Recurring concern
Failure to reliably prevent patient escape from wards
Pin
Get email alerts
Request correctionFirst reported 21 Aug 2013•Latest report 6 Feb 2026
What this concern includes
Includes failures of dedicated ward-security controls intended to prevent or detect patient escape, including perimeter and door security, environmental checks for escape routes, access-control arrangements and reassessment of security measures after an escape or attempted escape.
Not included
- Excludes failures limited to patient observation frequency, quality or staffing where no ward-security or escape-prevention deficiency is identified.
- Excludes generic staffing, training, documentation or risk-assessment deficiencies unless they are directly tied to ward escape-prevention controls.
- Excludes visitor sign-in and general ward access-control deficiencies unless they materially concern preventing patients from escaping.
- Excludes unrelated environmental hazards, roof access or fire-escape protection where patient escape from the ward is not the shared safety condition.
- Reports
- 8
- Individual concerns
- 9
- Date range
- 2013–2026
- Stated actions
- 11
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
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.
-
Concerns raised1
Repeated escape from the ward in identical circumstances
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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
-
Action
Deliver mandatory refresher training on structured risk assessment, dynamic risk documentation and appropriate observation levels, with monthly compliance audits.
Stated by The Trust
-
Concerns raised1
Lack of national guidance on perimeter fencing and security for outside areas of mental health locked wards
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 concernsEach statement is shown once, even when linked to more than one concern.
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
-
Action
Work with stakeholders to expand evidence on physical barriers and explore approaches to reduce absconding risk.
Stated by Department of Health and Social Care
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
Current guidance does not prescribe acute-ward fence heights; appropriate security measures are determined by the service location and layout.
Stated by Department of Health and Social Care
-
Concerns raised1
Unsafe courtyard perimeter fence for preventing absconding and ligature risk
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 concernsEach statement is shown once, even when linked to more than one concern.
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
-
Action
Excavate, level and landscape the Beech ward courtyard, install anti-climb roller bars, and ensure the fence is at least 3.2 metres high.
Stated by Priory Group -
Action
Implement a programme to increase acute-unit courtyard and garden fence heights to at least 3.2 metres and fit anti-climb roller bars where required.
Stated by Priory Group
-
Concerns raised1
Failure to prevent patients from climbing over the Laurel Ward garden perimeter fence
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 concernsEach statement is shown once, even when linked to more than one concern.
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
-
Action
Complete and document the Laurel Ward garden safety review, including identified environmental risks and remedial actions.
Stated by Midlands Partnership University NHS Foundation Trust -
Action
Move the perimeter-adjacent bench to a safer location within the garden.
Stated by Midlands Partnership University NHS Foundation Trust -
Action
Review the fence structure and assess replacement or anti-climb retrofit options using quotes and evidence from an existing installation.
Stated by Midlands Partnership University NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
Existing garden foliage is considered sufficient because it balances concealment risk and reduces access to the fence.
Stated by Midlands Partnership University NHS Foundation Trust
-
Concerns raised2
Failure to properly carry out environmental checks for ward escape routes
Failure to enshrine environmental checks in Trust policy and mandatory ward-staff training
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 concernsEach statement is shown once, even when linked to more than one concern.
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
-
Action
Implement ward-specific environmental checklists and procedures as Trust policy, including shift-start and shift-end nurse-in-charge checks and joint handover checks.
Stated by Herefordshire and Worcestershire Health and Care NHS Trust -
Action
Train ward staff on the ward-specific environmental checklists and policy through new-starter induction and existing-staff supervision sessions.
Stated by Herefordshire and Worcestershire Health and Care NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
Position
A single environmental checklist cannot safely be used across all wards because each ward has different environmental factors and risks.
Stated by Herefordshire and Worcestershire Health and Care NHS Trust
-
Position
Environmental-checklist training cannot be added to general mandatory training because ward forms differ; it will instead be covered through induction and supervision.
Stated by Herefordshire and Worcestershire Health and Care NHS Trust
-
Concerns raised1
Ability of patients detained under the Mental Health Act 1983 to abscond from the ward
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure of the ward door policy to prevent or promptly detect patient absconding
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 concernsEach statement is shown once, even when linked to more than one concern.
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
-
Action
Maintain an up-to-date door-locking policy covering authorisation and recording requirements.
Stated by Hywel Dda University LHB
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
The ward’s current door-locking policy and continuous risk and observation assessments are relied on instead of further door-policy changes.
Stated by Hywel Dda University LHB
-
Concerns raised1
Scalable fences surrounding ward external common areas
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 concernsEach statement is shown once, even when linked to more than one concern.
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
-
Action
Alter hospital fences to make them more difficult to climb over while keeping garden doors open.
Stated by Sussex Partnership NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
Position
An open ward does not require secure-unit-height fencing; supervision would be increased if staff identified an absconding risk.
Stated by Sussex Partnership NHS Foundation Trust
-
Position
The patient’s manner of absconding was not foreseeable based on the information available to staff.
Stated by Sussex Partnership NHS Foundation Trust
Data last updated 7 September 2026