Recurring concern

Unreliable response to patient absconding

First to latest report 20 Feb 2015 — 6 Feb 2026

Reports that mention this concern
5
Times this concern has been raised
8
Stated actions linked to this concern
9

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.

What is 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 and published responses 5 reports

See individual reports that have raised this concern, and the actions taken in response

  1. East London

    AI-generated summary

    Mansoor Zaman · 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

    Mansoor Zaman, a 27-year-old man with a history of suicidality, substance misuse and EUPD, absconded from a mental health ward on 8 December 2024 after displaying suicidal intent and erratic and aggressive behaviour. His body was recovered on 29 December 2024. The substantive concerns included failures to use available mental health authorisations, reassess risk and observation levels, adequately document care, and promptly report him missing to police; the inquest jury identified some of these failures as factors that probably or possibly contributed to his death.

    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 instigate an S.5(4) MHA 1983 authorisation when a patient returns after absconding

    Wider context from the report

    “1. The failure of nurses on the ward to instigate an authorisation under S.5(4) MHA 1983 when Mr Zaman returned to the ward after absconding on the afternoon of 8th December 2024. ”

    Source location

    Mansoor Zaman · Prevention of Future Deaths report
    Page 3 · 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

    Provide ward staff with further refresher training on holding powers, emergency MCA use and related legal requirements.

    Verbatim wording from the response

    “24. That said, I was appraised of the oral evidence heard at inquest. The explanations provided by some (but not all) of the staff as to how section 5(4) or 5(2) are used were not in-line with the legal requirements set out in the MHA. This is a matter of concern to the Trust. Consequently, at the time of inquest, I requested that the ward staff undergo refresher training in relation to their holding powers. This took place on 25 February 2026. Within the next 6 months, the Associate Director of Mental Health Law is going to hold a further refresher session with the all the ward staff to include situations when the MCA may be used in an emergency. They will also update the rapid tranquilisation policy to ensure it restates this position with clarity.”

    Source location

    2026-0072 - Response from East London NHS Foundation Trust
    Page 6 · response
    Published 12 February 2026

    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 the rapid tranquilisation policy to clearly restate the relationship between holding powers, consent and emergency alternatives.

    Verbatim wording from the response

    “24. That said, I was appraised of the oral evidence heard at inquest. The explanations provided by some (but not all) of the staff as to how section 5(4) or 5(2) are used were not in-line with the legal requirements set out in the MHA. This is a matter of concern to the Trust. Consequently, at the time of inquest, I requested that the ward staff undergo refresher training in relation to their holding powers. This took place on 25 February 2026. Within the next 6 months, the Associate Director of Mental Health Law is going to hold a further refresher session with the all the ward staff to include situations when the MCA may be used in an emergency. They will also update the rapid tranquilisation policy to ensure it restates this position with clarity.”

    Source location

    2026-0072 - Response from East London NHS Foundation Trust
    Page 6 · response
    Published 12 February 2026

    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

    Section 5(4) powers were unavailable because a doctor’s immediate attendance had been secured.

    Verbatim wording from the response

    “17. In the present case, the immediate attendance of a doctor was secured. Therefore, section 5(4) powers were not lawfully available for the nurse to invoke.”

    Source location

    2026-0072 - Response from East London NHS Foundation Trust
    Page 5 · response
    Published 12 February 2026

    Open published response

  2. Inner North London

    AI-generated summary

    Heather FINDLAY · 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

    Heather Findlay was detained under section 2 of the Mental Health Act at Mile End Hospital and ran away while on escorted leave on 11 June 2020. She was later found by a member of the public in a nearby park; the inquest concluded that she died by suicide, with a medical cause of death of hypoxic ischaemic encephalopathy and ████████ toxicity. The principal concerns included staff preparedness and procedures when a detained patient absconds, unclear responsibilities between ELFT and the police, communication of suicide risk, and the adequacy of risk grading and organisational learning.

    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

    Lack of instructions for staff following an absconded patient

    Wider context from the report

    “2. By the time the HCA rang the duty senior nurse for advice Ms Findlay was out of sight, and so the HCA was instructed to return to the ward. I heard evidence that an email is to be sent out shortly to explain that a new ELFT absent without leave policy will be in place by the end of June 2023. The new policy will confirm that, if it is safe to do so an escort may follow a patient who has absconded, keeping them in line of sight whilst ringing the duty senior nurse for instructions. However, there is no ELFT policy for what those instructions should be or even what they could include. No member of ELFT gave evidence of any organisational thought having gone into how then to progress such a situation, other than the ward calling the police to report a missing person. No member of ELFT giving evidence was able to set out what the staff member following should do. This appears to be a significant omission. ”

    Source location

    Heather FINDLAY · Prevention of Future Deaths report
    Page 3 · concerns

    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 prepare clinical staff to maintain line of sight when a patient absconds

    Wider context from the report

    “1. When Ms Findlay ran off, the HCA escorting her was so panicked that she did not even think of following. Ms Findlay had run across a road and so chasing her at speed did present safety considerations. However, the ELFT policy, training, culture and expectation was such, that there the HCA did not at any point consider attempting to walk after her to keep her in sight. Clinical staff must be adequately prepared for such an eventuality. That means more than simply a change in policy wording. ”

    Source location

    Heather FINDLAY · 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

    Revise the Missing and AWOL Policy to clarify safe responses when patients abscond from escorted leave.

    Verbatim wording from the response

    “Although this was the practice in operation at the time, the Trust has taken action to review the relevant part of its Missing and Absent Without Leave (AWOL) Policy to reflect this practice. The updated version will read as below:”

    Source location

    Response from East London NHS Foundation Trust
    Page 1 · response
    Published 22 June 2023

    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

    Add escorted-leave AWOL scenarios to relevant staff induction and provide two-yearly refresher training.

    Verbatim wording from the response

    “The Trust intends to incorporate scenarios involving patients going AWOL on escorted leave into its induction training for new staff in the relevant services. In addition there will be a 2-yearly refresher for Section 17 and Escort training. The scenario training will incorporate such situations and include reference to the information that needs to be considered by the escorting staff and fed back to staff on the wards to help in making a decision around risk and level of escalation needed. The Trust expects this to be in place in the next 3-6 months.”

    Source location

    Response from East London NHS Foundation Trust
    Page 2 · response
    Published 22 June 2023

    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

    Many concerns concern East London Foundation Trust and Metropolitan Police policy, making NHS England inappropriate to respond to them.

    Verbatim wording from the response

    “The concerns in your Report relate to organisational policy at East London Foundation Trust as well as policy within the Metropolitan Police Service. NHS England is not therefore the appropriate organisation to respond to many of the concerns raised.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 22 June 2023

    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

    Senior nurses should use clinical judgement and existing principles rather than follow a prescribed response in line-of-sight scenarios.

    Verbatim wording from the response

    “In relation to your second concern, the Trust believes that the appropriate response from a senior nurse in the envisaged ‘line of sight’ advice-giving scenario should be driven by that senior nurse’s clinical judgement at the time of the event, and that attempting to prescribe a response in advance in a policy document would be unhelpful given the number of dynamic factors that could be relevant.”

    Source location

    Response from East London NHS Foundation Trust
    Page 2 · response
    Published 22 June 2023

    Open published response

  3. West Sussex

    AI-generated summary

    Jack Stephen TAYLOR · 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

    Jack Stephen TAYLOR was a detained inpatient who left escorted leave on 17 March 2021 and was found unresponsive at premises in Worthing on 19 March 2021, where he died despite urgent medical assistance. The report raised concerns about Mill View Hospital’s reliance on police support and failure to consider the full range of powers for returning absconded patients, as well as weaknesses in joint hospital-police AWOL and missing-person procedures that could delay locating and returning high-risk patients.

    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

    Insufficient appropriately trained staffing to secure the return of absconding PICU patients

    Wider context from the report

    “1. s.18 Mental Health Act 1983 powers & Mill View Hospital. During the inquest Mill View Hospital accepted that it was their responsibility to secure the return of a patient who was detained under s.3 of the Mental Health Act 193 and who had absconded. However I heard that they were often not able to do so without the support of the police. The evidence I heard was that the Psychiatric Intensive Care Unit (PICU), known as the Pavilion Ward, rarely had sufficient staff resources to allow them to send the required minimum of 2 staff members to try and negotiate a return of an absconding patient. I also heard that, if the Hospital considered that the patient would be unwilling to return, it would require them to send at least 5 appropriately trained staff members. This would mean that the staffing of other wards would be impacted and also that the Prevention and Management of Violence and Aggression (PMVA) trained team might not be available for any other incidents. In addition the evidence was that the Hospital had no means of transporting a patient in these circumstances. The Pavilion Ward Matron informed me that the ward relied on assistance from the police in relation to all patients who absconded from the PICU. The matron was not aware of any circumstances where Mill View Hospital had utilised its powers under s.18(1) of the Mental Health Act 1983 to authorise in writing ‘any other person’ to exercise their powers to seek the return of an absconding patient. I am concerned that Mill View Hospital rely solely upon the police to assist them when the police have their own resourcing issues. I am further concerned that the Hospital has not considered the full range of their powers to secure the return of PICU patients who might pose a significant risk of harm, or death, to themselves and/or others after absconding. ”

    Source location

    Jack Stephen TAYLOR · Prevention of Future Deaths report
    Page 1 · 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 an escalation process clarifying site-wide colleague support when additional resources are needed for patient return.

    Verbatim wording from the response

    “In addition, an improved escalation process has been implemented and added to the AWOL Policy so that SPFT staff are clear about site-wide support available from colleagues when additional resource is required to facilitate a patient's return.”

    Source location

    2022-0029-Response-from-Sussex-Partnership-NHS-Foundation-Trust_Published
    Page 3 · response
    Published 3 February 2022

    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

    S18 Mental Health Act powers and Mill View Hospital matters fall outside the respondent’s remit.

    Verbatim wording from the response

    “This relates to our partners at Sussex Partnership Foundation Trust (SPFT) and therefore we are unable to comment on it. In the work we have completed in response to your concerns, we have worked closely with our SPFT partners and are advised that they will, of course, be addressing this in their response to you.”

    Source location

    2022-0029-Response-from-Sussex-Police_Published
    Page 1 · response
    Published 3 February 2022

    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

    Sussex Partnership Foundation Trust is responsible for addressing S18 powers and Mill View Hospital matters.

    Verbatim wording from the response

    “This relates to our partners at Sussex Partnership Foundation Trust (SPFT) and therefore we are unable to comment on it. In the work we have completed in response to your concerns, we have worked closely with our SPFT partners and are advised that they will, of course, be addressing this in their response to you.”

    Source location

    2022-0029-Response-from-Sussex-Police_Published
    Page 1 · response
    Published 3 February 2022

    Open published response

  4. West Yorkshire Eastern

    AI-generated summary

    Alexandra Jane Tolley · 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

    Alexandra Jane Tolley, aged 20, was detained in a psychiatric hospital and absconded while being escorted in the hospital grounds on 27 October 2019. She was found in cardiac arrest and died at hospital the following day. Concerns included instructions not to restrain or follow her, the informal approval of ground leave without documented criteria, and the continued use of similar absconding instructions despite an ongoing risk of further deaths.

    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

    Disclosure of absconding-response arrangements enabling circumvention of detention safeguards

    Wider context from the report

    “6. The care plan containing the staff instruction not to restrain or follow was discussed and agreed with Ms Tolley. She was thus expressly aware that if she did decide to abscond, she knew she would be able to do so. Moreover, she was explicitly told that the staff member escorting her would return to the reception area and wait for a short period in the hope Ms Tolley would return voluntarily. The implication of this was that Ms Tolley knew she had a period of grace of around 10 minutes in which to get clear of the hospital, before the police would be asked to search for her. Whilst potentially beneficial from a therapeutic perspective, such knowledge may also inform a vulnerable patient on ways in which the protection afforded by a MHA Section could be undermined. The wisdom of explaining to a patient how the hospital staff would respond to them absconding should be reviewed. ”

    Source location

    Alexandra Jane Tolley · Prevention of Future Deaths report
    Page 2 · concerns

    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 dynamic risk-assessment discretion for escorts responding to absconding

    Wider context from the report

    “5. The permission given to walk in the grounds of the hospital was not considered to amount to section 17 MHA 1983 leave. The informality involved in the decision missed an opportunity to consider issues such as: (a) Whether two escorts would be appropriate in view of Ms Tolley having absconded three days earlier. This would have facilitated one person following her to monitor and report on her whereabouts. In a time critical situation this could have altered the tragic outcome; (b) Providing the escort with a discretion in the manner of a dynamic risk assessment whether or not to follow Ms Tolley. (c) Reviewing the type of ████████ applied to her wounds, before she was permitted to leave the ward, in the light of her misuse of these ████████. ”

    Source location

    Alexandra Jane Tolley · Prevention of Future Deaths report
    Page 2 · concerns

    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 absconding instructions to prioritise patient safety

    Wider context from the report

    “1. The Care Plan agreed between Ms Tolley and the team treating her, included a provision that in the event she absconded, she would neither be restrained, nor followed. Given her history and risk profile, it appeared this contingent instruction to staff regarding the risk of absconding, placed too much emphasis on her long term ability to manage her own turbulent emotions, at the expense of the imperative of keeping her safe. The priorities underlying such instructions merit further review. ”

    Source location

    Alexandra Jane Tolley · 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

    Develop and incorporate scenario-based escorting and leave-risk decision-making training into initial and updated PMVA training for all staff, including bank staff.

    Verbatim wording from the response

    “The Trust has reviewed its Prevention, Management of Violence and Aggression (PMVA) training provision offered to staff regarding the role of escorting patients outside of the ward and is developing training for all staff, including bank staff. This training will be included in the initial and updated PMVA training provision. The training will be scenario and role play based and will include discussions regarding decision making related to risk whilst escorting somebody outside of the ward.”

    Source location

    2021-0344-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
    Page 2 · response
    Published 18 October 2021

    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 care plans and leave agreements, considering adjustments to least-restrictive interventions based on patients’ changing presentation and risk.

    Verbatim wording from the response

    “In order to ensure the Trust has learnt lessons from Ms Tolley’s death, it is vital that team and clinical services review interventions described within care plans and leave agreements and consider how these interventions can be altered based on an individual’s presentation at a moment in time or following any change in the baseline mental state or any significant events. This will allow staff to use a more collaborative approach of engagement to enable them to respond to risk and also balance the risk associated with needing to potentially intervene when leave is in progress.”

    Source location

    2021-0344-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
    Page 2 · response
    Published 18 October 2021

    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

    Communicate case learning through procedures and provide staff with clear guidance on actions when escorted leave breaks down or a patient leaves the escort.

    Verbatim wording from the response

    “We will ensure that the learning from this case is communicated within our procedure – ensure that staff are provided with clear guidance when escorting patients of the action to be taken should leave start to break down or the patient leaves the member of staff.”

    Source location

    2021-0344-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
    Page 5 · response
    Published 18 October 2021

    Open published response

  5. Carmarthenshire & Pembrokeshire

    AI-generated summary

    Laura Hill · 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

    Laura Hill, aged 21, was admitted to a psychiatric ward after a serious overdose and later absconded twice before being found hanging from a tree in a wooded area. The concerns identified included information-sharing failures, stretched staffing, training needs around police handovers, absconding, personality disorders and detention powers, and the ward door policy.

    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

    Insufficient staff training to recognise absconding and respond after an absconding incident

    Wider context from the report

    “(4) There was a training need identified in relation to what constitutes ‘absconding’ and what should be done by staff following an incident of absconding. ”

    Source location

    Laura Hill · 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

    Provide absconding-management guidance to relevant ward staff.

    Verbatim wording from the response

    “Guidance in relation to the management of those patients who abscond from the in-patient ward has been provided to all relevant staff by the Head of Acute Care Services.”

    Source location

    2015-0092-Response-by-University-Health-Board
    Page 2 · response
    Published 20 February 2015

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026