Recurring concern

Unreliable AWOL response processes

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First reported 21 Aug 2013•Latest report 7 Apr 2025

Definition

What this concern includes

Includes failures in the dedicated AWOL, missing-person or absent-patient response process, including usable policy and flow-chart guidance, staff training and drills, recognition of AWOL status, timely application of the procedure, coordination with police and family, return arrangements, action planning and contemporaneous recording of response steps.

Not included

Excludes general missing-person responses where the person is not an AWOL or absent patient within the same healthcare or mental-health response process.
Excludes generic policy, training, communication or documentation deficiencies unless they directly impair the AWOL response process.
Excludes routine authorised leave, discharge or patient absence where no AWOL-response duty or safety concern is identified.
Excludes failures occurring after an AWOL response has operated reliably when the remaining issue is unrelated clinical care or treatment.

Reports: 9
Individual concerns: 11
Date range: 2013–2025
Stated actions: 15

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.

Sussex Partnership NHS Foundation Trust2

Cambridgeshire and Peterborough NHS Foundation Trust1

Cambridgeshire County Council1

Central and North West London NHS Foundation Trust1

Lancashire & South Cumbria NHS Foundation Trust1

Metropolitan Police Service1

National Police Chiefs’ Council1

North London NHS Foundation Trust1

Oxford Health NHS Foundation Trust1

Pennine Care NHS Foundation Trust1

South London and Maudsley NHS Foundation Trust1

Sussex Police1

Tees, Esk and Wear Valleys NHS Foundation Trust1

Wife of the deceased1

Woodhill Prison1

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.

7 Apr2025
South London
Concerns raised1
1. Lack of staff knowledge and understanding of the AWOL, missing and absent persons policy
This report raised 3 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 2
1. Action
  Deliver bespoke AWOL Policy refresher training to the National Psychosis Unit and monitor attendance.
  Stated by South London and Maudsley NHS Foundation TrustStated planned
2. Action
  Cascade the AWOL safety measures through Trust-wide bulletins and briefings, obtaining formal directorate confirmation of implementation.
  Stated by South London and Maudsley NHS Foundation TrustStated planned
AI-generated summary

Christopher McDonald · 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

Christopher McDonald, who had been detained under section 3 of the Mental Health Act and was receiving care at Bethlem Royal Hospital, died by strangulation by a ligature he had applied around his neck. Concerns included shortcomings in the individualised assessment and management of his leave after he went AWOL, failure to follow the AWOL policy, inadequate review of observation levels, and avoidable delay in identifying the ligature and communicating his relevant medical history to ambulance staff.

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 staff knowledge and understanding of the AWOL, missing and absent persons policy
Wider context from the report
“The evidence heard at the inquest demonstrated that staff working on the NPU did not have knowledge or a clear understanding of the “AWOL - Missing & Absent Persons Policy” of South London and Maudsley NHS Foundation Trust (“SLAM”) Specifically: (1) Whilst there should be an individualised assessment of whether it is appropriate to suspend section 17 when a patient goes AWOL: (a) one member of staff at the inquest gave evidence that it was “standard practice” and “protocol” that leave would be suspended; and (b) there was no evidence of any individualised assessment in Mr McDonald’s case. (2) The policy provides that SLAM staff should always accompany the police if the patient is to be returned from their home. This was not done in this case, and there was no evidence that any member of NPU staff considered this once Mr McDonald was located at his mother’s address on 24 February 2023. (3) The policy provides that if the police are likely to be involved in returning the patient to hospital then an action plan – jointly drafted between the police and Trust staff - needs to be drawn up. This was not done in this case, and there was no evidence that this was considered or completed by SLAM staff. ”
Source location
Christopher McDonald · 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
Deliver bespoke AWOL Policy refresher training to the National Psychosis Unit and monitor attendance.

Verbatim wording from the response
“• Bespoke Refresher training on all aspects of the AWOL Policy will be delivered to the National Psychosis Unit. Attendance will be monitored to ensure consistent understanding and application of the policy.”

Source location
Response from South London and Maudsley NHS Foundation Trust
Page 2 · response
Published 11 April 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
Cascade the AWOL safety measures through Trust-wide bulletins and briefings, obtaining formal directorate confirmation of implementation.

Verbatim wording from the response
“• These actions will be shared and cascaded via Trust-wide through a blue light bulletin. Each directorate will be required to provide formal confirmation of full implementation to ensure accountability.”

Source location
Response from South London and Maudsley NHS Foundation Trust
Page 2 · response
Published 11 April 2025
Open published response
28 May2021
Cambridgeshire and Peterborough
Concerns raised2
1. AWOL policy failing to provide concise and usable live-incident guidance
2. Conflicting or confusing AWOL policies
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 3
1. Action
  Review the AWOL policy with staff, service users and carers to address its meaningfulness and usability concerns.
  Stated by Cambridgeshire and Peterborough NHS Foundation TrustStated in progress
2. Action
  Review all Trust policies to align them with best-practice guidance and make them understandable and usable for staff.
  Stated by Cambridgeshire and Peterborough NHS Foundation TrustStated in progress
3. Action
  Clarify which AWOL policy has been superseded.
  Stated by Cambridgeshire and Peterborough NHS Foundation TrustStated completed
AI-generated summary

SAMANTHA JANE GOULD and CHRISTINE ELIZABETH GOULD · 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

Sam died by suicide from an overdose of prescribed medication on 2 September 2018, aged 16. Chris died by suicide after deliberately stepping in front of a passing train on 26 January 2019, aged 17. The principal concerns included insufficient overnight support for adolescents cared for at home, shortcomings in local authority support and coordination, reluctance to use a Borderline Personality Disorder diagnosis, and unclear and inadequately implemented procedures for patients absent without 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
AWOL policy failing to provide concise and usable live-incident guidance
Wider context from the report
“(4) AWOL patients from Darwin Centre for Young People (For CPFT). I heard evidence that since Chris’ death, staff have been reminded of the applicable policies; and that an audit has shown good compliance with the provision for calling the local signallers. I heard evidence that there is to be a further review of CPFT’s own AWOL policy. I remain concerned that: (i) CPFT’s own policy is too lengthy and complex to serve as reference-guidance during a live AWOL incident. In particular the flow chart summary is unnecessarily complex and hard to follow (at least as a tool to consult during a stressful incident); (ii) there is a risk of confusion in having two policies both of which are meant to be followed; (iii) there did not appear be desktop-drills / other training exercises / information grab-packs (etc.) to ensure that all nurses in charge are properly equipped and trained to deal with AWOL incidents effectively (iv) steps ought to be taken at managerial level to ensure that the confusion over the two policies and whether one had been superseded (evidence of which only emerged during the inquest) cannot recur in this, or other areas, when new policies are introduced. ”
Source location
SAMANTHA JANE GOULD and CHRISTINE ELIZABETH GOULD · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Conflicting or confusing AWOL policies
Wider context from the report
“(4) AWOL patients from Darwin Centre for Young People (For CPFT). I heard evidence that since Chris’ death, staff have been reminded of the applicable policies; and that an audit has shown good compliance with the provision for calling the local signallers. I heard evidence that there is to be a further review of CPFT’s own AWOL policy. I remain concerned that: (i) CPFT’s own policy is too lengthy and complex to serve as reference-guidance during a live AWOL incident. In particular the flow chart summary is unnecessarily complex and hard to follow (at least as a tool to consult during a stressful incident); (ii) there is a risk of confusion in having two policies both of which are meant to be followed; (iii) there did not appear be desktop-drills / other training exercises / information grab-packs (etc.) to ensure that all nurses in charge are properly equipped and trained to deal with AWOL incidents effectively (iv) steps ought to be taken at managerial level to ensure that the confusion over the two policies and whether one had been superseded (evidence of which only emerged during the inquest) cannot recur in this, or other areas, when new policies are introduced. ”
Source location
SAMANTHA JANE GOULD and CHRISTINE ELIZABETH GOULD · 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
Review the AWOL policy with staff, service users and carers to address its meaningfulness and usability concerns.

Verbatim wording from the response
“CPFT accepts the concerns with regard to the AWOL policy and has commenced the process of reviewing this. In order to ensure that the concerns about meaningfulness and useability are fully addressed this will involve engagement with staff groups, service users and carers. That work is expected to be completed by October 2021. In the meantime clarity has been given with regard to the superseded policy.”

Source location
2021-0184-Response-from-Cambridgeshire-and-Peterborough-NHS-Foundation-Trust_Published
Page 3 · 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
Review all Trust policies to align them with best-practice guidance and make them understandable and usable for staff.

Verbatim wording from the response
“The Trust is currently undertaking a full review of all policies which will ensure that they are fully in line with the latest best practice guidance and that they are written in such a way that they are clearly understandable and usable by all members of staff. The review is led by myself as Medical Director and ████████, the Director of Nursing, Allied Health Professions and Quality, and will run over the next six months.”

Source location
2021-0184-Response-from-Cambridgeshire-and-Peterborough-NHS-Foundation-Trust_Published
Page 3 · 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
Clarify which AWOL policy has been superseded.

Verbatim wording from the response
“CPFT accepts the concerns with regard to the AWOL policy and has commenced the process of reviewing this. In order to ensure that the concerns about meaningfulness and useability are fully addressed this will involve engagement with staff groups, service users and carers. That work is expected to be completed by October 2021. In the meantime clarity has been given with regard to the superseded policy.”

Source location
2021-0184-Response-from-Cambridgeshire-and-Peterborough-NHS-Foundation-Trust_Published
Page 3 · response
Published 2 June 2021
Open published response
6 Feb2020
Lancashire and Blackburn with Darwen
Concerns raised1
1. Failure to follow the AWOL procedure
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 4
1. Action
  Update the AWOL policy and procedure, including agreeing return times and initiating procedures when service users do not return.
  Stated by Lancashire & South Cumbria NHS Foundation TrustStated completed
2. Action
  Provide AWOL procedure training through inpatient development days and follow-up email communication.
  Stated by Lancashire & South Cumbria NHS Foundation TrustStated completed
3. Action
  Complete supervision for the Ward Manager and Matron on AWOL procedures.
  Stated by Lancashire & South Cumbria NHS Foundation TrustStated completed
1. Action
  Review the Trust AWOL policy and procedure to reflect investigation learning.
  Stated by Lancashire & South Cumbria NHS Foundation TrustStated completed
AI-generated summary

David Clark · 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 Clark was detained at Orchard Hospital under section 3 of the Mental Health Act and left on escorted leave on 26 June 2019. He was found in the Lancaster canal the following morning; the reported concerns included incomplete leave documentation, failure to follow the AWOL procedure, inadequate handover and training, and an outstanding action plan.

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 follow the AWOL procedure
Wider context from the report
“(2) That the AWOL procedure was not followed. ”
Source location
David Clark · 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
Update the AWOL policy and procedure, including agreeing return times and initiating procedures when service users do not return.

Verbatim wording from the response
“Unit Level: o The Trust policy and procedure for AWOL has been updated and is in line with this staff agree with service users the time they will return from leave. If the service user has not returned by the agreed time AWOL procedures are implemented (SaS documentation, attachment 6).”

Source location
2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
Page 2 · response
Published 8 February 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 AWOL procedure training through inpatient development days and follow-up email communication.

Verbatim wording from the response
“o AWOL procedure has been discussed at the Orchard In-Patient Development days and followed up with email to ensure all staff understand new process (email re AWOL procedures, attachment 7).”

Source location
2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
Page 2 · response
Published 8 February 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
Complete supervision for the Ward Manager and Matron on AWOL procedures.

Verbatim wording from the response
“o The Head of Nursing has completed a supervision session with the Ward Manager and Matron.”

Source location
2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
Page 2 · response
Published 8 February 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
Review the Trust AWOL policy and procedure to reflect investigation learning.

Verbatim wording from the response
“Trust Level: o The Trust policy and procedure for AWOL has been reviewed and reflects the learning from the investigation (attachment 8).”

Source location
2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
Page 2 · response
Published 8 February 2020
Open published response
20 Nov2019
Inner North London
Concerns raised1
1. Lack of ward staff understanding of MPS actions in response to absent-without-leave reports
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.

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

Nimo Younis · 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

Nimo Younis was detained in a psychiatric intensive care unit and was granted unescorted leave on 24 January 2019, but did not return. She was found at a friend's home the following day after hanging herself. The concerns included shortcomings in communication and understanding between ward staff and the police, the escalation and handling of the missing-person enquiry, the information provided to police decision-makers, and the use of the patient's friends in searching for her.

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 ward staff understanding of MPS actions in response to absent-without-leave reports
Wider context from the report
“1. C&I ward staff did not have a proper understanding of what action the MPS would take in what circumstances, following the report of a patient absent without leave. ”
Source location
Nimo Younis · Prevention of Future Deaths report
Page 2 · concerns
Open source report
18 Jan2018
West Sussex
Concerns raised1
1. Unclear AWOL policy on waiting for clinical staff discussion
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 1
1. Action
  Review the jointly agreed absent-without-leave and informal-missing-patients policy through partner-agency consultation, including seeking Safeguarding Board comments and considering coroner recommendations.
  Stated by Sussex PoliceStated in progress
AI-generated summary

Paul Lawrence Hanton · 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

Paul Hanton was an informal patient at Langley Green Mental Health Hospital when he absconded during an escorted walk on 18 April 2016. Eight days later, he jumped in front of a train at Kings Cross Underground Station and died from head injuries. The principal concerns included the information provided during the missing-person call, delays and gaps in police action, inaccessible hospital CCTV, and differing responses to informal and sectioned patients assessed as being at high risk of self-harm or suicide.

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 AWOL policy on waiting for clinical staff discussion
Wider context from the report
“3) Langley Green to consider review and amendment of current AWOL policy. This may be necessary given ████████ indication that he does not believe staff need to wait to have a discussion with clinical staff. ”
Source location
Paul Lawrence Hanton · 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
Review the jointly agreed absent-without-leave and informal-missing-patients policy through partner-agency consultation, including seeking Safeguarding Board comments and considering coroner recommendations.

Verbatim wording from the response
“Point five identifies the need to consider a joint policy with the Adult Safeguarding Board. Sussex Police and Sussex Partnership NHS Foundation have a jointly agreed policy relating to patients absent without leave / informal missing patients which applies to all patients including those detained under the Mental Health Act 1983, subject to Guardianship, Supervised Community Treatment Orders as well as those in hospital informally. The document provides guidance for managers and staff regarding duties, responsibilities and actions to be taken when a patient is absent without leave or provides the legal framework which sets out these duties and responsibilities. This Policy (a copy of which is attached) was due for review in November 2017 and is currently in the process of consultation with all partner agencies prior to the finalisation of any amendments and additions.”

Source location
2018-0021-Response-by-Sussex-Police
Page 2 · response
Published 14 March 2018
Open published response
21 Feb2017
Buckinghamshire
Concerns raised1
1. Failure to establish and communicate a clear AWOL and leave authorisation procedure
This report raised 15 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
  Complete governance approval and implement the amended section 17 leave form, including recording whether copies should be provided and to whom.
  Stated by Oxford Health NHS Foundation TrustStated in progress
2. Action
  Test the new leave-management SOP on Sapphire ward, review it, and expand implementation across all adult wards.
  Stated by Oxford Health NHS Foundation TrustStated in progress
3. Action
  Communicate AWOL procedures to staff and provide guidance and Missing Patient Action Checklists on all acute inpatient wards.
  Stated by Oxford Health NHS Foundation TrustStated completed
AI-generated summary

JACK OLIVER PORTLAND · 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 Oliver Portland was a prisoner who was diagnosed with substance-induced psychosis and later detained under the Mental Health Act. He died on 27 December 2015 at Wycombe Hospital while on unescorted leave from the Whiteleaf Centre; the medical cause of death was morphine and ethanol toxicity. Concerns included the management and communication of ACCT documents, family communication, discharge planning for a vulnerable and homeless prisoner, and the coordination of coronial disclosure.

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 and communicate a clear AWOL and leave authorisation procedure
Wider context from the report
“(3) The implementation of the AWOL procedure and checklist, including the application of 10-minute buffer time immediately at the end of scheduled leave was not clearly understood by witnesses in person and there appeared to be no proper overarching leave policy including proper recording of who assessed a patient prior to leave and who authorised a particular leave. There was no proper contemporaneous record of all the steps actually taken in connection of Mr Portland’s AWOL. ”
Source location
JACK OLIVER PORTLAND · 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
Complete governance approval and implement the amended section 17 leave form, including recording whether copies should be provided and to whom.

Verbatim wording from the response
“The provision of copies of leave forms is not in fact mandatory under either the Mental Health Act Code of Practice or Trust policy (the Trust’s current granting of leave form, which suggests that this is the case, is misleading). Nevertheless, it is acknowledged that in many cases patients and their families find it useful to have a copy of the form in addition to being involved in discussions around the granting of any leave and conditions. The section 17 leave form has been amended and is currently going through the Trust’s governance processes for approval. It is anticipated that use of the new form will be implemented no later than 28th April 2017. The newly designed form allows the consultant to indicate, following discussions with patients and families, if copies should be provided and, if so, to whom.”

Source location
2017-0049-Response-by-Oxford-Health-NHS-Trust
Page 1 · response
Published 5 March 2017
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
Test the new leave-management SOP on Sapphire ward, review it, and expand implementation across all adult wards.

Verbatim wording from the response
“In addition, a new standard operating procedure (SOP) for managing leave (appendix 1) includes the need for staff to have a discussion with the family, where appropriate consent is given by the patient, regarding the patient’s leave from the ward and to do this every time there is a change to the leave agreed.”

Source location
2017-0049-Response-by-Oxford-Health-NHS-Trust
Page 1 · response
Published 5 March 2017
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Communicate AWOL procedures to staff and provide guidance and Missing Patient Action Checklists on all acute inpatient wards.

Verbatim wording from the response
“The responsibility for ensuring that patients are back from leave now clearly rests with the person allocated to carry out general observations. That staff member is also responsible for informing the shift co-ordinator, who will co-ordinate the implementation of the AWOL policy, if a patient does not return on time (appendix 3). The shift co-ordinator is always a qualified nurse.”

Source location
2017-0049-Response-by-Oxford-Health-NHS-Trust
Page 2 · response
Published 5 March 2017
Open published response
15 Aug2016
County Durham and Darlington
Concerns raised1
1. Lack of staff knowledge of leave and missing-patient policies
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.

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

Michael Peter McMonigle · 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

Michael Peter McMonigle was admitted as an informal patient to Farnham Ward at Lanchester Road Hospital and was assessed as being at significant risk of self-harm. On 11 August 2015 he left the hospital during accompanied leave, was later found suspended by a ligature, and was declared dead on 12 August. The principal concerns included failures to update and communicate risk information and leave arrangements, inadequate handover and policy implementation, and delays and omissions in responding to his absence.

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 staff knowledge of leave and missing-patient policies
Wider context from the report
“(1) The lack of knowledge of the policy for leave for informal patients amongst ward staff and the Consultant Psychiatrist in particular. (2) The failure to follow the policy in terms of conducting an assessment prior to the handover. (3) The failure to apply the policy in terms of ensuring that leave arrangements are clearly understood by the patient and communicated to relatives. See paragraphs 6.7 and 6.8, the policy of Leave from Hospital and Leave of Absence under Section 17 Mental Health Act 1973, policy no CLIN00025. (4) The Face risk assessment, PARIS case notes and intervention plan were not updated with assessment of risk of self-harm or suicide and details of conditions for escorted leave following the formulation meeting on 10th August 2015. Instead, it fell to staff to verbally convey this information to colleagues who had not attended at the formulation meeting and to members of the family. (5) Failure to respond to Michael’s absence until well after 19:20 hrs, when it was admitted by ward staff in evidence that interventions could have been commenced, alternatively at 21:00hrs when it was conceded that the alarm could have been raised given that was the normal time for return from leave. (6) The response to Michael’s absence did not conform with paragraphs 7.3 of the Missing Patients Procedure, ref. CLIN-0006-V4 in that there was no search of the hospital internally, a search of the grounds, enquiry with other staff users, check of CCTV footage. (6) The following responses were undertaken after 19.20 and 21.00 when in conclusion of the jury the alarm could have been raised: enquiry with friends or relatives from 22:30hrs at earliest, an attempt to telephone Michael from 22:40 hrs at earliest, contact with relatives from 22:30 hrs at the earliest (Michael’s mother said 23.15), Police at 23:45hrs at the earliest, other hospital staff at 00:15hr on 12th August at the earliest, the medical staff at 12:20hrs at the earliest. Staff knowledge of the Leave policy and Missing Patients Procedure was inadequate. ”
Source location
Michael Peter McMonigle · Prevention of Future Deaths report
Page 3 · concerns
Open source report
12 Nov2015
Manchester North
Concerns raised2
1. Lack of Trust-wide staff familiarity with the AWOL protocol and process
2. Failure to apply the AWOL protocol appropriately and in a timely manner
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 2
1. Action
  Implement the revised AWOL Policy Trust-wide, incorporating additional guidance on actions required when a person goes absent without leave.
  Stated by Pennine Care NHS Foundation TrustStated completed
2. Action
  Share the revised AWOL Policy with staff and provide a flowchart explaining when to contact police about patients who do not return from leave.
  Stated by Pennine Care NHS Foundation TrustStated completed
AI-generated summary

Guy Jeffrey Robinson · 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

Guy Jeffrey Robinson, a 31-year-old man with mental and physical health problems, left a mental health ward on leave on 10 July 2014 and did not return. He was found deceased outdoors on 15 July 2014; the inquest found the cause of death to be multiple drug toxicity and exposure. Concerns included delay and inadequate familiarity with the AWOL protocol, and a lack of direct inpatient access to Clinical Psychology services.

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 Trust-wide staff familiarity with the AWOL protocol and process
Wider context from the report
“1. The ‘AWOL’ protocol was not applied appropriately/in a timely manner and during the course of the evidence it became apparent that some of clinicians lacked familiarity with the protocol and process. Whilst the Trust has taken steps to ensure that the protocol has been discussed with all staff based on the ward in question, action has not been taken Trust-wide to ensure that all staff are fully familiar with this policy. ”
Source location
Guy Jeffrey Robinson · 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 apply the AWOL protocol appropriately and in a timely manner
Wider context from the report
“1. The ‘AWOL’ protocol was not applied appropriately/in a timely manner and during the course of the evidence it became apparent that some of clinicians lacked familiarity with the protocol and process. Whilst the Trust has taken steps to ensure that the protocol has been discussed with all staff based on the ward in question, action has not been taken Trust-wide to ensure that all staff are fully familiar with this policy. ”
Source location
Guy Jeffrey Robinson · 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
Implement the revised AWOL Policy Trust-wide, incorporating additional guidance on actions required when a person goes absent without leave.

Verbatim wording from the response
“Following the Trust’s investigation, the Absence without Leave (AWOL) Policy was reviewed and additional guidance included in relation to actions that should be taken when a person goes AWOL. This policy was initially piloted within the Trust’s Mental Health In-Patient Unit at Tameside General Hospital. The revised policy was implemented Trust wide on the 1st April 2015.”

Source location
2015-0432-Response
Page 1 · response
Published 12 November 2015
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
Share the revised AWOL Policy with staff and provide a flowchart explaining when to contact police about patients who do not return from leave.

Verbatim wording from the response
“I have been assured by both In-Patient Service Manager for the North (Oldham/Rochdale/Bury) and the South (Stockport/Tameside) that this information has been shared and staff are familiar with the policy. In order to assist staff a flowchart has been produced as part of the policy, which also explains to staff when to contact the police to inform them of a patient who has not returned from leave (attached).”

Source location
2015-0432-Response
Page 1 · response
Published 12 November 2015
Open published response
21 Aug2013
West Sussex
Concerns raised1
1. Delays in declaring an AWOL patient missing and informing the police
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.
Respondent positions 1
1. Position
  The AWOL policy was implemented appropriately, including searching and contacting police after the patient was found missing.
  Stated by Sussex Partnership NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Mr Walker · 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

Mr Walker, who had depression, suicidal ideation and a history of impulsive self-harm attempts, died after leaving the hospital ward and hanging himself in nearby woodland. Concerns included insufficient risk care planning, unexplained reductions in observation levels, the time taken to declare him missing and inform police, and the scalability of the ward’s external fences.

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 declaring an AWOL patient missing and informing the police
Wider context from the report
“(3) Whilst it was accepted in evidence that the hospital's AWOL policy was robust and activated and implemented appropriately, concern was raised by the family with regard to the length of time taken before Mr Walker could be declared missing and the police informed. ”
Source location
Mr Walker · 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
The AWOL policy was implemented appropriately, including searching and contacting police after the patient was found missing.

Verbatim wording from the response
“3. AWOL Staff contacted the Police within 50 minutes of them noticing that Mr Walker was missing. This was after a full search of the ward, hospital, and hospital grounds was conducted, and after attempts were made to contact Mr Walker and his family. It was also the conclusion from our internal investigation that the AWOL policy was implemented appropriately.”

Source location
2013-0213-Response-by-Sussex-Partnership-NHS-Foundation-Trust
Page 2 · response
Published 21 August 2013
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of staff knowledge and understanding of the AWOL, missing and absent persons policy

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

Concerns raised2

AWOL policy failing to provide concise and usable live-incident guidance

Conflicting or confusing AWOL policies

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 raised1

Failure to follow the AWOL procedure

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.4

Concerns raised1

Lack of ward staff understanding of MPS actions in response to absent-without-leave reports

Concerns raised1

Unclear AWOL policy on waiting for clinical staff discussion

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 raised1

Failure to establish and communicate a clear AWOL and leave authorisation procedure

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 raised1

Lack of staff knowledge of leave and missing-patient policies

Concerns raised2

Lack of Trust-wide staff familiarity with the AWOL protocol and process

Failure to apply the AWOL protocol appropriately and in a timely manner

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

Actions described in response 2

Actions described in response 3

Actions described in response 4

Actions described in response 1

Actions described in response 3

Actions described in response 2