Unsafe clinical responsibility for mental health leave and detention decisions
First to latest report 24 May 2017 — 10 Mar 2026
Reports that mention this concern
5
Times this concern has been raised
7
Stated actions linked to this concern
17
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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
Reports and published responses 5 reports
See individual reports that have raised this concern, and the actions taken in response
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.
Linked response
Alternative Futures Group Limited
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Alternative Futures Group Limited
Document all clinical and Mental Health Act decisions in patient files, the DSR system and relevant meeting minutes.
Alternative Futures Group Limited
Reissue section 17 guidance and use separate escorted/emergency and unescorted leave forms for each patient.
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.
Linked responses
Department of Health and Social Care
Epsom and St Helier University Hospitals NHS Trust
NHS Southwest London Integrated Care Board
Surrey and Borders Partnership NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Surrey and Borders Partnership NHS Foundation Trust
Continue the Mind and Body Provider Collaborative improvement programme with acute care partners, using clinical, escalation and risk-management frameworks.
Department of Health and Social Care
Engage stakeholders to clarify how the current legal framework applies to holding patients in A&E and identify solutions to the reported problems.
Department of Health and Social Care
Provide further guidance on the legal framework and handover protocol in the next revision of the Mental Health Act Code of Practice.
Department of Health and Social Care
Engage further to understand application of the current legal framework and identify solutions to unlawful detention risks in A&E.
Department of Health and Social Care
Provide further guidance on the legal framework and health-police handover protocol in the next revision of the Mental Health Act Code of Practice.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Surrey and Borders Partnership NHS Foundation Trust
The acute hospital’s management is responsible for deciding whether to detain a patient to an acute hospital bed.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Epsom and St Helier University Hospitals NHS Trust
Providing mental health care for patients without physical health needs is outside the Trust’s commissioned remit.
Outside remitThe respondent said that this matter was outside its role or authority.
Epsom and St Helier University Hospitals NHS Trust
Surrey and Borders Partnership provides local mental health services, while NHS Surrey Heartlands ICB commissions those services.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
NHS Southwest London Integrated Care Board
Clinical matters fall outside the commissioning organisation’s remit.
Outside remitThe respondent said that this matter was outside its role or authority.
NHS Southwest London Integrated Care Board
Clinical matters are the responsibility of the relevant Trusts.
Redirects 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.
Linked response
Leeds and York Partnership NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Leeds and York Partnership NHS Foundation Trust
Review medical staff training provision on mental capacity assessments.
Leeds and York Partnership NHS Foundation Trust
Undertake a Trust-wide audit of mental capacity assessments and best-interest decisions, including possible detention-rescission decisions.
Leeds and York Partnership NHS Foundation Trust
Discuss amending the Responsible Clinician form to prompt documentation of mental capacity assessments when rescinding detention.
Leeds and York Partnership NHS Foundation Trust
Review the induction package to formalise explicit, proportionate support and supervision for locum medics.
Leeds and York Partnership NHS Foundation Trust
Review the clinical handover process for locum medics to support robust clinical decision-making.
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.
Linked response
South West Yorkshire Partnership Teaching NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
South West Yorkshire Partnership Teaching NHS Foundation Trust
Employ several Matrons with clinical and operational responsibility for inpatient wards.
South West Yorkshire Partnership Teaching NHS Foundation Trust
Provide inpatient staff with the Patient Flow Procedure and information clarifying patient-flow roles and responsibilities.
South West Yorkshire Partnership Teaching NHS Foundation Trust
Monitor inpatient staff understanding of patient-flow procedures and responsibilities through the Matrons’ monthly checklist.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
South West Yorkshire Partnership Teaching NHS Foundation Trust
Existing clinical patient-flow procedures, ward oversight and escalation arrangements are considered sufficient to support clinically led admission decisions.
Existing 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.
Linked responses
North London NHS Foundation Trust
Whittington Health NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
North London NHS Foundation Trust and Whittington Health NHS Trust
Update mental health policies and the joint observation protocol to define roles, responsibilities and decision-making case studies.
North London NHS Foundation Trust and Whittington Health NHS Trust
Conduct five daily senior-staff situation reports and follow-up reviews covering mental health patients’ risks, observation compliance, care quality and confirmed plans.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
North London NHS Foundation Trust and Whittington Health NHS Trust
The London Borough of Islington is responsible for responding to concerns about Approved Mental Health Professional decision-making.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.