Recurring concern
Unreliable response to patient absconding
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Request correctionFirst reported 20 Feb 2015•Latest report 6 Feb 2026
What this concern includes
Includes failures in dedicated arrangements for recognising and responding to patient absconding, including staff preparation and understanding, maintaining line of sight where safe, following the patient, initiating escalation and taking appropriate action after an absconding incident.
Not included
- Excludes failures to prevent patients from leaving a ward or facility where the response after absconding is not the deficient condition; those belong to ward-security or exit-prevention concerns.
- Excludes generic staff training, staffing, communication or supervision deficiencies unless they directly concern the response to an absconding patient.
- Excludes missing-person responses after the patient has become unaccounted for where no patient-absconding response process is identified.
- Excludes clinical assessment, treatment or detention decisions unrelated to responding to the absconding event.
- Reports
- 5
- Individual concerns
- 8
- Date range
- 2015–2026
- Stated actions
- 9
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Failure to instigate an S.5(4) MHA 1983 authorisation when a patient returns after absconding
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Provide ward staff with further refresher training on holding powers, emergency MCA use and related legal requirements.
Stated by The Trust -
Action
Update the rapid tranquilisation policy to clearly restate the relationship between holding powers, consent and emergency alternatives.
Stated by The Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Section 5(4) powers were unavailable because a doctor’s immediate attendance had been secured.
Stated by The Trust
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Concerns raised2
Lack of instructions for staff following an absconded patient
Failure to prepare clinical staff to maintain line of sight when a patient absconds
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Revise the Missing and AWOL Policy to clarify safe responses when patients abscond from escorted leave.
Stated by East London NHS Foundation Trust -
Action
Add escorted-leave AWOL scenarios to relevant staff induction and provide two-yearly refresher training.
Stated by East London NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Many concerns concern East London Foundation Trust and Metropolitan Police policy, making NHS England inappropriate to respond to them.
Stated by NHS England
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Position
Senior nurses should use clinical judgement and existing principles rather than follow a prescribed response in line-of-sight scenarios.
Stated by East London NHS Foundation Trust
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Concerns raised1
Insufficient appropriately trained staffing to secure the return of absconding PICU patients
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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.1
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Action
Implement an escalation process clarifying site-wide colleague support when additional resources are needed for patient return.
Stated by Sussex Partnership NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
S18 Mental Health Act powers and Mill View Hospital matters fall outside the respondent’s remit.
Stated by Sussex Police
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Position
Sussex Partnership Foundation Trust is responsible for addressing S18 powers and Mill View Hospital matters.
Stated by Sussex Police
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Concerns raised3
Disclosure of absconding-response arrangements enabling circumvention of detention safeguards
Lack of dynamic risk-assessment discretion for escorts responding to absconding
Failure of absconding instructions to prioritise patient safety
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 concernsEach 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.3
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Action
Develop and incorporate scenario-based escorting and leave-risk decision-making training into initial and updated PMVA training for all staff, including bank staff.
Stated by Leeds and York Partnership NHS Foundation Trust -
Action
Review care plans and leave agreements, considering adjustments to least-restrictive interventions based on patients’ changing presentation and risk.
Stated by Leeds and York Partnership NHS Foundation Trust -
Action
Communicate case learning through procedures and provide staff with clear guidance on actions when escorted leave breaks down or a patient leaves the escort.
Stated by Leeds and York Partnership NHS Foundation Trust
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Concerns raised1
Insufficient staff training to recognise absconding and respond after an absconding incident
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 concernsEach 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.1
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Action
Provide absconding-management guidance to relevant ward staff.
Stated by Hywel Dda University LHB
Data last updated 7 September 2026