Recurring concern

Failure to communicate relevant risk information during patient leave

First to latest report 3 Apr 2014 — 10 Mar 2026

Reports that mention this concern
4
Times this concern has been raised
4
Stated actions linked to this concern
7

What this concern includes

Includes failures to communicate information materially relevant to a patient’s safety during authorised or escorted leave, including handover to leave decision-makers, escorts and staff monitoring return.

What is not included
  • Excludes generic staff handover failures unrelated to patient leave.
  • Excludes failures in leave monitoring, supervision or escalation where the problem is not the communication of relevant risk information.
  • Excludes failures concerning the substantive correctness of a leave decision when information handover was adequate.

Reports and published responses 4 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Cheshire

    AI-generated summary

    Ruariri Thomas STEWART · 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

    Ruariri Thomas Stewart, aged 29, died from fatal cocaine toxicity at Weaver Lodge Independent Hospital on 31 July 2025 after a period of unescorted leave during which he probably obtained cocaine. The report identifies concerns about failures in documentation, communication, information sharing, leave decision-making, substance-misuse management, record keeping, and the quality of post-incident investigation.

    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 hand over information about intended continued cocaine use

    Wider context from the report

    “8. Information from the patient that he intended to carry on taking cocaine was not handed over to the staff who made the final decisions about leave and checked the patient on return ”

    Source location

    Ruariri Thomas STEWART · 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

    Require material disclosures in handovers and MDTs, using an updated handover template with monthly senior-practitioner and registered-manager audits.

    Verbatim wording from the response

    “• Staff are required, and have been reminded to record in handover notes and MDT meetings, all material disclosures. To help with this process, the handover template has been reviewed and updated, to ensure it adheres to national standards and guidance. The adequacy of handover notes, and sufficiency of information provided, is reviewed monthly by a senior practitioner, and are also audited by a service’s registered manager to ensure appropriate completion and provision of information.”

    Source location

    Response from Alternative Futures Group
    Page 4 · response
    Published 12 March 2026

    Open published response

  2. Inner North London

    AI-generated summary

    Hilary Clare (Billy) Guedalla · 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

    Hilary Clare (Billy) Guedalla died by suicide after leaving Gardener Ward, Homerton Hospital, unaccompanied on 29 October 2021 and was found on 30 October 2021. The report identifies concerns including failures to communicate the decision restricting unescorted leave and information about suicide risk, inadequate risk assessment, delays and failures in contacting emergency services and family, non-compliance with missing-patient procedures, and inadequate staffing.

    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 communicate leave restrictions to all unit staff

    Wider context from the report

    “2. The decision that the deceased should not be allowed unescorted leave was not communicated to all members of staff working in the unit such that the person who allowed the deceased to leave was unaware that the decision had been made. ”

    Source location

    Hilary Clare (Billy) Guedalla · 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

    Remind Gardner Ward and City and Hackney inpatient staff to record clinical decisions, review RIO notes, and discuss leave-recording requirements at scheduled away days.

    Verbatim wording from the response

    “In order to ensure that this does not occur again, at the next Gardner Ward away day on 23 August 2023 all staff will be reminded again of the importance of properly recording clinical decisions (whether made by themselves or in Ward Management Meetings or Ward Rounds). As well as reviewing the RIO notes prior to making important clinical decisions. This same discussion will be repeated at the next away days for all City and Hackney inpatient wards. Considerations about the differences in recording such information between formal and informal service users will be discussed. A memo has been sent out to all ward staff on 27 July 2023 by the Clinical Director reinforcing these expectations too.”

    Source location

    Response from East London NHS Foundation Trust
    Page 3 · response
    Published 22 June 2023

    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

    Send ward staff a memo reinforcing requirements to record and communicate clinical decisions about patient leave.

    Verbatim wording from the response

    “In order to ensure that this does not occur again, at the next Gardner Ward away day on 23 August 2023 all staff will be reminded again of the importance of properly recording clinical decisions (whether made by themselves or in Ward Management Meetings or Ward Rounds). As well as reviewing the RIO notes prior to making important clinical decisions. This same discussion will be repeated at the next away days for all City and Hackney inpatient wards. Considerations about the differences in recording such information between formal and informal service users will be discussed. A memo has been sent out to all ward staff on 27 July 2023 by the Clinical Director reinforcing these expectations too.”

    Source location

    Response from East London NHS Foundation Trust
    Page 3 · response
    Published 22 June 2023

    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

    Include leave-recording and information-sharing requirements in the junior doctor induction programme.

    Verbatim wording from the response

    “Additionally, the Clinical Director for City and Hackney has updated the junior doctor induction programme to include this information.”

    Source location

    Response from East London NHS Foundation Trust
    Page 3 · response
    Published 22 June 2023

    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

    Conduct daily multidisciplinary Safety Huddles on City and Hackney inpatient wards to share critical clinical, risk and leave information.

    Verbatim wording from the response

    “In order to provide an additional safety net to ensure that appropriate information sharing occurs, a daily Safety Huddle comprised of the entire multi-disciplinary team now takes place on all City and Hackney inpatient wards each morning. Critical clinical information about all service users is shared during the Safety Huddles. Important clinical decisions and risk information discussed at the Safety Huddles are expected to be documented on RIO (this expectation will also be further reinforced at the away day and junior doctor induction).”

    Source location

    Response from East London NHS Foundation Trust
    Page 3 · response
    Published 22 June 2023

    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

    Document inpatient leave arrangements on ward nursing-office whiteboards, reassess them at handover, and require staff to check them before authorising leave.

    Verbatim wording from the response

    “Additionally, all inpatient leave arrangements (for both formal and informal service users) are now documented on the relevant nursing office whiteboard in each City and Hackney inpatient ward. The leave arrangements are reassessed at every shift handover and the whiteboard is updated accordingly. It is expected that all staff members check the whiteboard before allowing leave of any type.”

    Source location

    Response from East London NHS Foundation Trust
    Page 3 · response
    Published 22 June 2023

    Open published response

  3. Bedfordshire and Luton

    AI-generated summary

    Mr Thomas Antony Smith · 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 Thomas Antony Smith died in a drugs-related death after serious failings in his care on Coral Ward during the night of 29–30 December 2020. The principal concerns were inadequate staff knowledge about the dangers and presentation of drugs, insufficient observation and escalation after a positive drugs test and signs of deterioration, and weaknesses in the system for assessing risks associated with Section 17 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 ensure escorting staff receive and review patient-specific risk information before s.17 leave

    Wider context from the report

    “2) The system for assessing risks associated with s.17 leave I was told that, when a staff member is escorting a service user out of the ward, there is an expectation for that staff member to be aware of the location, general mental state and wellbeing of the service user; and that a ‘mental state assessment’ should be carried out on the ward prior to leave taking place, as a further safeguard once s.17 leave had been granted. However, the evidence of the healthcare assistant who took Mr Smith out on leave, on the occasion (29 December 2020) that the jury concluded it was possible that he was able to buy the ████████ the misuse of which caused his death, was that: (i) He would not necessarily read a patient’s RiO (electronic continuous) notes before taking a patient out on leave; (ii) He had not read Mr Smith’s care plan before taking him on leave; (iii) There had been no handover from other staff to him of Mr Smith’s presentation on 28 December 2020 presentation (when he was suspected of being ‘under the influence’ of a substance); and (iv) Although he had read the form authorising Mr Smith’s leave (i.e. the s.17 form), that form – a statutory document – does not contain information about particular risks posed to a patient by or when out on s.17 leave. As a result of the above, this particular healthcare assistant was unaware that: (i) On 28 December 2020 Mr Smith had been suspected of being under the influence of drugs; (ii) Mr Smith’s care plan of 20 December 2020 set out as a ‘risk issue’ the fact that “Thomas has a history of using illicit substances”; and (iii) The care plan set out as an ‘intervention’ for Mr Smith: “Nursing staff to do random urine drug screening and breathalysing upon return to the ward.” The healthcare assistant therefore appears to have been in a position of escorting a patient on leave without knowledge of a patient’s very recent potential drug-related presentation, or of a specified intervention aimed at reducing the risk posed to that patient by drugs as set out in his care plan. There was, however, no suggestion in the evidence of any witness during Mr Smith’s inquest that the situation in which the escorting healthcare assistant found himself represented a failure to follow policy or expected procedure. In the event that this is correct there appears to be a wider issue – and this Report is therefore directed to NHS England and NHS Improvement. ”

    Source location

    Mr Thomas Antony Smith · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  4. Brighton and Hove

    AI-generated summary

    DANUTA Bronislawa CORBETT · 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

    Danuta Bronislawa Corbett jumped from the window of her eighth-floor flat during escorted leave on 4 November 2013 and died. The report raises concerns that decisions about her leave were not documented in accordance with policy and that the agency escort was not given important information about her distress, her home, or her stated threat to kill herself by jumping from it.

    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 hand over relevant patient and suicide-risk information to the leave escort

    Wider context from the report

    “(1) The report concerns the leave policy so far as it relates to Informal Patients. (Copy enclosed – refer to S. 4.5 and then S. 43). (2) Leave was considered first on 1.11.2013 when Mrs. Corbett was on 15 minute observations. The Ward Review documents that she wants leave to go to her home to collect some papers over the next 2 – 3 days- Escorted leave agreed. No Leave occurred on 1st, 2nd or 3rd November, 2013 but no reason for this is documented. On the 4th she has another Ward Review. She remained on 15 minute observations. As to leave, none of the matters referred to in the Policy at S.4.3 are documented in the Progress Note or in the Clinical Review or in the Electronic Note of the ward review on 4th November. In the afternoon of 4th November, Mrs. Corbett repeated her request to the Charge Nurse to go home. She was apparently Risk Assessed again and an escort was allocated. The escort was an agency health care worker who had never met the patient and had never worked on this ward before. No note by the risk assessment, or the decision to allow escorted leave was made in accordance with S.4.3 of the Policy. The patient’s details and details of the reasons for her admission were not handed over to the escort, in particular neither the fact that her flat/home was central to her distress or the fact that she had threatened to kill herself by jumping from it were known to the escort. Thus none of the decisions regarding her Leave on the 4th November are documented. This patient jumped out of her 8th floor flat window at home during this escorted leave. ”

    Source location

    DANUTA Bronislawa CORBETT · 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

    Ensure proper handovers with agency nurses accompanying patients.

    Verbatim wording from the response

    “Finally, it is clear that the communication with the agency nurse who was accompanying Danuta should have been much better. The nurse responsible acknowledges this and will always ensure proper handovers take place in the future.”

    Source location

    2014-0150-Response-by-Sussex-Partnership-NHS-Trust
    Page 1 · response
    Published 3 April 2014

    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 shortcomings identified were unlikely to have prevented the tragic outcome.

    Verbatim wording from the response

    “It seems unlikely that any of the shortcomings highlighted by this very sad case would have prevented the tragic outcome. However, all the staff involved in Danuta’s care have carefully reflected on what happened and used the learning to improve their practice.”

    Source location

    2014-0150-Response-by-Sussex-Partnership-NHS-Trust
    Page 2 · response
    Published 3 April 2014

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026