Recurring concern

Unreliable lawful decision-making for mental health patient detention and return

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First reported 24 Feb 2016•Latest report 28 Oct 2025

Definition

What this concern includes

Includes failures in the dedicated mental health process for establishing legal authority, seeking appropriate consultation and making or documenting decisions about a patient's detention, return to a ward or supported care after leaving or being absent from care.

Not included

Excludes general legal or policy deficiencies that are not directly tied to detention or return decisions for mental health patients.
Excludes prison-custody care and treatment legal-framework concerns unless the assertion specifically concerns a mental health patient's detention or return process.
Excludes general clinical consultation, discharge or care-planning failures where lawful authority or detention-or-return decision-making is not the unsafe condition.
Excludes failures confined to Deprivation of Liberty Safeguards authorisation or Mental Health Act assessment where those named statutory processes provide the more specific supported boundary.

Reports: 10
Individual concerns: 12
Date range: 2016–2025
Stated actions: 18

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.

Department of Health and Social Care2

NHS England2

Pennine Care NHS Foundation Trust2

Epsom Hospital1

Greater Manchester Mental Health NHS Foundation Trust1

Health and Care Professions Council1

Health Services Safety Investigations Body1

Midlands Partnership University NHS Foundation Trust1

NHS South West London Integrated Care Board1

South East Coast Ambulance Service NHS Foundation Trust1

Surrey and Borders Partnership NHS Foundation Trust1

Sussex Partnership NHS Foundation Trust1

Sussex Police1

Tameside and Glossop Integrated Care NHS Foundation Trust1

TRU (Transitional Rehabilitation Unit) Ltd1

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.

28 Oct2025
West Sussex, Brighton and Hove
Concerns raised1
1. Lack of a safe lawful detention pathway for people who cannot be held under s.3 at the hospital
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Establish Mental Health Emergency Departments co-located with Type 1 Emergency Departments.
  Stated by NHS EnglandStated planned
AI-generated summary

Patricia Genders · 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

Patricia Genders died on 22 February 2024 after absconding from the Enhanced Observation Unit at the Royal Sussex County Hospital while detained under the Mental Health Act. She was found on the coastal side of a safety fence, taken to A&E, and pronounced dead shortly afterwards. The concerns included the use of A&E for people in mental health crisis, the absence of an agreed home-care package, the decision not to transport Patricia to a more therapeutic setting, and shortcomings in hospital security, communication and responses to absconding.

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 a safe lawful detention pathway for people who cannot be held under s.3 at the hospital
Wider context from the report
“My concern is that despite significant ongoing efforts by the various partner agencies (particularly the hospital trust (University Hospitals Sussex NHS Foundation Trust (“UHS”)), the trust making most of the mental health provision in this area (Sussex Partnership NHS Foundation Trust (“SPFT”)), the local authorities (West Sussex and Brighton and Hove) and the police, there is still far too much use of A&E space for those in mental health crisis, pending finding a dedicated mental health placement. My concern is that without specific investment (particularised below), from the commissioner of services, too many people will continue to be held in A&E for too long. This case shows, in quite dramatic form, some of the consequences of the use of A&E. See again the jury's conclusions, but a noisy and busy department, lit 24 hours, with limited space, may well make someone worse, and probably did here. Moreover, A&E departments cannot be made fully secure. People are coming and going; doors cannot always be monitored; and it is harder to restrain someone in a relatively public space and with fewer mental health practitioners around. Tricia was able, quite easily, to abscond. The detail of what happened next, and its impact on all, will be obvious. That impact was not just on the family but most obviously also the nurse who tried to stall her, and the member of the public and the police and fireman at the cliffs. All of these people are victims of a system which cannot do what is being asked of it. Significant steps have been made to try to improve, again, the partnership working between the relevant trusts and the police, and in trying to improve the security of the hospital. It is now not possible to hold someone under s.3 at the hospital (although that produces a new set of onwards risks. It arguably focuses minds on the need to move someone on faster, but also creates a risk that someone will simply be left with no basis for detention at all). All this, however, is just patching a fundamentally unsatisfactory situation. I took a lot of evidence about the remaining risks and the need for action. It is clear that joint working between health and social care is required (which is why I am sending this report to the Secretary of State for Health and Social Care as well as to NHS England). It is also clear that there is a limit to what the local trusts and other agencies can do on their own. The problem may be particularly pronounced in Brighton where the numbers of mentally ill people are well above the national average, but I am told it is of wider concern. The evidence I heard is that three things are required of those responsible for commissioning these services: 1. Strengthening the 111 and Blue Light Line services so that calls are answered and people are diverted to better places where such places are available. At the moment, I was told, only about half of those calls are answered. That requires recruitment, which requires investment. 2. An improved 24/7 crisis response, to deal with those who present at A&E out of hours. Solving that requires the establishment of teams who can formally gatekeep inpatient admissions. 3. For a while, there will need to be an increase in the number of mental health beds available in the independent sector. This would be to provide beds and alleviate flow pressures whilst longer term, systemic change, embeds. Absent something along these lines, it seems to me there is a real risk that the events seen in this case will recur. ”
Source location
Patricia Genders · 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
Establish Mental Health Emergency Departments co-located with Type 1 Emergency Departments.

Verbatim wording from the response
“Colleagues in NHS England’s South East Region have confirmed that, to improve their ability to respond to patients in mental health crisis and ensure the needs of mental health patients are met in an appropriate environment, the NHS has committed to establish Mental Health Emergency Departments (MHEDs), also described as Crisis Assessment Centres (CACs), which will be co-located with Type 1 Emergency Departments. They aim to offer calm, therapeutic settings and ensure timely onward connection into mental health inpatient provision or into broader community services.”

Source location
Response from NHS England
Page 2 · response
Published 31 October 2025
Open published response
4 Aug2025
Surrey
Concerns raised2
1. Unclear legal authority for preventing psychiatric patients leaving the emergency department
2. Failure to provide lawful Mental Health Act detention safeguards and Responsible Clinician oversight
This report raised 11 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 5
1. 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 planned
2. 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 planned
3. 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 planned
1. 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 planned
2. 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 progress
Respondent positions 5
1. Position
  Clinical matters fall outside the commissioning organisation’s remit.
  Stated by NHS Southwest London Integrated Care BoardOutside remit
1. Position
  Clinical matters are the responsibility of the relevant Trusts.
  Stated by NHS Southwest London Integrated Care BoardRedirects responsibility
2. 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 responsibility
3. 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 remit
4. 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 responsibility
AI-generated summary

Tracey Ostler · 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

Tracey Ostler, who had severe Emotionally Unstable Personality Disorder and a history of self-harm and overdoses, took an overdose and cut her wrists on 12 June 2023. After paramedics attended her home on 16 June following a further overdose, they left her there after deciding she had capacity to refuse hospital treatment; she was later found unconscious and died in hospital on 18 June 2023. The principal concerns were inadequate capacity assessment and clinical consultation, failures to share information and coordinate mental-health and ambulance care, the absence of multi-agency safety planning, and insufficient psychiatric hospital beds.

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
Unclear legal authority for preventing psychiatric patients leaving the emergency department
Wider context from the report
“Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: , Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care 1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed. 2. I remain concerned that there in no plan to stop this practice and that therefore: a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team. b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients. c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients. d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician. e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area. f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement. g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient. ”
Source location
Tracey Ostler · Prevention of Future Deaths report
Page 5 · 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 provide lawful Mental Health Act detention safeguards and Responsible Clinician oversight
Wider context from the report
“Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: , Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care 1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed. 2. I remain concerned that there in no plan to stop this practice and that therefore: a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team. b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients. c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients. d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician. e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area. f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement. g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient. ”
Source location
Tracey Ostler · Prevention of Future Deaths report
Page 5 · 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
Engage stakeholders to clarify how the current legal framework applies to holding patients in A&E and identify solutions to the reported problems.

Verbatim wording from the response
“We accept that there may be a need to provide greater clarity on what powers are available to health professionals to hold someone in A&E, until an assessment can be completed. We will engage further to understand how the current legal framework is applied and identify solutions to the problems raised. We will seek to provide further guidance on the existing legal framework and the handover protocol between health and police in the next revision of the Mental Health Act Code of Practice.”

Source location
Response from Department for Health and Social Care
Page 2 · response
Published 13 August 2025
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
Provide further guidance on the legal framework and handover protocol in the next revision of the Mental Health Act Code of Practice.

Verbatim wording from the response
“We accept that there may be a need to provide greater clarity on what powers are available to health professionals to hold someone in A&E, until an assessment can be completed. We will engage further to understand how the current legal framework is applied and identify solutions to the problems raised. We will seek to provide further guidance on the existing legal framework and the handover protocol between health and police in the next revision of the Mental Health Act Code of Practice.”

Source location
Response from Department for Health and Social Care
Page 2 · response
Published 13 August 2025
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
Engage further to understand application of the current legal framework and identify solutions to unlawful detention risks in A&E.

Verbatim wording from the response
“We accept that there may be a need to provide greater clarity on what powers are available to health professionals to hold someone in A&E, until an assessment can be completed. We will engage further to understand how the current legal framework is applied and identify solutions to the problems raised. We will seek to provide further guidance on the existing legal framework and the handover protocol between health and police in the next revision of the Mental Health Act Code of Practice.”

Source location
Response from Department for Health and Social Care
Page 2 · response
Published 13 August 2025
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
Provide further guidance on the legal framework and health-police handover protocol in the next revision of the Mental Health Act Code of Practice.

Verbatim wording from the response
“We accept that there may be a need to provide greater clarity on what powers are available to health professionals to hold someone in A&E, until an assessment can be completed. We will engage further to understand how the current legal framework is applied and identify solutions to the problems raised. We will seek to provide further guidance on the existing legal framework and the handover protocol between health and police in the next revision of the Mental Health Act Code of Practice.”

Source location
Response from Department for Health and Social Care
Page 2 · response
Published 13 August 2025
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
Continue the Mind and Body Provider Collaborative improvement programme with acute care partners, using clinical, escalation and risk-management frameworks.

Verbatim wording from the response
“Further improvement work continues through the Mind and Body Provider Collaborative, which is a programme of work chaired by our Chief Nursing Officer and undertaken with our acute care partners.”

Source location
Response from NHS Surrey and Borders Partnership NHS Foundation Trust
Page 1 · response
Published 13 August 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
Clinical matters fall outside the commissioning organisation’s remit.

Verbatim wording from the response
“As you may be aware, as a commissioning organisation, the ICB can only comment on the commissioning and oversight of the relevant services. We cannot comment on clinical matters, which are for the relevant Trusts. Our response to the relevant sections of the report are set out below.”

Source location
Response from NHS South West London Integrated Care Board
Page 1 · response
Published 13 August 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
Clinical matters are the responsibility of the relevant Trusts.

Verbatim wording from the response
“As you may be aware, as a commissioning organisation, the ICB can only comment on the commissioning and oversight of the relevant services. We cannot comment on clinical matters, which are for the relevant Trusts. Our response to the relevant sections of the report are set out below.”

Source location
Response from NHS South West London Integrated Care Board
Page 1 · response
Published 13 August 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
The acute hospital’s management is responsible for deciding whether to detain a patient to an acute hospital bed.

Verbatim wording from the response
“A person can only be detained once admitted to an acute hospital bed. While the Trust’s position is that steps should be taken to ensure an appropriate legal framework, the decision to detain to an acute hospital bed lies with the management of the acute hospital. This is not an issue unique to Surrey; one of the proposed amendments to the Mental Health Bill is to allow people to be detained in emergency departments in recognition of the current gap in legislation.”

Source location
Response from NHS Surrey and Borders Partnership NHS Foundation Trust
Page 2 · response
Published 13 August 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
Providing mental health care for patients without physical health needs is outside the Trust’s commissioned remit.

Verbatim wording from the response
“Epsom and St Helier University Hospitals NHS Trust is an acute trust, offering inpatient physical healthcare services at Epsom Hospital and St Helier Hospital. For patients within our locality, mental health services are provided by Surrey and Borders Partnership NHS Foundation Trust (‘SABP’). Whilst we are not commissioned to provide care for patients who do not have physical health needs, we acknowledge and are mindful of the situation that is faced across the country where the demand for mental health services far exceeds the availability. We work collaboratively with our partners in SABP to provide care for patients whilst they remain in the Trust. I welcome the opportunity to respond to your concerns on behalf of the Trust.”

Source location
Response from Epsom General Hospital
Page 2 · response
Published 13 August 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
Surrey and Borders Partnership provides local mental health services, while NHS Surrey Heartlands ICB commissions those services.

Verbatim wording from the response
“NHS Surrey Heartlands ICB (‘the ICB’) is the responsible ICB for the geographical area in which the Trust sits. It is responsible for commissioning the mental health care provision for the population within its geographical area.”

Source location
Response from Epsom General Hospital
Page 2 · response
Published 13 August 2025
Open published response
16 May2023
Manchester South
Concerns raised1
1. Failure to seek lawful consultation about supported return to the ward
This report raised 9 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

Carl Garry Thompson · 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

Carl Garry Thompson died from a drug overdose while on leave from Arden Ward, Stepping Hill Hospital, and was likely to have died on the night of 9 March 2022. Concerns included inadequate risk assessments and planning for his leave, insufficient response and escalation after family concerns about increased risk, and failure to provide a face-to-face Community Mental Health Team assessment or allocate a care coordinator before leave.

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 seek lawful consultation about supported return to the ward
Wider context from the report
“2. I am concerned that the Trust’s own internal review found that whilst Carl was on leave from the 7th March, the clinical team were made aware of an increase in Carl’s risk factors when contacted by his mother who outlined her concerns. 3. The review concluded that this represented a missed opportunity for the clinical team to understand how several factors may be combining to increase the risk for Carl, including his use of non-prescription medication and illicit substance misuse. 4. The Trust’s own review concluded that the clinical team could have sought to understand these risk factors through direct contact with Carl. 5. The Trusts own review concluded that following such direct contact, consultation could have been sought with others within a legal framework to ask Carl to return to the ward with support from services or family. The review concluded that the nursing team could have escalated this information via the on-call system for further medical support. ”
Source location
Carl Garry Thompson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
27 Apr2023
West Yorkshire (Western)
Concerns raised1
1. Delays in completing Mental Health Act detention when no bed is available overnight
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.

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

Ben Alan SHIPLEY · 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

Ben Alan Shipley, aged 22, died on 29 August 2019 after absconding from hospital and being struck by a train. The report raises concern about delays in securing a mental health bed, during which a section 2 detention could not be completed and Ben was reliant on the goodwill of A&E staff and his family for safety.

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
Delays in completing Mental Health Act detention when no bed is available overnight
Wider context from the report
“Ben was assessed at 22.00 on 28th August 2019. It seems to me that there are about 12 hours of delay following a 22.00 assessment Health Act assessment built into the system if there is no bed. Presumably this would be longer if Ben had been assessed earlier in the night shift. I am told beds do not become available over night. This means Ben cannot be legally detained as the section 2 is not complete until there is a bed. He is therefore subject to the goodwill of the A&E (who are not trained in mental health) and the goodwill of the family (who are similarly not trained in mental health). ████████ ████████ ”
Source location
Ben Alan SHIPLEY · Prevention of Future Deaths report
Page 2 · concerns
Open source report
28 Jan2022
West Sussex
Concerns raised1
1. Failure to consider the full range of powers 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 concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 2
1. Position
  S18 Mental Health Act powers and Mill View Hospital matters fall outside the respondent’s remit.
  Stated by Sussex PoliceOutside remit
1. Position
  Sussex Partnership Foundation Trust is responsible for addressing S18 powers and Mill View Hospital matters.
  Stated by Sussex PoliceRedirects responsibility
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
Failure to consider the full range of powers 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 2 · concerns
Open source report
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
28 May2021
Manchester North
Concerns raised1
1. Lack of a formal second-opinion process for Consultant Psychiatrists
This report raised 2 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 3
1. Action
  Write a formal process enabling consultants, healthcare professionals, patients, families and carers to request second opinions.
  Stated by Pennine Care NHS Foundation TrustStated completed
2. Action
  Submit the drafted second-opinion process to the Trust Quality Group for scrutiny and sign-off.
  Stated by Pennine Care NHS Foundation TrustStated planned
3. Action
  Implement the second-opinion process across all Trust services.
  Stated by Pennine Care NHS Foundation TrustStated planned
AI-generated summary

Angela Marie FROST · 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

Angela Marie FROST was admitted to hospital after a mixed overdose and later went missing with the intention of starving herself to death. She was found at home on 24 August 2020 after taking an intentional overdose of her partner’s old medication; the inquest recorded the medical cause of death as amitriptyline overdose and concluded suicide whilst the balance of her mind was disturbed. The principal concerns included the absence of formal processes for seeking second opinions and inadequate understanding of confidentiality and permissible communication with family members.

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 a formal second-opinion process for Consultant Psychiatrists
Wider context from the report
“(1) There is no formal guidance or process in place at the Trust for Consultant Psychiatrists to seek a second opinion in relation to diagnosis, treatment plans or whether a patient meets the criteria for detention under the Mental Health Act. The evidence was that whilst there is nothing to prohibit a Consultant requesting a second opinion, it rarely happens in practice. ”
Source location
Angela Marie FROST · 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
Write a formal process enabling consultants, healthcare professionals, patients, families and carers to request second opinions.

Verbatim wording from the response
“Since Ms Frost's untimely death, the Triumvirate Leadership Team for Oldham's Mental Health Services has reviewed the Trusts internal processes to request second opinions. Below is a summary of the work that has been done so far:”

Source location
2021-0183-Response-from-Pennine-Care-NHS-Foundation-Trust_Published
Page 1 · response
Published 2 June 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
Submit the drafted second-opinion process to the Trust Quality Group for scrutiny and sign-off.

Verbatim wording from the response
“- A draft process for requesting second opinions has been written, and this will be submitted to the Trusts Quality Group for scrutiny and sign-off. The process includes guidance for how Consultant Psychiatrists, Health Care Professionals, patients, families and carers can request a second opinion. - The process will be implemented across all of Pennine Care NHS Foundation Trust's (PCFT's) services.”

Source location
2021-0183-Response-from-Pennine-Care-NHS-Foundation-Trust_Published
Page 1 · response
Published 2 June 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
Implement the second-opinion process across all Trust services.

Verbatim wording from the response
“- A draft process for requesting second opinions has been written, and this will be submitted to the Trusts Quality Group for scrutiny and sign-off. The process includes guidance for how Consultant Psychiatrists, Health Care Professionals, patients, families and carers can request a second opinion. - The process will be implemented across all of Pennine Care NHS Foundation Trust's (PCFT's) services.”

Source location
2021-0183-Response-from-Pennine-Care-NHS-Foundation-Trust_Published
Page 1 · response
Published 2 June 2021
Open published response
15 Jan2020
Manchester West
Concerns raised2
1. Failure to keep contemporaneous documentation of self-discharge and detention decision-making rationale
2. Failure to recognise when to seek senior opinions about Mental Health Act section 5(2) detention criteria
This report raised 5 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

Daniel Jeffrey Moran · 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

Daniel Jeffrey Moran was pronounced dead at home on 14 July 2019 after using a rope as a ligature to partially suspend himself from a window. He had a history of depression, alcohol misuse and multiple recent suicide attempts, and had self-discharged from hospital after being assessed as not meeting the criteria for detention under the Mental Health Act. Concerns included staff understanding of confidentiality, patient-flow prioritisation, roles and responsibilities in managing risk, documentation, and decisions about self-discharge and detention.

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 keep contemporaneous documentation of self-discharge and detention decision-making rationale
Wider context from the report
“4. Doctors and ward staff involved in making decisions about self-discharge should consider the circumstances of admission as well as current risks when making decisions around discharge. They also need a greater understanding of the circumstances when it is appropriate to seek more senior opinions in regards to whether the patients meets the criteria to be detained under the Mental Health Act, section 5 (2) and ensuring contemporaneous documentation are kept in relation to their decision making rationale. ”
Source location
Daniel Jeffrey Moran · 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 to recognise when to seek senior opinions about Mental Health Act section 5(2) detention criteria
Wider context from the report
“4. Doctors and ward staff involved in making decisions about self-discharge should consider the circumstances of admission as well as current risks when making decisions around discharge. They also need a greater understanding of the circumstances when it is appropriate to seek more senior opinions in regards to whether the patients meets the criteria to be detained under the Mental Health Act, section 5 (2) and ensuring contemporaneous documentation are kept in relation to their decision making rationale. ”
Source location
Daniel Jeffrey Moran · Prevention of Future Deaths report
Page 2 · concerns
Open source report
20 Dec2019
Manchester (West)
Concerns raised1
1. Failure to inform families and seek their views about decisions to remove a Mental Health Act section
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 4
1. Action
  Revise and introduce the organisation-wide MH28 care planning and care coordination policy, including decision-making, communication, review, transition and discharge tools.
  Stated by TRU (Transitional Rehabilitation Unit) LtdStated completed
2. Action
  Provide further training to management teams on the revised care planning and care coordination policy.
  Stated by TRU (Transitional Rehabilitation Unit) LtdStated completed
3. Action
  Revise and implement MH12 Section 117 planning and MH10 family and external communication policies for people detained under the Mental Health Act.
  Stated by TRU (Transitional Rehabilitation Unit) LtdStated completed
1. Action
  Establish an audit framework and conduct regular reviews to monitor compliance and service delivery across the revised care planning procedures.
  Stated by TRU (Transitional Rehabilitation Unit) LtdStated completed
AI-generated summary

David Richard Fowler · 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

David Richard Fowler, who had a significant history of mental illness, substance misuse and a brain injury, died after falling from a motorway bridge on 26 December 2018 with the intention of ending his life. Eight days earlier, his detention under section 3 of the Mental Health Act 1983 was removed without a community plan or legal framework. The report identified concerns that his family was not invited to the relevant meeting or consulted, and that there was confusion about responsibility for informing family members.

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 inform families and seek their views about decisions to remove a Mental Health Act section
Wider context from the report
“In David’s case, no steps were taken to invite ████████ (or any other family member) to the MDT meeting on the 18th December 2018 when the decision was made by the Responsible Clinician to remove David from the confines of section 3 (and section 17) of the Mental Health Act 1983. It is a requirement of the Mental Health Act 1983 that the nearest relative is informed. Further, family views were not sought regarding the decision to lift the section in any other way. At the inquest, staff remained unclear between themselves as to whose responsibility it was to inform the family. Whilst I was informed that a Policy has been drafted and is in the process of being ratified, it remained the case that there was no formal Policy in place covering contact with families in respect of the above decisions and/or in respect of inviting family members to MDTs more generally. I was further concerned that there was on-going confusion between witnesses (in particular the Acting Manager and the Responsible Clinician) as to who is tasked with informing the family of MDTs and of any potential decision to remove a “section”. ”
Source location
David Richard Fowler · 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 and introduce the organisation-wide MH28 care planning and care coordination policy, including decision-making, communication, review, transition and discharge tools.

Verbatim wording from the response
“There has been a comprehensive review of the policies and procedures underpinning critical decision making in care planning including individuals requiring treatment under the Mental Health Act and those being discharged from the Act. This has included a revision of procedures regarding multidisciplinary team communications, mental capacity assessments, care coordination and care planning, communication with family and statutory services and aftercare and discharge planning processes. A revised policy responding to all of the points raised in the Regulation 28 has been completed and introduced with further training to management teams in relation to this. This policy introduced various checklists and tools to be used in practice in accordance with this policy and ensures all relevant processes are followed at each stage of the care planning process.”

Source location
2019-0450-Response-from-Transitional-Rehabilitation-Unit-Redacted
Page 1 · response
Published 6 January 2020
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
Provide further training to management teams on the revised care planning and care coordination policy.

Verbatim wording from the response
“There has been a comprehensive review of the policies and procedures underpinning critical decision making in care planning including individuals requiring treatment under the Mental Health Act and those being discharged from the Act. This has included a revision of procedures regarding multidisciplinary team communications, mental capacity assessments, care coordination and care planning, communication with family and statutory services and aftercare and discharge planning processes. A revised policy responding to all of the points raised in the Regulation 28 has been completed and introduced with further training to management teams in relation to this. This policy introduced various checklists and tools to be used in practice in accordance with this policy and ensures all relevant processes are followed at each stage of the care planning process.”

Source location
2019-0450-Response-from-Transitional-Rehabilitation-Unit-Redacted
Page 1 · response
Published 6 January 2020
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
Revise and implement MH12 Section 117 planning and MH10 family and external communication policies for people detained under the Mental Health Act.

Verbatim wording from the response
“I have also attached two revised policies specific to care planning policies for adults detained under the Mental Health Act most relevant to this regulation. These are the MH12 Section 117 planning policy and the MH10 Communicating to family and external parties’ policy for people under the Mental Health Act. These two policies outline specifically:”

Source location
2019-0450-Response-from-Transitional-Rehabilitation-Unit-Redacted
Page 2 · response
Published 6 January 2020
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
Establish an audit framework and conduct regular reviews to monitor compliance and service delivery across the revised care planning procedures.

Verbatim wording from the response
“I confirm there have been regular reviews of these procedures since the inquest and an audit framework has been devised to monitor continued compliance and service delivery in these areas including direct audit of the stages outlined in appendix 1.0 (care planning framework).”

Source location
2019-0450-Response-from-Transitional-Rehabilitation-Unit-Redacted
Page 2 · response
Published 6 January 2020
Open published response
19 Nov2019
Birmingham and Solihull
Concerns raised1
1. Failure to apply the Mental Health Act appropriately to informal patients who are effectively detained
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.

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

Andrew Peter Wells · 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

Andrew Peter Wells, who had anxiety and depression and had repeatedly expressed suicidal thoughts and attempted suicide during a psychiatric admission, left the unit on 27 December 2018. He was later found hanging from a tree, suffered a severe hypoxic brain injury, and died in hospital on 31 December 2018. Concerns included the robustness of the Trust’s root cause analysis process and the inappropriate application of the Mental Health Act, including decisions about detention and observation levels.

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 apply the Mental Health Act appropriately to informal patients who are effectively detained
Wider context from the report
“2. The expert witness also stated the Mental Health Act was not applied appropriately. Namely, whilst Mr Wells was technically an informal patient, the clinicians recognised that he would be detained if he tried to leave i.e. he was ‘de-facto’ detained without additional resources and safeguards applicable to a detained patient being put in place. The expert witness said ‘de-facto’ detention was contrary to the Code of Practice to the Mental Health Act and Mr Wells should have been detained. Therefore, my on-going concern is that the Trust’s clinicians are not applying the Mental Health Act appropriately. ”
Source location
Andrew Peter Wells · Prevention of Future Deaths report
Page 3 · concerns
Open source report
24 Feb2016
Manchester South
Concerns raised1
1. Failure to establish lawful authority for detaining an agitated patient
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Employ a Lead Nurse to advise staff and monitor compliance with Deprivation of Liberty Safeguards processes.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completed
2. Action
  Deliver continuing Mental Capacity and Deprivation of Liberty Safeguards training for Trust staff, including the scheduled May 2016 session.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progress
3. Action
  Promote Deprivation of Liberty Safeguards principles through executive bulletins and Trust-wide posters.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completed
1. Action
  Monitor Deprivation of Liberty Safeguards compliance and timescales through weekly reports to the Director of Quality and Governance.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completed
2. Action
  Work with local-authority Deprivation of Liberty Safeguards leads and Mental Capacity Advocates on safeguarding processes.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progress
AI-generated summary

Wilfrid Pearson · 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

Wilfrid Pearson was admitted to Tameside Hospital on 22 April 2015 with epilepsy, developed status epilepticus, and died at a local hospice about a month later. Concerns included possible failures in updating and communicating the status epilepticus protocol, unclear and incomplete records, inadequate escalation of care, staffing pressures, and the legal basis for detaining him after he left the ward.

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 establish lawful authority for detaining an agitated patient
Wider context from the report
“5. The deceased “absconded” from the ward and was described as agitated and confrontational. He was “brought back to the ward by Security”. I was told that no D.O.L.S. order was made or even contemplated, and he was not subject to compulsory detention under the Mental Health Act, therefore one has to ask where they derived the legal authority to detain the patient? ”
Source location
Wilfrid Pearson · 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
Employ a Lead Nurse to advise staff and monitor compliance with Deprivation of Liberty Safeguards processes.

Verbatim wording from the response
“Again I am disappointed and concerned that HM Coroner found that it was unclear where the Trust derived that Legal Authority to detain the patient. I would like to take this opportunity to reassure HM Coroner that the Trust has undertaken a significant amount of work in relation to Safeguarding Adults and DOLS since 2014, and in particular promotion of when a DOLS is to be considered. The Trust employed a Lead Nurse who provides support and advice on DOLS for staff in May 2014 and who also monitors that processes are followed. The Trust works closely with the local Authority DOLS leads and Mental Capacity Advocates. Regular MCA/DOLS training sessions have been held in the Trust provided by an external expert in Mental Capacity and DOLS; this is open to all staff in the Trust.”

Source location
W-Pearson-Response
Page 3 · response
Published 24 February 2016
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
Deliver continuing Mental Capacity and Deprivation of Liberty Safeguards training for Trust staff, including the scheduled May 2016 session.

Verbatim wording from the response
“Again I am disappointed and concerned that HM Coroner found that it was unclear where the Trust derived that Legal Authority to detain the patient. I would like to take this opportunity to reassure HM Coroner that the Trust has undertaken a significant amount of work in relation to Safeguarding Adults and DOLS since 2014, and in particular promotion of when a DOLS is to be considered. The Trust employed a Lead Nurse who provides support and advice on DOLS for staff in May 2014 and who also monitors that processes are followed. The Trust works closely with the local Authority DOLS leads and Mental Capacity Advocates. Regular MCA/DOLS training sessions have been held in the Trust provided by an external expert in Mental Capacity and DOLS; this is open to all staff in the Trust.”

Source location
W-Pearson-Response
Page 3 · response
Published 24 February 2016
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
Promote Deprivation of Liberty Safeguards principles through executive bulletins and Trust-wide posters.

Verbatim wording from the response
“In addition Weightmans LLP have provided four sessions of Mental Capacity Training in September and October of 2015 for medical staff and Consultants. The Trust has another session scheduled for May 2016. To further promote the principles of DOLS and ensure staff are aware of these the trust has promotes this through the Trusts communication including my Chief Executive Bulletins ‘Catch up with Karen’ and posters have been distributed and displayed across the Trust. The Quality and Governance Team monitor DOLS and the timescales and a report is produced weekly which provides an update to the Director of Quality and Governance on the status of DOLS. Since the admission of Mr Pearson the Trust has undergone two CQC visits during which we have been challenged and scrutinised against the Trusts processes in place for Safeguarding Adults and Mental Capacity.”

Source location
W-Pearson-Response
Page 3 · response
Published 24 February 2016
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
Monitor Deprivation of Liberty Safeguards compliance and timescales through weekly reports to the Director of Quality and Governance.

Verbatim wording from the response
“In addition Weightmans LLP have provided four sessions of Mental Capacity Training in September and October of 2015 for medical staff and Consultants. The Trust has another session scheduled for May 2016. To further promote the principles of DOLS and ensure staff are aware of these the trust has promotes this through the Trusts communication including my Chief Executive Bulletins ‘Catch up with Karen’ and posters have been distributed and displayed across the Trust. The Quality and Governance Team monitor DOLS and the timescales and a report is produced weekly which provides an update to the Director of Quality and Governance on the status of DOLS. Since the admission of Mr Pearson the Trust has undergone two CQC visits during which we have been challenged and scrutinised against the Trusts processes in place for Safeguarding Adults and Mental Capacity.”

Source location
W-Pearson-Response
Page 3 · response
Published 24 February 2016
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
Work with local-authority Deprivation of Liberty Safeguards leads and Mental Capacity Advocates on safeguarding processes.

Verbatim wording from the response
“Again I am disappointed and concerned that HM Coroner found that it was unclear where the Trust derived that Legal Authority to detain the patient. I would like to take this opportunity to reassure HM Coroner that the Trust has undertaken a significant amount of work in relation to Safeguarding Adults and DOLS since 2014, and in particular promotion of when a DOLS is to be considered. The Trust employed a Lead Nurse who provides support and advice on DOLS for staff in May 2014 and who also monitors that processes are followed. The Trust works closely with the local Authority DOLS leads and Mental Capacity Advocates. Regular MCA/DOLS training sessions have been held in the Trust provided by an external expert in Mental Capacity and DOLS; this is open to all staff in the Trust.”

Source location
W-Pearson-Response
Page 3 · response
Published 24 February 2016
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of a safe lawful detention pathway for people who cannot be held under s.3 at the hospital

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

Concerns raised2

Unclear legal authority for preventing psychiatric patients leaving the emergency department

Failure to provide lawful Mental Health Act detention safeguards and Responsible Clinician oversight

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5

Concerns raised1

Failure to seek lawful consultation about supported return to the ward

Concerns raised1

Delays in completing Mental Health Act detention when no bed is available overnight

Concerns raised1

Failure to consider the full range of powers to secure the return of absconding PICU patients

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Lack of a formal second-opinion process for Consultant Psychiatrists

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

Concerns raised2

Failure to keep contemporaneous documentation of self-discharge and detention decision-making rationale

Failure to recognise when to seek senior opinions about Mental Health Act section 5(2) detention criteria

Concerns raised1

Actions described in response 1

Actions described in response 5

Respondent positions 5

Respondent positions 2

Actions described in response 3