Recurring concern

Failure to escalate safety concerns after a high-risk patient leaves hospital

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First reported 29 Apr 2015•Latest report 15 Oct 2025

Definition

What this concern includes

Includes failures in the dedicated hospital patient-departure safeguarding and escalation process, including risk assessment, emergency characterisation, notification of relevant services, police, primary care or family, and actions intended to prevent or respond to unsafe departure.

Not included

Generic failures to share information that are not tied to a high-risk patient's departure from hospital.
Failures in routine referral, discharge or inter-service communication without a patient-departure safeguarding context.
Failures to provide emergency response capabilities that do not concern escalation after a patient leaves hospital.
The specific clinical, behavioural or documentation mechanism of a departure-related failure when the broader departure escalation concern is supported.

Reports: 2
Individual concerns: 3
Date range: 2015–2025
Stated actions: 1

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.

Metropolitan Police Service1

North London NHS Foundation Trust1

South London and Maudsley 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.

15 Oct2025
City of London
Concerns raised2
1. Failure to alert relevant services, the GP, or family about a high-risk patient’s departure
2. Failure to retain and re-assess a high-risk patient before departure
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 1
1. Action
  Embed documented carer-contact prompts in the Liaison Psychiatry departmental handover board before discharge.
  Stated by South London and Maudsley NHS Foundation TrustStated planned
Respondent positions 3
1. Position
  Family contact may not be possible if a capacitated patient refuses permission, although the refusal should be documented.
  Stated by South London and Maudsley NHS Foundation TrustUnable to act
1. Position
  Doctor referral was not initially indicated because the established pathway covered admission, medication changes and other clinical complexities, with senior psychiatric doctors available continuously.
  Stated by South London and Maudsley NHS Foundation TrustExisting arrangements considered sufficient
2. Position
  A patient with capacity could not lawfully be detained or prevented from leaving when insisting on self-discharge.
  Stated by South London and Maudsley NHS Foundation TrustUnable to act
AI-generated summary

Tony Montana Duncan · 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

Tony Montana Duncan had a long-term mental health condition and, during an acute deterioration, told healthcare services that he had suicidal thoughts and planned to jump from a bridge. He was assessed by a psychiatric liaison team and discharged without medication review, admission, documented risk assessment, or follow-up safeguarding, despite information about his suicide plan. On 4 July 2024, he jumped into the River Thames and likely died shortly afterwards; the report identified concerns about the response of mental health services to the risks he presented.

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 alert relevant services, the GP, or family about a high-risk patient’s departure
Wider context from the report
“3. The Deceased was subsequently seen in the Accident and Emergency Department by a Social Worker from the homelessness team. The Deceased insisted that he was not homeless and that he had attended the hospital for help with his mental health, without which he would jump from London Bridge. The Social Worker immediately passed this information to members of the psychiatric liaison team who he found, together, in their office. Subsequently, whilst still in the department, the Deceased became agitated and abusive, which behaviour was a recognised aspect of his behaviour when he was unwell. It seems he later left the department and/or was escorted out as he was being abusive; the records show that at least one member of the psychiatric liaison team was aware of this development but took no action to prevent the Deceased from leaving or to encourage him to stay in order to re-assess him, nor to alert the Crisis and/or Home Treatment teams, the GP, or the Deceased’s family as to the situation. ”
Source location
Tony Montana Duncan · Prevention of Future Deaths report
Page 4 · 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 retain and re-assess a high-risk patient before departure
Wider context from the report
“3. The Deceased was subsequently seen in the Accident and Emergency Department by a Social Worker from the homelessness team. The Deceased insisted that he was not homeless and that he had attended the hospital for help with his mental health, without which he would jump from London Bridge. The Social Worker immediately passed this information to members of the psychiatric liaison team who he found, together, in their office. Subsequently, whilst still in the department, the Deceased became agitated and abusive, which behaviour was a recognised aspect of his behaviour when he was unwell. It seems he later left the department and/or was escorted out as he was being abusive; the records show that at least one member of the psychiatric liaison team was aware of this development but took no action to prevent the Deceased from leaving or to encourage him to stay in order to re-assess him, nor to alert the Crisis and/or Home Treatment teams, the GP, or the Deceased’s family as to the situation. ”
Source location
Tony Montana Duncan · Prevention of Future Deaths report
Page 4 · 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
Embed documented carer-contact prompts in the Liaison Psychiatry departmental handover board before discharge.

Verbatim wording from the response
“Ideally, the PLN would have sought Mr Duncan’s consent to contact a named person/carer, ideally his mother with whom he lived, but did not do this; the AAR has made a recommendation to address this omission by embedding ‘carer contact’ in the Liaison Psychiatry departmental handover board; this must be done and documented before patients can be discharged. The Trust is accredited under the Triangle of Care initiative led by the Carers Trust and endorsed by NHS England, which seeks to implement six key standards required to achieve better collaboration and partnership with carers, including identification of carers at first contact; the implementation of this in the ED can be difficult for reasons outlined in the AAR, and this extra flag is intended to provide further operational support for future patient cases.”

Source location
Response from South London and Maudsley NHS Foundation Trust
Page 5 · response
Published 20 October 2025
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
Family contact may not be possible if a capacitated patient refuses permission, although the refusal should be documented.

Verbatim wording from the response
“The AAR did note that adult patients with mental capacity to make the relevant decision may well decline or refuse a request to contact their family, but in this case there is no documentation that this discussion took place. Family members are often able to provide useful collateral information which can assist in care planning, even if the patient does not permit the clinician to share information about them. However, if a patient refuses to allow contact, it may not be possible to make this contact. This should be noted in the electronic record.”

Source location
Response from South London and Maudsley NHS Foundation Trust
Page 5 · response
Published 20 October 2025
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
Doctor referral was not initially indicated because the established pathway covered admission, medication changes and other clinical complexities, with senior psychiatric doctors available continuously.

Verbatim wording from the response
“Referral by the PLN to a doctor was not clearly indicated, as this pathway is for those who may require admission under the Mental Health Act, or changes to their medication, or for other complexities as deemed by the assessing clinician. The AAR explored onward referral to doctors by PLNs and this was thought to be working well, with senior psychiatric doctors available 24 hours a day. Mr Duncan initially presented as calm and without signs or symptoms of affective disorder or psychosis. Later, when Mr Duncan became agitated, referral to a doctor to consider next steps (including potential referral to a crisis team) may have been indicated, and his self-discharge without further review or discussion was a lost opportunity to review the assessment and offer further support.”

Source location
Response from South London and Maudsley NHS Foundation Trust
Page 5 · response
Published 20 October 2025
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
A patient with capacity could not lawfully be detained or prevented from leaving when insisting on self-discharge.

Verbatim wording from the response
“Had Mr Duncan been found to have capacity to make decisions around treatment and care, as he was in the initial assessment, there would have been no grounds to detain him and stop him if he insisted on leaving. However, it would have been useful to review his mental state again, given that his presentation appeared to change while he was in the ED. It does not appear that the Liaison Psychiatry team were informed by the ED team that Mr Duncan was trying to leave the ED and self-discharge, until such time as he was being escorted out by security. The AAR recommends that potential self-discharges must be flagged to the Liaison Psychiatry Team by Emergency Department colleagues early and there must be consideration whether further assessment is warranted to ensure self-discharge is safe.”

Source location
Response from South London and Maudsley NHS Foundation Trust
Page 5 · response
Published 20 October 2025
Open published response
29 Apr2015
Inner North London
Concerns raised1
1. Failure to characterise urgent police contact as an emergency after a patient leaves hospital
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Finnulla Catherine MARTIN · 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

Finnulla Catherine Martin took her own life by jumping from the sixth-floor balcony of her home less than an hour after discharge from Whittington Hospital following a mental health assessment. Concerns included failures to obtain and share relevant information, incomplete assessment of suicide and harm risks, inadequate collateral history-taking, uncertainty about procedures for police-accompanied voluntary attendance, and failure to characterise the police contact as an emergency after Ms Martin left hospital.

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 characterise urgent police contact as an emergency after a patient leaves hospital
Wider context from the report
“7. When they obtained this afterwards and then realised that Ms Martin had left the hospital, they contacted the police but did not characterise this as an emergency. ”
Source location
Finnulla Catherine MARTIN · Prevention of Future Deaths report
Page 3 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Failure to alert relevant services, the GP, or family about a high-risk patient’s departure

Failure to retain and re-assess a high-risk patient before departure

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Failure to characterise urgent police contact as an emergency after a patient leaves hospital

Actions described in response 1

Respondent positions 3