Recurring concern

Unreliable safeguards when patients leave before clinical assessment

First to latest report 17 Oct 2014 — 8 Nov 2024

Reports that mention this concern: 2
Times this concern has been raised: 4
Stated actions linked to this concern: 7

What this concern includes

Includes failures in hospital processes for recognising and managing patients who leave or may leave before clinical assessment, including temporary exit safeguards, assessment of capacity and risk, clear departure procedures, notification, escalation and arrangements for completing assessment or follow-up.

What is not included

Excludes ordinary planned discharge or leave after the patient has received an adequate clinical assessment and the departure decision is appropriately managed.
Excludes general ward security, door-locking or patient-escape concerns where departure before clinical assessment is not the material safety condition.
Excludes failures in the quality of clinical assessment after the patient has remained safely available for assessment.
Excludes generic communication, staffing or documentation deficiencies unless they directly impair safeguards for a patient leaving before clinical assessment.

Trends

Reports over time

Reports mentioning this concern, 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.

NHS England2

Barts Health NHS Trust1

NHS Tower Hamlets Clinical Commissioning Group1

Northern Care Alliance NHS Foundation Trust1

Tredegar Practice1

Reports and published responses 2 reports

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

8 Nov2024
Manchester West
Concerns raised3
1. Failure to assess capacity to decide to leave hospital
2. Lack of clarity in the standard operating procedure for patients leaving hospital before clinical assessment
3. Delays in clinical assessment resulting in patients leaving hospital before assessment
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses

NHS England
Northern Care Alliance NHS Foundation Trust
Stated actions 7
1. Northern Care Alliance NHS Foundation Trust
  Implement the NHSE Acuity Tool for initial assessment and routing of patients attending Salford Royal’s emergency department.
2. Northern Care Alliance NHS Foundation Trust
  Continue work to achieve the 15-minute target for secondary assessment and enable early intervention and frontloading of essential investigations.
3. Northern Care Alliance NHS Foundation Trust
  Develop and obtain approval for a Standard Operating Procedure governing patients leaving the emergency department before assessment or treatment.
1. Northern Care Alliance NHS Foundation Trust
  Disseminate the approved Standard Operating Procedure across urgent and emergency care areas.
2. NHS England
  Publish and implement the two-year delivery plan for recovering urgent and emergency care services.
3. NHS England
  Support regions and providers to eliminate longer-term crowding in emergency departments and improve patient flow.
4. NHS England
  Use operational planning guidance to direct health systems toward improved patient flow and clinical outcomes.
Respondent positions 1
1. NHS England
  Salford Royal Hospital Foundation Trust is the appropriate organisation to respond to the concerns raised.
  Redirects responsibility
AI-generated summary

Anne Taylor · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Anne Taylor sustained a head injury after banging her head on a bedside cabinet and falling from a bed during a holiday. After initially leaving hospital before assessment because of waiting times, she returned the next day and was diagnosed with a traumatic brain injury involving bilateral acute subdural bleeding and midline shift; she deteriorated and died on 31 July 2024. Concerns included the lack of consideration of investigations during the waiting period, the absence of evidence that her capacity to leave was assessed, and uncertainty about a new procedure for patients leaving before clinical assessment.

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 assess capacity to decide to leave hospital
Wider context from the report
“3. No evidence was provided that the deceased’s capacity to decide to leave the hospital was assessed given the history of suspected head injury. ”
Source location
Anne Taylor · 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 clarity in the standard operating procedure for patients leaving hospital before clinical assessment
Wider context from the report
“4. Reference was made to a new standard operating procedure being developed relating to patients leaving the hospital before a clinical assessment occurs, but it was unclear what this will include. ”
Source location
Anne Taylor · 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
Delays in clinical assessment resulting in patients leaving hospital before assessment
Wider context from the report
“1. During evidence, it was heard that the deceased had elected to leave the Hospital on Friday 19 July because of waiting times, before being clinically assessed. ”
Source location
Anne Taylor · 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 NHSE Acuity Tool for initial assessment and routing of patients attending Salford Royal’s emergency department.

Verbatim wording from the response
“In addition to the above, as of 25th November 2024, Salford Royal Hospital has become an early adopter of the NHSE Acuity Tool, an initial assessment model which aims to standardize the measurement of acuity in Emergency Departments and Urgent Treatment Centres. Patients who attend the ED at Salford Royal now receive an initial, primary assessment to identify patients with an acuity 1, 2 or 5 which will allow them to either be directed immediately to a receiving location or be directed to an alternative provider such as primary care. Acuity 1 patients are those with immediate life/limb threatening illness/injury, acuity 2 are those with imminent life/limb threatening illness/injury and acuity 5 denotes no threat to life or limb, no ED specific resource necessary. Patients who do not meet an acuity 1, 2 or 5 will then go on to receive a secondary assessment.”

Source location
Response from Northern Care Alliance
Page 2 · response
Published 11 November 2024
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 work to achieve the 15-minute target for secondary assessment and enable early intervention and frontloading of essential investigations.

Verbatim wording from the response
“The target time for secondary assessment is 15 minutes, Salford Care Organisation are on track to achieve this. Progress of the early adopter programme is being shared with NHSE at regular intervals. Patients receiving a secondary assessment can be identified for early clinical intervention and front loading of essential investigations such as, CT scan. Work is ongoing to meet the NHSE secondary assessment target to provide the significant benefits it offers of reducing the risk of patients with serious conditions sitting in the waiting room for a long time undiagnosed. In addition, the new acuity tool, has a specific question regarding mental capacity assessment relating to a patient’s decision to leave the department.”

Source location
Response from Northern Care Alliance
Page 2 · response
Published 11 November 2024
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 and obtain approval for a Standard Operating Procedure governing patients leaving the emergency department before assessment or treatment.

Verbatim wording from the response
“Additionally, it was highlighted that at the time of Mrs Taylor’s attendance there was no formalized Standard Operating Procedure within Salford Royal’s Emergency Department defining the actions to take when a patient leaves before clinical assessment. Salford site has an electronic self-discharge checklist designed for ward-based use, but no guidance or policy to describe the appropriate completion of this, or relevant steps to take, in the emergency department setting.”

Source location
Response from Northern Care Alliance
Page 2 · response
Published 11 November 2024
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
Disseminate the approved Standard Operating Procedure across urgent and emergency care areas.

Verbatim wording from the response
“A Standard Operating Procedure (SOP) for patients who leave the emergency department whilst waiting to be seen has now been drafted and is going through NCA approval processes, with an estimated approval date of 6th February 2025. We append the working draft for your information. This guideline sets out the responsibilities of clinical and nursing staff when an adult leaves an emergency care setting prior to being assessed or receiving treatment, so that the patient is safeguarded appropriately with the aim of:”

Source location
Response from Northern Care Alliance
Page 2 · response
Published 11 November 2024
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
Publish and implement the two-year delivery plan for recovering urgent and emergency care services.

Verbatim wording from the response
“NHS England recognises the significant pressures on all NHS services and, in January 2023, published a two-year Delivery plan for recovering urgent and emergency care (UEC) services. The plan prioritised improvements to four hour performance in Emergency Departments and outlined key actions to recover and improve urgent and emergency care services. Despite significant challenges, including higher than anticipated demand, there has been a marked improvement in the headline ambition, with over 2.5 million more people completing their Accident & Emergency treatment within four hours in 2023/24 compared to 2022/23.”

Source location
Response from NHS England
Page 2 · response
Published 11 November 2024
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
Support regions and providers to eliminate longer-term crowding in emergency departments and improve patient flow.

Verbatim wording from the response
“NHS England is working to support its regions to support providers to eliminate crowding in Emergency Departments in the longer term. Improvements are being demonstrated through NHS England’s operational planning guidance where health systems were asked to focus on areas to deliver improved patient flow and this has included increasing the productivity of acute and non-acute hospital services, improving flow as well as clinical outcomes.”

Source location
Response from NHS England
Page 2 · response
Published 11 November 2024
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
Use operational planning guidance to direct health systems toward improved patient flow and clinical outcomes.

Verbatim wording from the response
“NHS England is working to support its regions to support providers to eliminate crowding in Emergency Departments in the longer term. Improvements are being demonstrated through NHS England’s operational planning guidance where health systems were asked to focus on areas to deliver improved patient flow and this has included increasing the productivity of acute and non-acute hospital services, improving flow as well as clinical outcomes.”

Source location
Response from NHS England
Page 2 · response
Published 11 November 2024
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
Salford Royal Hospital Foundation Trust is the appropriate organisation to respond to the concerns raised.

Verbatim wording from the response
“I note that your Report has also been sent to Salford Royal Hospital Foundation Trust, who are the appropriate organisation to respond to the concerns raised. NHS England has asked to be sighted on the Trust’s response to the Coroner and will review this once received.”

Source location
Response from NHS England
Page 1 · response
Published 11 November 2024
Open published response
17 Oct2014
Inner North London
Concerns raised1
1. Lack of appropriate safeguards to prevent patients at risk from leaving before capacity assessment
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Stephen Atherton · 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

Stephen Atherton, aged 27, died on 16 May 2013 from severe head injuries after falling from height after leaving a neurosurgical ward. The report identified concerns about delays and communication in referrals and investigations, and about the absence of safeguards to prevent him leaving the ward despite risks to himself.

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 appropriate safeguards to prevent patients at risk from leaving before capacity assessment
Wider context from the report
“(4) The neurosurgical ward from which Mr Atherton self-discharged was not locked. This was despite the risk he posed to himself and the fact that the staff were clear he should not be free to leave, without medical assessment of his capacity to self-discharge. I heard evidence that the current legislative framework and case law means that locking of wards is not acceptable. Whilst it is clear that locking ward doors by default is not appropriate, I did not hear compelling evidence as to why mechanisms could not be put in place to facilitate temporary locking. I am concerned that the legal position is being interpreted so that no appropriate safeguards exist, which would have prevented Mr Atherton from absconding. This raises concerns that future deaths could result in such circumstances, if this issue is not addressed. ”
Source location
Stephen Atherton · Prevention of Future Deaths report
Page 2 · concerns
Open source report

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

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised3

Failure to assess capacity to decide to leave hospital

Lack of clarity in the standard operating procedure for patients leaving hospital before clinical assessment

Delays in clinical assessment resulting in patients leaving hospital before assessment

Linked responses

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.7

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Lack of appropriate safeguards to prevent patients at risk from leaving before capacity assessment

Stated actions 7

Respondent positions 1