First reported 24 May 2017•Latest report 10 Mar 2026
Definition
What this concern includes
Includes failures in the dedicated decision process for granting, changing or rescinding mental health patient leave, detention or related restrictions where responsibility is unclear or held by inappropriate personnel, responsible clinicians lack suitable experience or assessment, or non-clinical pressures or staff override clinically accountable decision-making.
Not included
Excludes general clinical staffing, training or bed-capacity concerns unless they directly affect responsibility or decision-making for mental health leave or detention.
Excludes ordinary Mental Health Act assessment, Tribunal, discharge or care-planning failures where leave or detention decision responsibility is not the unsafe condition.
Excludes decisions made by appropriately experienced responsible clinicians where the concern is only disagreement with the clinical judgment.
Excludes generic organisational accountability or non-clinical influence concerns outside mental health leave or detention decisions.
Reports
5
Distinct published reports
Individual concerns
7
A report can raise multiple concerns
Date range
2017–2026
First to latest report issue date
Stated actions
17
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.
Alternative Futures Group Limited1
Department of Health and Social Care1
Epsom Hospital1
Health and Care Professions Council1
Health Services Safety Investigations Body1
Leeds and York Partnership NHS Foundation Trust1
NHS South West London Integrated Care Board1
North London NHS Foundation Trust1
South East Coast Ambulance Service NHS Foundation Trust1
South West Yorkshire Partnership Teaching NHS Foundation Trust1
Surrey and Borders Partnership NHS Foundation Trust1
Whittington Health NHS Trust1
NHS trust4
Company limited by guarantee1
Executive non-departmental public body1
Health and care professional regulator1
Healthcare site1
Integrated care board1
Ministerial department1
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.
Cheshire
Concerns raised2
Failure to document and formalise leave reinstatement decisions
Leave management by a non-s12 doctor during responsible-clinician absence
This report raised 12 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
Document all clinical and Mental Health Act decisions in patient files, the DSR system and relevant meeting minutes.
Stated by Alternative Futures Group LimitedStated completedThe respondent said that this action was complete when they made their response on 12 March 2026.
Action
Reissue section 17 guidance and use separate escorted/emergency and unescorted leave forms for each patient.
Stated by Alternative Futures Group LimitedStated completedThe respondent said that this action was complete when they made their response on 12 March 2026.
Surrey
Concerns raised1
Failure to provide lawful Mental Health Act detention safeguards and Responsible Clinician oversight
This report raised 12 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.5
Action
Continue the Mind and Body Provider Collaborative improvement programme with acute care partners, using clinical, escalation and risk-management frameworks.
Stated by Surrey and Borders Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 August 2025.
Action
Engage stakeholders to clarify how the current legal framework applies to holding patients in A&E and identify solutions to the reported problems.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 13 August 2025.
Action
Provide further guidance on the legal framework and handover protocol in the next revision of the Mental Health Act Code of Practice.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 13 August 2025.
Action
Engage further to understand application of the current legal framework and identify solutions to unlawful detention risks in A&E.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 13 August 2025.
Action
Provide further guidance on the legal framework and health-police handover protocol in the next revision of the Mental Health Act Code of Practice.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 13 August 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
The acute hospital’s management is responsible for deciding whether to detain a patient to an acute hospital bed.
Stated by Surrey and Borders Partnership NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Providing mental health care for patients without physical health needs is outside the Trust’s commissioned remit.
Stated by Epsom and St Helier University Hospitals NHS TrustOutside remitThe respondent said that this matter was outside its role or authority.
Position
Surrey and Borders Partnership provides local mental health services, while NHS Surrey Heartlands ICB commissions those services.
Stated by Epsom and St Helier University Hospitals NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Clinical matters fall outside the commissioning organisation’s remit.
Stated by NHS Southwest London Integrated Care BoardOutside remitThe respondent said that this matter was outside its role or authority.
Position
Clinical matters are the responsibility of the relevant Trusts.
Stated by NHS Southwest London Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
West Yorkshire Eastern
Concerns raised2
Failure to undertake a formalised mental capacity assessment before section rescission decisions
Use of a responsible clinician with insufficient role experience for section rescission decisions
This report raised 12 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.5
Action
Review medical staff training provision on mental capacity assessments.
Stated by Leeds and York Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 4 November 2021.
Action
Undertake a Trust-wide audit of mental capacity assessments and best-interest decisions, including possible detention-rescission decisions.
Stated by Leeds and York Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 4 November 2021.
Action
Discuss amending the Responsible Clinician form to prompt documentation of mental capacity assessments when rescinding detention.
Stated by Leeds and York Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 4 November 2021.
Action
Review the induction package to formalise explicit, proportionate support and supervision for locum medics.
Stated by Leeds and York Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 4 November 2021.
Action
Review the clinical handover process for locum medics to support robust clinical decision-making.
Stated by Leeds and York Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 4 November 2021.
West Yorkshire, Western Division
Concerns raised1
Failure to ensure clinical management and leave decisions are made by responsible clinical staff
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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
Action
Employ several Matrons with clinical and operational responsibility for inpatient wards.
Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 March 2021.
Action
Provide inpatient staff with the Patient Flow Procedure and information clarifying patient-flow roles and responsibilities.
Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 March 2021.
Action
Monitor inpatient staff understanding of patient-flow procedures and responsibilities through the Matrons’ monthly checklist.
Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 March 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing clinical patient-flow procedures, ward oversight and escalation arrangements are considered sufficient to support clinically led admission decisions.
Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Inner North London
Concerns raised1
Inadequate clinical decision-making for granting leave to detained patients at risk of absconding
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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
Update mental health policies and the joint observation protocol to define roles, responsibilities and decision-making case studies.
Stated by North London NHS Foundation Trust and Whittington Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 August 2017.
Action
Conduct five daily senior-staff situation reports and follow-up reviews covering mental health patients’ risks, observation compliance, care quality and confirmed plans.
Stated by North London NHS Foundation Trust and Whittington Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 4 August 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The London Borough of Islington is responsible for responding to concerns about Approved Mental Health Professional decision-making.
Stated by North London NHS Foundation Trust and Whittington Health NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Pin
Get email alerts
Request correction
Includes failures in the dedicated decision process for granting, changing or rescinding mental health patient leave, detention or related restrictions where responsibility is unclear or held by inappropriate personnel, responsible clinicians lack suitable experience or assessment, or non-clinical pressures or staff override clinically accountable decision-making.
