the alarm could have been raised given that was the normal time for return from leave.
(6) The response to Michael’s absence did not conform with paragraphs 7.3 of the Missing Patients Procedure, ref. CLIN-0006-V4 in that there was no search of the hospital internally, a search of the grounds, enquiry with other staff users, check of CCTV footage.
(6) The following responses were undertaken after 19.20 and 21.00 when in conclusion of the jury the alarm could have been raised: enquiry with friends or relatives from 22:30hrs at earliest, an attempt to telephone Michael from 22:40 hrs at earliest, contact with relatives from 22:30 hrs at the earliest (Michael’s mother said 23.15), Police at 23:45hrs at the earliest, other hospital staff at 00:15hr on 12th August at the earliest, the medical staff at 12:20hrs at the earliest. Staff knowledge of the Leave policy and Missing Patients Procedure was inadequate.
” Source location Michael Peter McMonigle · Prevention of Future Deaths report
Open source report
15 Apr 2016 Adele Blakeman · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Lack of understanding of the IMU role in missing person enquiries View source
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.
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AI-generated summary
Adele Blakeman · 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
Adele Blakeman, who had a history of mental health difficulties and self-harming behaviour, died after taking her own life at Gateley Railway Station on 28 September 2015. The substantive concerns included failures in police information recording and access, classification and escalation of the call, timely allocation of resources, and understanding of the role of the Missing Persons 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 understanding of the IMU role in missing person enquiries
Wider context from the report “4. There is a lack of understanding of the role of the IMU in missing person enquiries .
” Source location Adele Blakeman · 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 Highlight the Information Management Unit’s role in triaging missing-from-home incidents through Divisional Orders.
Verbatim wording from the response “In light of this regulation 28, the role of the Information Management Unit has been highlighted throughout the OCB via inclusion on Divisional Orders on 27th May 2016. This highlights their role in the triage of MFH incidents amongst their other duties.” Source location 2016-0145-Response-by-Greater-Manchester-Police
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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.
