Recurring concern

Unreliable completion of mental health assessments when patients leave or disengage

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First reported 12 Nov 2015•Latest report 25 Aug 2022

Definition

What this concern includes

Includes failures in mental health assessment processes to anticipate, identify and respond to patient departure or disengagement before assessment completion, including contingency planning, immediate risk action, efforts to complete or resume assessment, and appropriate follow-up or escalation.

Not included

Excludes general mental health appointment, referral, discharge or follow-up failures where interruption by patient departure or disengagement is not the unsafe condition.
Excludes failures in assessment quality when the assessment was completed and the problem is not patient departure or disengagement.
Excludes generic staffing, communication or documentation deficiencies unless they directly impair safe progression or completion of a mental health assessment after a patient leaves or disengages.
Excludes ordinary patient choice to leave where the service has appropriately assessed risk and implemented a safe response.

Reports: 2
Individual concerns: 2
Date range: 2015–2022
Stated actions: 5

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Bedfordshire Hospitals NHS Foundation Trust1

North London NHS Foundation Trust1

Whittington Health NHS Trust1

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.

25 Aug2022
Bedfordshire and Luton
Concerns raised1
1. Failure to prevent at-risk patients from leaving the emergency department while awaiting mental health 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.
Actions described in response 3
1. Action
  Implement the revised Transfer Policy, including requirements and supporting appendices for patients at risk of absconding.
  Stated by Bedfordshire Hospitals NHS Foundation TrustStated completed
2. Action
  Review Emergency Department staff provision for Mental Capacity Act and restraint training with ELFT colleagues.
  Stated by Bedfordshire Hospitals NHS Foundation TrustStated completed
3. Action
  Update Mental Capacity Act and restraint training for Emergency Department junior doctors.
  Stated by Bedfordshire Hospitals NHS Foundation TrustStated completed
AI-generated summary

Yuksel Bedri ISMAIL · 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

Yuksel Bedri ISMAIL, aged 23, absconded from hospital while awaiting a mental health assessment and was struck by an HGV on the M1 motorway on 28 November 2021, suffering fatal injuries. The concerns included hospital transfer arrangements for patients at risk of absconding and insufficient staff training and understanding regarding the Mental Capacity Act and preventing high-risk patients from leaving the emergency department.

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 prevent at-risk patients from leaving the emergency department while awaiting mental health assessment
Wider context from the report
“2. Although ELFT's SI Report (disclosed to the Trust before the PIRH held on 26 May 2022) had highlighted that "There is a need for staff involved in transferring patients, including security staff, to have training in the exercise of the Mental Capacity Act to ensure that patients who are assessed as lacking capacity with identified risks to self are unable to leave the emergency department" and recommended that "training be provided to acute Trust colleagues on the application of the Mental Capacity Act, its use to restrain/prevent somebody leaving the department if they are deemed to lack capacity and there are concerns regarding their risk should they leave, and where the person has capacity but remains a risk to themselves", there was no evidence before the Inquest of Bedford Hospitals NHS Trust's acknowledgment or consideration of this. Instead: - The Court heard from several Trust witnesses including a ED Sister, that they considered they had no powers to detain someone within the ED; - The statement provided to the Inquest by the ED Lead, ████████ (provided to the Court along with notice that he would NOT be available to attend the Inquest even though at the PIRH the Court had made it clear that the witness providing evidence of relevant Trust Policy would need to attend the Inquest) appeared confused about the powers available: Para 12 "Physical restraint is permitted in circumstances where the patient is confirmed to lack mental capacity and the restraint is necessary to preserve life or health and is proportionate to risk" Para 17 "Even if a single security officer had assisted with the transfer, they would be unable to physically restrain as the restraint policy specifies a minimum of two security officers are required for this and Mr Ismail was not subject to lawful DOLS at that point"; - PLS Staff stated that they have known of other patients leaving the ED whilst awaiting a MHA assessment ”
Source location
Yuksel Bedri ISMAIL · Prevention of Future Deaths report
Page 2 · concerns
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 the revised Transfer Policy, including requirements and supporting appendices for patients at risk of absconding.

Verbatim wording from the response
“We note that at the SI decision panel, PEARL, whilst we did identify that immediate improvements were required to our Transfer Policy, these had not been fully actioned by the time of the inquest. For this we apologise and have included a copy of the revised policy. The policy has been updated in collaboration with colleagues at ELFT and now more fully addresses patient needs. We have added Section 4.7 around patient transfers for those identified at risk of absconding, and Appendices 6, 7 and 8 now support this addition to the policy.”

Source location
Response from Bedfordshire Hospital NHS Foundation Trust
Page 1 · response
Published 3 October 2022
Open published response
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
Review Emergency Department staff provision for Mental Capacity Act and restraint training with ELFT colleagues.

Verbatim wording from the response
“In response to concerns regarding application of the Mental Capacity Act and restraint training, the Emergency Department together with the Trust’s Safeguarding Team have worked with colleagues at ELFT to review the current provision for staff in the Emergency Department. This has led to amendments which include updates to MCA and restraint training for junior doctors in the Emergency Department and monthly shared learning forums with the PLS and the acute medicine team where particularly complex cases are also reviewed.”

Source location
Response from Bedfordshire Hospital NHS Foundation Trust
Page 2 · response
Published 3 October 2022
Open published response
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
Update Mental Capacity Act and restraint training for Emergency Department junior doctors.

Verbatim wording from the response
“In response to concerns regarding application of the Mental Capacity Act and restraint training, the Emergency Department together with the Trust’s Safeguarding Team have worked with colleagues at ELFT to review the current provision for staff in the Emergency Department. This has led to amendments which include updates to MCA and restraint training for junior doctors in the Emergency Department and monthly shared learning forums with the PLS and the acute medicine team where particularly complex cases are also reviewed.”

Source location
Response from Bedfordshire Hospital NHS Foundation Trust
Page 2 · response
Published 3 October 2022
Open published response
12 Nov2015
Inner North London
Concerns raised1
1. Failure to plan action if a mental health assessment is interrupted by a patient leaving
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.
Actions described in response 2
1. Action
  Prepare a joint emergency-department framework and reference document covering risk assessment, capacity, security, observation, documentation and inter-service communication when patients leave.
  Stated by North London NHS Foundation Trust and Whittington Health NHS TrustStated in progress
2. Action
  Prepare a joint emergency-department framework and reference document covering risk, capacity, security, observation, documentation and inter-service communication when patients may leave.
  Stated by North London NHS Foundation Trust and Whittington Health NHS TrustStated in progress
Respondent positions 4
1. Position
  Informal patients cannot lawfully be prevented from leaving without sufficient grounds for detention or proportionate physical intervention.
  Stated by North London NHS Foundation Trust and Whittington Health NHS TrustUnable to act
1. Position
  The patient did not display behaviour indicating immediate risk, requiring detention, restraint, or an active police search.
  Stated by North London NHS Foundation Trust and Whittington Health NHS TrustDisputes the concern
2. Position
  The patient was not considered an immediate risk requiring detention, restraint, or an active police search.
  Stated by North London NHS Foundation Trust and Whittington Health NHS TrustDisputes the concern
3. Position
  Informal patients cannot lawfully be prevented from leaving unless applicable legal grounds for detention or physical intervention exist.
  Stated by North London NHS Foundation Trust and Whittington Health NHS TrustUnable to act
AI-generated summary

Matthew Marc GROOM · 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

Matthew Marc Groom stood in front of a lorry after spending seven hours in the emergency unit of Whittington Hospital, where he was seen by emergency medicine and mental health staff. Concerns included delays in his mental health assessment, prescribed diazepam not being administered, inadequate planning for his possible departure, failure to seek urgent hospital security assistance, and incomplete communication with police.

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 plan action if a mental health assessment is interrupted by a patient leaving
Wider context from the report
“3. The mental health nurse who then saw him did not consider what action to take if he should suddenly decide to leave, most particularly given that she felt unable to conclude the assessment without waiting for a doctor to come in from home to assist. ”
Source location
Matthew Marc GROOM · Prevention of Future Deaths report
Page 2 · concerns
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
Prepare a joint emergency-department framework and reference document covering risk assessment, capacity, security, observation, documentation and inter-service communication when patients leave.

Verbatim wording from the response
“Improvement in response to Concern To improve the reliability of assessments made by the Whittington and Camden and Islington frontline staff to consider and plan what action to take should a patient suddenly decide to leave, both organisations are jointly preparing a joint framework and reference document that will be used in the ED to outline and further reinforce clear steps with regard to:”

Source location
Matthew-Groom-Response
Page 4 · response
Published 12 November 2015
Open published response
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
Prepare a joint emergency-department framework and reference document covering risk, capacity, security, observation, documentation and inter-service communication when patients may leave.

Verbatim wording from the response
“Both Trusts have committed to improving staff awareness of their legal duties, what the options are associated with the various circumstances and clinical contingency planning in line with legal options. These are detailed under point 4.”

Source location
2015-0503-Response
Page 3 · response
Published 12 November 2015
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
Informal patients cannot lawfully be prevented from leaving without sufficient grounds for detention or proportionate physical intervention.

Verbatim wording from the response
“Individuals who have attended the ED voluntarily are informal patients and are not subject to any form of legal detention such as the Mental Health Act. For informal patients staff may try and persuade patients not to leave, but cannot in any manner prevent them leaving. A general duty of care can be applied in circumstances where someone is actively violent or is actively trying to hurt themselves or others, and then a physical intervention can be applied by NHS staff. This was not the case for Mr Groom.”

Source location
Matthew-Groom-Response
Page 3 · response
Published 12 November 2015
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
The patient did not display behaviour indicating immediate risk, requiring detention, restraint, or an active police search.

Verbatim wording from the response
“The Mental Health Act enables appropriately trained staff to deprive someone of their liberty and enforce treatment; rightly this assessment requires a high threshold to be met. Alongside this the assessors have to consider the persons capacity to make this decision. Camden and Islington NHS Foundation Trust is satisfied that Mr Groom did not display behaviour that was sufficiently concerning that it required Mr Groom to be immediately detained under the Mental Health Act or any other Act.”

Source location
Matthew-Groom-Response
Page 3 · response
Published 12 November 2015
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
The patient was not considered an immediate risk requiring detention, restraint, or an active police search.

Verbatim wording from the response
“The Mental Health Act enables appropriately trained staff to deprive someone of their liberty and enforce treatment; rightly this assessment requires a high threshold to be met. Alongside this assessment, staff have to consider the person’s capacity to make this decision. Camden and Islington NHS Foundation Trust is satisfied that Mr Groom did not display behaviour that was sufficiently concerning that it required Mr Groom to be immediately detained under the Mental Health Act or any other Act.”

Source location
2015-0503-Response
Page 3 · response
Published 12 November 2015
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
Informal patients cannot lawfully be prevented from leaving unless applicable legal grounds for detention or physical intervention exist.

Verbatim wording from the response
“Individuals who have attended the ED voluntarily are informal patients and are not subject to any form of legal detention such as the Mental Health Act. For informal patients staff may try and persuade patients not to leave, but cannot in any manner prevent them leaving. A general duty of care can be applied in circumstances where someone is actively violent or is actively trying to hurt themselves or others, and then a physical intervention can be applied by NHS staff. This was not the case for Mr Groom.”

Source location
2015-0503-Response
Page 3 · response
Published 12 November 2015
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to prevent at-risk patients from leaving the emergency department while awaiting mental health assessment

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised1

Failure to plan action if a mental health assessment is interrupted by a patient leaving

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4

Actions described in response 3

Actions described in response 2

Respondent positions 4