Recurring concern

Unreliable mental-health patient leave arrangements

First to latest report 21 Oct 2013 — 1 Jun 2026

Reports that mention this concern
22
Times this concern has been raised
32
Stated actions linked to this concern
29

What this concern includes

Includes failures in dedicated mental-health patient-leave arrangements, including assessment of readiness and community risks, use of extended or escorted leave to assess functioning, leave decision-making, communication of conditions, documentation, family or staff information, and agreed actions if the leave plan breaks down.

What is not included
  • Excludes general mental-health assessment, discharge or care-planning failures where patient leave is not the deficient process.
  • Excludes generic documentation, communication, staffing or risk-assessment deficiencies unless they directly impair a mental-health patient-leave arrangement.
  • Excludes substance-use investigation during leave unless it is part of the leave-safety decision or response process.
  • Excludes routine absence, travel or tenancy-support concerns outside a mental-health patient-leave context.

Reports and published responses 22 reports

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

  1. Essex

    AI-generated summary

    Katharine Emma Corrigan · 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

    Katharine Emma Corrigan, a patient detained under the Mental Health Act, died by suicide after failing to return from unescorted leave on 22 July 2023. The report identifies concerns about failures in the management and recording of Section 17 leave, inadequate risk assessments and care planning, staffing and oversight, and failures concerning access to recognised treatment for a pre-existing hormonal imbalance.

    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    Failure to prevent and scrutinise access to unauthorised or rescinded Section 17 Leave

    Wider context from the report

    “5. Ms Corrigan was absent without leave on multiple occasions and this had been facilitated by staff. There was a lack of scrutiny as to how and why Ms Corrigan was able to access leave that had not been authorised under section 17 Mental Health Act and/or had been rescinded by the Responsible Clinician due to risks of self-harm. On one occasion the Family went and searched for Ms Corrigan and returned her to the ward with reported risks that she was found near to train tracks and where her mother was buried. ”

    Source location

    Katharine Emma Corrigan · Prevention of Future Deaths report
    Page 4 · concerns

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    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 staff understand Section 17 Leave requirements and conduct required risk assessments

    Wider context from the report

    “2. Policies and protocols on section 17 Leave granted under the Mental Health Act (Section 17 Leave) were not properly understood by all staff and the required risk assessments were not conducted by appropriately qualified and trained staff. ”

    Source location

    Katharine Emma Corrigan · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  2. Kent and Medway

    AI-generated summary

    Catherine Mary MORGAN · 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

    Catherine Mary Morgan, who was receiving mental health care, left hospital on unescorted leave and was later located near Dover Castle. She jumped to her death at 20.16 on 4 September 2024. Concerns included delays in the police response to reports that she was missing, and inadequate systems for assessing, authorising, communicating and monitoring voluntary patients’ 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

    Inconsistent approach to leave and return for detained and voluntary patients

    Wider context from the report

    “4. Ward staff appeared to take a different approach to leave and return depending upon the status of the patient as a detained or voluntary patient; ”

    Source location

    Catherine Mary MORGAN · 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

    Develop a replacement electronic patient record system incorporating redesigned risk assessment, safety planning, leave documentation and monitoring capabilities.

    Verbatim wording from the response

    “The Trust has recently completed a procurement in relation to a new Electronic Patient Record (“EPR”) system and work is underway with the appointed provider to develop a new EPR system with a plan for this to be in place by 2028.”

    Source location

    Response from South London and Maudsley NHS Foundation Trust
    Page 3 · response
    Published 28 July 2026

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    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 and update the leave, informal-patient leave, and absent-or-missing-person policies to align practice, NICE guidance and legal requirements, including photographs and voluntary-patient checklists.

    Verbatim wording from the response

    “The Trust continues to evaluate its transition towards a personalised approach to risk assessment and suicide prevention. In respect of the Inquest process, it was identified there is still some work to be done with respect to aligning all other policies with the transformed Clinical Risk Assessment and Management of Harm policy. In particular, there are aspects within the AWOL, Absent and Missing Persons policy which retain “old” low/medium/high classifications, i.e. the checklist used to guide decision making where a patient is identified as AWOL. This policy has now been marked as under review as was previously indicated in the Trust’s evidence in this case.”

    Source location

    Response from South London and Maudsley NHS Foundation Trust
    Page 3 · response
    Published 28 July 2026

    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

    Develop a standardised leave log suitable for detained and informal patients.

    Verbatim wording from the response

    “• The Ward Risk Assessment for Section 17/Informal Leave form that was in use when Ms Morgan was a patient on the ward was not included in any Trust policy but was produced by the ward by combining the Section 17 leave risk assessment checklist and the Daily Leave Log to produce a new form. Because of the reference to section 17 leave it was not felt that this was appropriate to both detained and informal patients and thus a new standardised Leave Log has been developed that is appropriate to both detained and informal patients (Appendix D). With respect to the Section 17 leave risk assessment checklist, it has been identified that this is not in accordance with NICE guidance 2022 which does not recommend the use of risk assessment tools to predict the risk of suicide or to decide which patients receive treatment or are discharged.”

    Source location

    Response from South London and Maudsley NHS Foundation Trust
    Page 4 · response
    Published 28 July 2026

    Open published response

  3. 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 document and formalise leave reinstatement decisions

    Wider context from the report

    “4. When the responsible clinician was away for an extended period, leave was managed by a non s12 doctor. There is no contemporaneous documentary evidence of the decision making process by that doctor to reinstate leave as decisions were made outside the formal s17 MHA framework. ”

    Source location

    Ruariri Thomas STEWART · 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

    Leave management by a non-s12 doctor during responsible-clinician absence

    Wider context from the report

    “4. When the responsible clinician was away for an extended period, leave was managed by a non s12 doctor. There is no contemporaneous documentary evidence of the decision making process by that doctor to reinstate leave as decisions were made outside the formal s17 MHA framework. ”

    Source location

    Ruariri Thomas STEWART · 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

    Document all clinical and Mental Health Act decisions in patient files, the DSR system and relevant meeting minutes.

    Verbatim wording from the response

    “• All clinical decision-making, including that relating to MHA matters, is now documented within each patients’ file, both within the DSR system as well as additionally in any relevant minutes – for example within MDT meeting minutes, where a clinical decision has been taken during the course of that meeting.”

    Source location

    Response from Alternative Futures Group
    Page 3 · response
    Published 12 March 2026

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    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

    Reissue section 17 guidance and use separate escorted/emergency and unescorted leave forms for each patient.

    Verbatim wording from the response

    “• Specifically in respect of s.17 MHA decision-making, AFG has updated and reissued to staff guidance as to the process to be followed. In addition, AFG has moved to a system of two leave forms for each patient: one that covers all escorted and emergency arrangements; and a second which covers unescorted leave, to minimise the impact to restriction and recovery.”

    Source location

    Response from Alternative Futures Group
    Page 3 · response
    Published 12 March 2026

    Open published response

  4. South London

    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

    Failure to individually assess whether to suspend section 17 leave when a patient goes AWOL

    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

    Mandate MDT risk assessment after every AWOL incident and prompt Responsible Clinician review of leave status.

    Verbatim wording from the response

    “Action:”

    Source location

    Response from South London and Maudsley NHS Foundation Trust
    Page 1 · response
    Published 11 April 2025

    Open published response

  5. Manchester North

    AI-generated summary

    Hayley Jayne Cowan · 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

    Hayley Jayne Cowan was detained under Section 3 of the Mental Health Act and absconded during accompanied leave to a local shop on 3 June 2022. She was found deceased the following day after using drugs; concerns included inconsistent definitions and guidance for accompanied and escorted leave, including what staff should do if they needed to use the bathroom while accompanying a patient.

    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 guidance on staff bathroom arrangements while accompanying patients on leave

    Wider context from the report

    “The court heard evidence as to the lack of consistency and clarity for Mental Health trusts in understanding and defining how Section 17 leave should be conducted. This issue was highlighted in the paper published in December 2022 ████████, “NHS mental health services policies on leave for detained patients in England and Wales: A national audit.” Journal Psychiatric Mental Health Nursing 2023; 30: 719-730. - Local policies appear to be shaped as a result of capacity - There is a lack of consistency as to how “accompanied leave” and “escorted leave” are defined. - Guidance as to whether a patient should remain in “eye-line” or at a “reasonable distance” is inconsistent and does not assist trusts in considering how trusts should work. The Mental Health Act Codes of Practice, Guidance from the MOJ to Forensic providers and Trust policy are inconsistent. This is particularly the case in considering whether a patient needs to be within “eyeline” or a “reasonable distance” when on leave. There is also no guidance as to how trusts instruct staff on practical matters such as what to do if the staff member needs the bathroom whilst out with a patient. ”

    Source location

    Hayley Jayne Cowan · 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

    Capacity-shaped local policies for Section 17 leave

    Wider context from the report

    “The court heard evidence as to the lack of consistency and clarity for Mental Health trusts in understanding and defining how Section 17 leave should be conducted. This issue was highlighted in the paper published in December 2022 ████████, “NHS mental health services policies on leave for detained patients in England and Wales: A national audit.” Journal Psychiatric Mental Health Nursing 2023; 30: 719-730. - Local policies appear to be shaped as a result of capacity - There is a lack of consistency as to how “accompanied leave” and “escorted leave” are defined. - Guidance as to whether a patient should remain in “eye-line” or at a “reasonable distance” is inconsistent and does not assist trusts in considering how trusts should work. The Mental Health Act Codes of Practice, Guidance from the MOJ to Forensic providers and Trust policy are inconsistent. This is particularly the case in considering whether a patient needs to be within “eyeline” or a “reasonable distance” when on leave. There is also no guidance as to how trusts instruct staff on practical matters such as what to do if the staff member needs the bathroom whilst out with a patient. ”

    Source location

    Hayley Jayne Cowan · 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

    Lack of consistency in definitions of accompanied and escorted leave

    Wider context from the report

    “The court heard evidence as to the lack of consistency and clarity for Mental Health trusts in understanding and defining how Section 17 leave should be conducted. This issue was highlighted in the paper published in December 2022 ████████, “NHS mental health services policies on leave for detained patients in England and Wales: A national audit.” Journal Psychiatric Mental Health Nursing 2023; 30: 719-730. - Local policies appear to be shaped as a result of capacity - There is a lack of consistency as to how “accompanied leave” and “escorted leave” are defined. - Guidance as to whether a patient should remain in “eye-line” or at a “reasonable distance” is inconsistent and does not assist trusts in considering how trusts should work. The Mental Health Act Codes of Practice, Guidance from the MOJ to Forensic providers and Trust policy are inconsistent. This is particularly the case in considering whether a patient needs to be within “eyeline” or a “reasonable distance” when on leave. There is also no guidance as to how trusts instruct staff on practical matters such as what to do if the staff member needs the bathroom whilst out with a patient. ”

    Source location

    Hayley Jayne Cowan · 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

    Inconsistent guidance on whether patients should remain within eyeline or at a reasonable distance during leave

    Wider context from the report

    “The court heard evidence as to the lack of consistency and clarity for Mental Health trusts in understanding and defining how Section 17 leave should be conducted. This issue was highlighted in the paper published in December 2022 ████████, “NHS mental health services policies on leave for detained patients in England and Wales: A national audit.” Journal Psychiatric Mental Health Nursing 2023; 30: 719-730. - Local policies appear to be shaped as a result of capacity - There is a lack of consistency as to how “accompanied leave” and “escorted leave” are defined. - Guidance as to whether a patient should remain in “eye-line” or at a “reasonable distance” is inconsistent and does not assist trusts in considering how trusts should work. The Mental Health Act Codes of Practice, Guidance from the MOJ to Forensic providers and Trust policy are inconsistent. This is particularly the case in considering whether a patient needs to be within “eyeline” or a “reasonable distance” when on leave. There is also no guidance as to how trusts instruct staff on practical matters such as what to do if the staff member needs the bathroom whilst out with a patient. ”

    Source location

    Hayley Jayne Cowan · 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 the Mental Health Act Code of Practice after introducing the reform legislation.

    Verbatim wording from the response

    “Regarding your comments on the inconsistencies between the Mental Health Act Code of Practice, guidance from the Ministry of Justice, and local Trust policy, this Government has announced we will be bringing forward legislation to reform the Mental Health Act in this Parliamentary Session. We will subsequently be revising the Code of Practice, and will be considering where further changes can be made to strengthen statutory guidance. We will consider the issues you have raised as part of that work.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 31 May 2024

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    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

    Consider the reported inconsistencies and identify further changes to strengthen statutory guidance.

    Verbatim wording from the response

    “Regarding your comments on the inconsistencies between the Mental Health Act Code of Practice, guidance from the Ministry of Justice, and local Trust policy, this Government has announced we will be bringing forward legislation to reform the Mental Health Act in this Parliamentary Session. We will subsequently be revising the Code of Practice, and will be considering where further changes can be made to strengthen statutory guidance. We will consider the issues you have raised as part of that work.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 31 May 2024

    Open published response

  6. 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 consult medical notes and records during leave risk assessment

    Wider context from the report

    “6. The member of staff who allowed the deceased to leave the unit made a brief risk assessment of them before deciding whether they should be allowed to leave. That person did not consult any medical notes or records about the deceased when making that assessment. Had that member of staff consulted the deceased’s medical notes and records, the serious suicide risk which they posed would have been evident. ”

    Source location

    Hilary Clare (Billy) Guedalla · 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

    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

  7. Manchester South

    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

    Inadequate risk assessment and planning for s.17 leave

    Wider context from the report

    “1. I am concerned that the jury have found that the risk assessments and risk planning for Carl’s s.17 leave in March 2023 was inadequate. This issue was not addressed in the Trusts’ internal investigation conducted by ████████ and I have not received any evidence that there have been reflections or changes following Carl’s death on this issue to reassure me that there is not a continuing risk of future deaths. ”

    Source location

    Carl Garry Thompson · 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

    Share learning on documented risk assessment through supervision, consultant meetings, trust-wide dissemination and the Care Hub Quality Learning forum.

    Verbatim wording from the response

    “To address this point, the steps the service has taken so far are: - Shared learning for the staff team, this has been shared via supervision and the Care Hub Quality Learning forum. - ████████ consultant team, this has been shared via the lead ████████ patient meeting to support the importance of well-documented risk assessments. - ████████ trust, this has been shared as trust wide learning for ████████ within the footprint to be aware of and learn from. - Continued commitment to booking staff on the Clinical Risk Formulation ████████ STORM (suicide prevention skills) training; ward manager and service manager will monitor uptake and compliance with essential to role training.”

    Source location

    Response from Pennine Care NHS Foundation Trust
    Page 2 · response
    Published 17 May 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

    Continue booking staff onto Clinical Risk Formulation and STORM training, while monitoring uptake and compliance with essential-to-role training.

    Verbatim wording from the response

    “To address this point, the steps the service has taken so far are: - Shared learning for the staff team, this has been shared via supervision and the Care Hub Quality Learning forum. - ████████ consultant team, this has been shared via the lead ████████ patient meeting to support the importance of well-documented risk assessments. - ████████ trust, this has been shared as trust wide learning for ████████ within the footprint to be aware of and learn from. - Continued commitment to booking staff on the Clinical Risk Formulation ████████ STORM (suicide prevention skills) training; ward manager and service manager will monitor uptake and compliance with essential to role training.”

    Source location

    Response from Pennine Care NHS Foundation Trust
    Page 2 · response
    Published 17 May 2023

    Open published response

  8. West Sussex, Brighton and Hove

    AI-generated summary

    Caroline Victoria Forte · 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

    Caroline Victoria Forte had been receiving inpatient mental health treatment and was granted Section 17 weekend leave to stay at her parents' address. She was found hanging on 20 February 2022. Concerns included inadequate communication within the ward and with her family, the absence of an overarching care plan or risk assessment before leave, failure to follow the Section 17 leave policy, and difficulties sharing information from her private psychiatrist with NHS 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

    Failure to provide the family with the Section 17 leave form

    Wider context from the report

    “The Jury in their findings found the following matter contributed to the death of Caroline namely 1. Inadequate communication within Amberley Ward. 2. Inadequate communication between Amberley ward and Caroline's family. 3. No evidence of an overnight care plan or risk assessment prior to leaving the ward. 4. Failure to follow the section 17 leave of Absence policy. During the course of the evidence we heard that:- a) The daily care log was not completed so it was not possible to ascertain who was the last person to see Caroline leave the ward. b) There was no record to show which nurse carried out a risk assessment before she left. c) There was no overnight care plan. d) The “My care and safety plan” had not been updated with regards to “My family will do” section. e) The family were not provided with a copy of the Section 17 leave form f) At the time of this leave the family were unaware that Caroline had self-harmed in the hospital by tying a ligature. Therefore, the family told the Inquest that they therefore had no strategies in place to minimise the risks of such an event. Similarly there was no communication with the hospital as to how to minimise Caroline’s risk. f) Senior Officers from the ward showed a lack of knowledge of the Trust’s own Section 17 leave policy and Safe and Effective Assessment & Management of Clinical risk: Risk Management Police and Procedure. ”

    Source location

    Caroline Victoria Forte · 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 record completion of a pre-leave risk assessment

    Wider context from the report

    “The Jury in their findings found the following matter contributed to the death of Caroline namely 1. Inadequate communication within Amberley Ward. 2. Inadequate communication between Amberley ward and Caroline's family. 3. No evidence of an overnight care plan or risk assessment prior to leaving the ward. 4. Failure to follow the section 17 leave of Absence policy. During the course of the evidence we heard that:- a) The daily care log was not completed so it was not possible to ascertain who was the last person to see Caroline leave the ward. b) There was no record to show which nurse carried out a risk assessment before she left. c) There was no overnight care plan. d) The “My care and safety plan” had not been updated with regards to “My family will do” section. e) The family were not provided with a copy of the Section 17 leave form f) At the time of this leave the family were unaware that Caroline had self-harmed in the hospital by tying a ligature. Therefore, the family told the Inquest that they therefore had no strategies in place to minimise the risks of such an event. Similarly there was no communication with the hospital as to how to minimise Caroline’s risk. f) Senior Officers from the ward showed a lack of knowledge of the Trust’s own Section 17 leave policy and Safe and Effective Assessment & Management of Clinical risk: Risk Management Police and Procedure. ”

    Source location

    Caroline Victoria Forte · 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

    Introduce the new Record of Patient Leaving Ward document across Trust wards and provide local staff training on its consistent use.

    Verbatim wording from the response

    “During the aforementioned improvement works, it was recognised that the existing 'log' did not sufficiently enable staff to be prompted to capture all relevant information, and needed improving in a number of areas. So, new documentation has now been created, in the form of a new 'Record of patient leaving ward' document, a copy of which I attach. This will be introduced on the Trust's wards from 1 July, with local training being provided to staff to ensure the importance of its consistent use is fully understood. As with any new documentation there will then be a review of the new documentation's efficacy; this will be done in 3 months' time and the findings reported through the Trust's Acute Care Forum.”

    Source location

    Response from Sussex Partnership Foundation Trust
    Page 2 · response
    Published 5 May 2023

    Open published response

  9. West London

    AI-generated summary

    Christopher Thomas Ace Ryan · 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 Thomas Ace Ryan was detained under section 3 of the Mental Health Act and absconded from escorted leave on 23 December 2020. He obtained and smoked heroin, developed laboured breathing, lost consciousness, and died despite CPR. Concerns included repeated absconding during escorted leave, access to illicit drugs, unclear boundaries around escorted leave, and the security and smoking arrangements at the hospital car park.

    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 and approve or refuse patients' escorted leave requests

    Wider context from the report

    “Chris was known to abscond from secure mental health detention during periods of "escorted leave". He had left the care of the Trust on 6 occasions during his final 3 month detention and was known to purchase and take illicit drugs on these occasions. His Consultant had discussed this high risk behaviour with him on many occasions. (1) The Consultant Psychiatrist had signed the agreed escorted leave form on the basis that Chris would be accompanied 1:1 with a nurse. The purpose of the leave was therapeutic, to enable Chris to access the community in a supported manner. Evidence was before the court that the hospital site is non-smoking, but the evidence was unclear whether the car park was considered to be part of the hospital site or separate. (2) The car park is entirely unsecure and open to the road. Evidence given in court was that the hospital site is non-smoking, but the evidence was unclear whether the car park was considered to be part of the hospital site or separate. (3) My concern is that there has been a tolerated blurring of the boundaries between the intentions of escorted leave for individuals under a MHA section, and the ward staff's ability to facilitate this in a meaningful and therapeutic way to benefit the patients, and that the clinical staff were not aware of this. Chris had indicated his desire to access the cash point and buy Christmas presents for his family, but there was no suggestion these requests had been considered by the Trust and either approved or refused. Chris therefore made the decision to leave the ward, with catastrophic consequences. Has the Trust given any consideration to the provision of a "safe" smoking area that patients can access without the need to be accompanied or to use their restricted escorted leave for this purpose alone? ”

    Source location

    Christopher Thomas Ace Ryan · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. West Yorkshire Eastern

    AI-generated summary

    Alexandra Jane Tolley · 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

    Alexandra Jane Tolley, aged 20, was detained in a psychiatric hospital and absconded while being escorted in the hospital grounds on 27 October 2019. She was found in cardiac arrest and died at hospital the following day. Concerns included instructions not to restrain or follow her, the informal approval of ground leave without documented criteria, and the continued use of similar absconding instructions despite an ongoing risk of further deaths.

    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 determine sufficient escort numbers for ground leave

    Wider context from the report

    “5. The permission given to walk in the grounds of the hospital was not considered to amount to section 17 MHA 1983 leave. The informality involved in the decision missed an opportunity to consider issues such as: (a) Whether two escorts would be appropriate in view of Ms Tolley having absconded three days earlier. This would have facilitated one person following her to monitor and report on her whereabouts. In a time critical situation this could have altered the tragic outcome; (b) Providing the escort with a discretion in the manner of a dynamic risk assessment whether or not to follow Ms Tolley. (c) Reviewing the type of ████████ applied to her wounds, before she was permitted to leave the ward, in the light of her misuse of these ████████. ”

    Source location

    Alexandra Jane Tolley · 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 define permissible physical interventions during escorted leave

    Wider context from the report

    “4. The instruction to staff stipulated ‘physical interventions’ will not be used to restrain Ms Tolley, yet this expression was not defined or particularised. Greater clarity might assist a staff escort (likely to be a relatively junior individual) to know whether it was permissible, for example, to put a gentle hand on Ms Tolley’s shoulder to steer her back towards the hospital. ”

    Source location

    Alexandra Jane Tolley · 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

    Develop and incorporate scenario-based escorting and leave-risk decision-making training into initial and updated PMVA training for all staff, including bank staff.

    Verbatim wording from the response

    “The Trust has reviewed its Prevention, Management of Violence and Aggression (PMVA) training provision offered to staff regarding the role of escorting patients outside of the ward and is developing training for all staff, including bank staff. This training will be included in the initial and updated PMVA training provision. The training will be scenario and role play based and will include discussions regarding decision making related to risk whilst escorting somebody outside of the ward.”

    Source location

    2021-0344-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
    Page 2 · response
    Published 18 October 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

    Communicate case learning through procedures and provide staff with clear guidance on actions when escorted leave breaks down or a patient leaves the escort.

    Verbatim wording from the response

    “We will ensure that the learning from this case is communicated within our procedure – ensure that staff are provided with clear guidance when escorting patients of the action to be taken should leave start to break down or the patient leaves the member of staff.”

    Source location

    2021-0344-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
    Page 5 · response
    Published 18 October 2021

    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

    Physical touch was considered likely to increase distress and emotional dysregulation, so alternative support strategies were preferred.

    Verbatim wording from the response

    “The care plan developed by the team and Ms Tolley considered the intervention of placing any form of touch to Ms Tolley. It was deemed this would increase the risk of further distress to Ms Tolley and may further increase the risk of emotional deregulation in the event of an individual placing a hand on her. However more consideration should have been given to the need to think about alternative means to support Ms Tolley, enabling her to maintain her self-control at the point of feeling distressed whilst out on leave. Alternative strategies that could have been considered at the point Ms Tolley indicated either physically or verbally that she was becoming distressed or that she was not coping with the period of escorted leave.”

    Source location

    2021-0344-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
    Page 3 · response
    Published 18 October 2021

    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