Report evidence summary
Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised. 26
Surrey and Borders Partnership NHS Foundation Trust Audit uploaded MISPER documentation for completeness.
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Surrey and Borders Partnership NHS Foundation Trust Emphasise and disseminate the MISPER process to ward staff and managers.
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Surrey and Borders Partnership NHS Foundation Trust Strengthen joint learning and improvement work with Surrey Police through the Crisis Concordat.
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Surrey and Borders Partnership NHS Foundation Trust Require ward managers to conduct quarterly audits of MISPER Appendices A and B and discuss emerging issues at the Acute Care Forum.
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Surrey and Borders Partnership NHS Foundation Trust Assign Clinical Assurance staff to test ward compliance with the MISPER agreement.
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Surrey and Borders Partnership NHS Foundation Trust Arrange mandatory MISPER training for all unit staff, with completion required by the end of February 2015.
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Surrey and Borders Partnership NHS Foundation Trust Include the identified concerns in the corporate action plan to support ongoing organisational learning.
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Surrey and Borders Partnership NHS Foundation Trust Develop and implement a flow chart directing staff through enquiries after a person goes missing.
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Surrey and Borders Partnership NHS Foundation Trust Require staff to complete and upload MISPER Appendix A information to RiO for missing-person reports.
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Surrey Police Continue working with NHS and medical partners to establish effective communication channels and consistent responses to mental-health issues.
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Surrey Police Modify TPT briefing training to align with the Surrey Police Missing Person Procedure’s definition of absent.
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Surrey Police Implement training and a familiarisation programme for police and mental-health or medical staff after completing the policy review.
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Surrey Police Draft mental-health booklets to improve officers’ and staff’s awareness of mental-health issues.
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Surrey Police Circulate guidance to personnel emphasising provision of all necessary information for accurate missing-person risk assessments.
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Surrey Police Update the Missing Person Policy to comply with current Association of Chief Police Officers guidelines.
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Surrey Police Develop and enhance the Force training programme addressing missing-person procedures and mental-health risk assessment.
View source
Surrey Police Roll out Force-wide e-learning packages on the Mental Capacity Act and practical responses to mental ill health.
View source
Surrey Police Provide section 136 information on Mobile Data Terminals to support paperwork completion and access to relevant legislation.
View source
Surrey Police Review the Force Missing Person Policy with NHS partners to address missing-person responsibilities and communication issues.
View source
Surrey Police Maintain Mental Health Liaison Officers who advise colleagues and receive periodic specialist updates.
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Surrey Police Maintain policies and procedures so they remain current, legally compliant and consistent with relevant guidance.
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Surrey Police Introduce Mobile Data Terminals across the Force to provide officers with documented information directly during missing-person responses.
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Surrey Police Share the updated Missing Person Policy with the Surrey Adult Safeguarding Board and discuss feedback with partners.
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Surrey Police Review mental-health policies and procedures with Crisis Care Concordat partners and draft new policies where required.
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Surrey Police Complete the review of initial training for probationary police officers and confirm it is fit for purpose.
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Surrey Police Deliver Mental Health Briefings to supervisors covering recent learning, protocols, legislation and case law.
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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. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure of communication between police and hospital staff about missing-person status
Wider context from the report “• Training procedures in respect of the police and hospital staff on Elgar Ward in the case of reports of missing persons and lack of understanding of areas of responsibility and appropriate actions.
• Critical information required to make an informed risk assessment as to whether was missing or absent was omitted.
• The decision to re classify from missing to absent was not communicated to the hospital
• As a result no enquiries or investigations were made by any agency to ascertain Mr Hafele’s whereabouts
• Adequate training on the Surrey Wide Response Agreement and Surrey Police Missing Person Procedure did not take place
• In relation to the Police, specific training with regards to risk assessments for mental health patients was lacking
• Surrey Police TPT briefing training did not correspond to the definition of Absent given in the Surrey Police Missing Person
• Ineffective communications between Police and Elgar Ward
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to make enquiries or investigations to ascertain a missing person’s whereabouts
Wider context from the report “• Training procedures in respect of the police and hospital staff on Elgar Ward in the case of reports of missing persons and lack of understanding of areas of responsibility and appropriate actions.
• Critical information required to make an informed risk assessment as to whether was missing or absent was omitted.
• The decision to re classify from missing to absent was not communicated to the hospital
• As a result no enquiries or investigations were made by any agency to ascertain Mr Hafele’s whereabouts
• Adequate training on the Surrey Wide Response Agreement and Surrey Police Missing Person Procedure did not take place
• In relation to the Police, specific training with regards to risk assessments for mental health patients was lacking
• Surrey Police TPT briefing training did not correspond to the definition of Absent given in the Surrey Police Missing Person
• Ineffective communications between Police and Elgar Ward
” Is this part of a recurring concern? Yes — Unreliable missing-person response .
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure of briefing training to accurately reflect the definition of absent
Wider context from the report “• Training procedures in respect of the police and hospital staff on Elgar Ward in the case of reports of missing persons and lack of understanding of areas of responsibility and appropriate actions.
• Critical information required to make an informed risk assessment as to whether was missing or absent was omitted.
• The decision to re classify from missing to absent was not communicated to the hospital
• As a result no enquiries or investigations were made by any agency to ascertain Mr Hafele’s whereabouts
• Adequate training on the Surrey Wide Response Agreement and Surrey Police Missing Person Procedure did not take place
• In relation to the Police, specific training with regards to risk assessments for mental health patients was lacking
• Surrey Police TPT briefing training did not correspond to the definition of Absent given in the Surrey Police Missing Person
• Ineffective communications between Police and Elgar Ward
” Is this part of a recurring concern? No recurring-concern membership is currently published.
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Lack of adequate training for police and hospital staff on missing-person procedures, responsibilities and risk assessment
Wider context from the report “• Training procedures in respect of the police and hospital staff on Elgar Ward in the case of reports of missing persons and lack of understanding of areas of responsibility and appropriate actions .
• Critical information required to make an informed risk assessment as to whether was missing or absent was omitted.
• The decision to re classify from missing to absent was not communicated to the hospital
• As a result no enquiries or investigations were made by any agency to ascertain Mr Hafele’s whereabouts
• Adequate training on the Surrey Wide Response Agreement and Surrey Police Missing Person Procedure did not take place
• In relation to the Police, specific training with regards to risk assessments for mental health patients was lacking
• Surrey Police TPT briefing training did not correspond to the definition of Absent given in the Surrey Police Missing Person
• Ineffective communications between Police and Elgar Ward
” Is this part of a recurring concern? Yes — Unreliable missing-person response .
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Omission of critical information required for missing-or-absent risk assessment
Wider context from the report “• Training procedures in respect of the police and hospital staff on Elgar Ward in the case of reports of missing persons and lack of understanding of areas of responsibility and appropriate actions.
• Critical information required to make an informed risk assessment as to whether was missing or absent was omitted.
• The decision to re classify from missing to absent was not communicated to the hospital
• As a result no enquiries or investigations were made by any agency to ascertain Mr Hafele’s whereabouts
• Adequate training on the Surrey Wide Response Agreement and Surrey Police Missing Person Procedure did not take place
• In relation to the Police, specific training with regards to risk assessments for mental health patients was lacking
• Surrey Police TPT briefing training did not correspond to the definition of Absent given in the Surrey Police Missing Person
• Ineffective communications between Police and Elgar Ward
” Is this part of a recurring concern? No recurring-concern membership is currently published.
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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 Audit uploaded MISPER documentation for completeness.
Verbatim wording from the response “photo and description of general appearance. To ensure that relevant information is recorded and reported to the Police as part of the missing persons report, it is now expected practice for all staff to ensure that they upload this document onto our Electronic Patient System (RiO) in a timely manner. This will now be audited for completeness.” Source location 2014-0511-Response-by-Surrey-Borders-Partnership-NHS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Emphasise and disseminate the MISPER process to ward staff and managers.
Verbatim wording from the response “We have further emphasised the importance of the Missing Persons (MISPER) process to all our staff on these units, including making this a part of our improvement work in the reduction of the numbers of people who may be Absence Without Leave (AWOL). A member of the Clinical Assurance team is specifically assigned to wards with the view to ensure compliance with the MISPER agreement is tested.” Source location 2014-0511-Response-by-Surrey-Borders-Partnership-NHS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen joint learning and improvement work with Surrey Police through the Crisis Concordat.
Verbatim wording from the response “We have enhanced our focus on reducing the number of people who go missing from our wards and we believe the work we are doing through our improvement team as outlined in our Quality Improvement Plan will start to show positive results. We have a close working relationship with Surrey Police which has further been strengthened through the Crisis Concordat work we are doing. This is also providing the opportunity for us to learn together on aspects on which we can improve.” Source location 2014-0511-Response-by-Surrey-Borders-Partnership-NHS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require ward managers to conduct quarterly audits of MISPER Appendices A and B and discuss emerging issues at the Acute Care Forum.
Verbatim wording from the response “The MISPER agreement has been widely discussed in teams and presented at our managers meetings on a number of occasions. In addition mandatory training has now been arranged for all staff within the unit to be completed by the end of February 2015. To further ensure embedding of the process, we will now require our ward managers to undertake a quarterly audit on MISPER forms Appendix A & B and any emerging issues are discussed at our Acute Care Forum meeting.” Source location 2014-0511-Response-by-Surrey-Borders-Partnership-NHS
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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 Assign Clinical Assurance staff to test ward compliance with the MISPER agreement.
Verbatim wording from the response “We have further emphasised the importance of the Missing Persons (MISPER) process to all our staff on these units, including making this a part of our improvement work in the reduction of the numbers of people who may be Absence Without Leave (AWOL). A member of the Clinical Assurance team is specifically assigned to wards with the view to ensure compliance with the MISPER agreement is tested.” Source location 2014-0511-Response-by-Surrey-Borders-Partnership-NHS
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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 Arrange mandatory MISPER training for all unit staff, with completion required by the end of February 2015.
Verbatim wording from the response “The MISPER agreement has been widely discussed in teams and presented at our managers meetings on a number of occasions. In addition mandatory training has now been arranged for all staff within the unit to be completed by the end of February 2015. To further ensure embedding of the process, we will now require our ward managers to undertake a quarterly audit on MISPER forms Appendix A & B and any emerging issues are discussed at our Acute Care Forum meeting.” Source location 2014-0511-Response-by-Surrey-Borders-Partnership-NHS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include the identified concerns in the corporate action plan to support ongoing organisational learning.
Verbatim wording from the response “We have included the concerns you have raised in our corporate action plan to ensure that there is ongoing learning from these. We would like to offer our sincere condolences again to the Hafele family for their loss and hope that the steps we have taken as outlined above assures you and them, that we have learnt and continue to learn from this event.” Source location 2014-0511-Response-by-Surrey-Borders-Partnership-NHS
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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 implement a flow chart directing staff through enquiries after a person goes missing.
Verbatim wording from the response “A flow chart clearly outlining the process to make inquiries further to a missing persons report to the Police has been developed. It contains clear directions on the process that needs to be undertaken when someone has not returned to the ward. This standardisation of approach will support staff in making enquiries or investigations when a person using our services goes missing from the wards.” Source location 2014-0511-Response-by-Surrey-Borders-Partnership-NHS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require staff to complete and upload MISPER Appendix A information to RiO for missing-person reports.
Verbatim wording from the response “Staff have been further clearly instructed to complete Appendix A of the MISPER agreement. This outlines details such as name and location of the unit reporting the missing person, the risk assessment zoning and clear justification for the category, personal details of the person who may have gone missing with an option to attach a” Source location 2014-0511-Response-by-Surrey-Borders-Partnership-NHS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with NHS and medical partners to establish effective communication channels and consistent responses to mental-health issues.
Verbatim wording from the response “The Force is committed to working with NHS and other medical partners to ensure effective channels of communication and consistent response and handling of mental ill health issues.” Source location 2014-0511-Response-by-Surrey-Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Modify TPT briefing training to align with the Surrey Police Missing Person Procedure’s definition of absent.
Verbatim wording from the response “This was noted by the Force and the TPT briefing training will be modified to take account of this and ensure consistency in the future.” Source location 2014-0511-Response-by-Surrey-Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement training and a familiarisation programme for police and mental-health or medical staff after completing the policy review.
Verbatim wording from the response “Once the review of the MPP is complete, training and a familiarisation programme will be implemented for officers and mental health/medical staff (which may even include consideration for joint enterprise) to ensure that all staff understand and implement the policy and work effectively together to deliver successful outcomes for missing individuals.” Source location 2014-0511-Response-by-Surrey-Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Draft mental-health booklets to improve officers’ and staff’s awareness of mental-health issues.
Verbatim wording from the response “• Other materials have been and are being produced to assist officers to properly and effectively support individuals in mental health crisis. For example, s136 information is now available on MDTs so that officers can complete appropriate s136 paperwork but also have access to relevant data and legislation to assist them. Mental health booklets are being drafted to enhance the awareness of officer and staff knowledge about mental health issues. It is proposed that this information will be made available in an interactive format, available on officers MDTs.” Source location 2014-0511-Response-by-Surrey-Police
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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 Circulate guidance to personnel emphasising provision of all necessary information for accurate missing-person risk assessments.
Verbatim wording from the response “Guidance has since been circulated to all appropriate personnel to emphasise and ensure, so far as is possible, that all necessary details are provided in order for an accurate risk assessment to be made.” Source location 2014-0511-Response-by-Surrey-Police
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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 Missing Person Policy to comply with current Association of Chief Police Officers guidelines.
Verbatim wording from the response “This document has been recently updated to ensure that it is compliant with the new Association of Chief Police Officers (ACPO) guidelines.” Source location 2014-0511-Response-by-Surrey-Police
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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 Develop and enhance the Force training programme addressing missing-person procedures and mental-health risk assessment.
Verbatim wording from the response “• The Force has in place a comprehensive program of training and is developing and enhancing this as an on-going matter.” Source location 2014-0511-Response-by-Surrey-Police
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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 Roll out Force-wide e-learning packages on the Mental Capacity Act and practical responses to mental ill health.
Verbatim wording from the response “• Two Back to Basics e-briefing/learning packages:” Source location 2014-0511-Response-by-Surrey-Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide section 136 information on Mobile Data Terminals to support paperwork completion and access to relevant legislation.
Verbatim wording from the response “• Other materials have been and are being produced to assist officers to properly and effectively support individuals in mental health crisis. For example, s136 information is now available on MDTs so that officers can complete appropriate s136 paperwork but also have access to relevant data and legislation to assist them. Mental health booklets are being drafted to enhance the awareness of officer and staff knowledge about mental health issues. It is proposed that this information will be made available in an interactive format, available on officers MDTs.” Source location 2014-0511-Response-by-Surrey-Police
Open published response
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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 the Force Missing Person Policy with NHS partners to address missing-person responsibilities and communication issues.
Verbatim wording from the response “The Force’s Missing Person Policy (MPP) is currently under review. The existing MPP, a policy jointly produced with NHS partners, is a comprehensive document setting out the way in which risk can be assessed and appropriate levels of responsibility:” Source location 2014-0511-Response-by-Surrey-Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain Mental Health Liaison Officers who advise colleagues and receive periodic specialist updates.
Verbatim wording from the response “• The Force’s Mental Health Liaison Officers (MHLOs) are a group of 21 officers and staff from across the Force and from various roles who have opted to ‘up skill’ in this area and develop their knowledge.” Source location 2014-0511-Response-by-Surrey-Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain policies and procedures so they remain current, legally compliant and consistent with relevant guidance.
Verbatim wording from the response “The Force will endeavour to remain vigilant in ensuring that these policies are maintained and up to date, compliant with statutory provisions and relevant guidance. The Force will continue in its endeavours to ensure staff and officers are trained appropriately in order to minimise the risk of breaches in procedure.” Source location 2014-0511-Response-by-Surrey-Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce Mobile Data Terminals across the Force to provide officers with documented information directly during missing-person responses.
Verbatim wording from the response “The risk of this happening again will also be significantly mitigated by the full introduction of Mobile Data Terminals (M.D.T’s). This will ensure that officers receive the necessary documented information first hand and do not have to rely on information being verbally relayed to them.” Source location 2014-0511-Response-by-Surrey-Police
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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 Share the updated Missing Person Policy with the Surrey Adult Safeguarding Board and discuss feedback with partners.
Verbatim wording from the response “This has been shared with the Surrey Adult Safeguarding Board and feedback will be provided and discussed at the next meeting in January 2015. The Force continues to work with its partners to ensure compliance with existing policy.” Source location 2014-0511-Response-by-Surrey-Police
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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 mental-health policies and procedures with Crisis Care Concordat partners and draft new policies where required.
Verbatim wording from the response “• The Force has reviewed all its (internal and external) mental health policies and procedures within the last 6 months and this review will be an on-going process alongside Crisis Care Concordat partners. New policies and procedures have been drafted where a requirement was identified as a need, for example the ‘Conveyance of Mental Health Patients’ and ‘Restraint of Mental Health Patients within a Mental Health or medical environment’.” Source location 2014-0511-Response-by-Surrey-Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete the review of initial training for probationary police officers and confirm it is fit for purpose.
Verbatim wording from the response “• A review of the initial training provided to Probationary police officers was carried out in accordance with peer review recommendations. This is now complete and the training has been found to be fit for purpose.” Source location 2014-0511-Response-by-Surrey-Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver Mental Health Briefings to supervisors covering recent learning, protocols, legislation and case law.
Verbatim wording from the response “• Mental Health Briefings to Supervisors will begin in February 2015 and will include an overview of issues and learning from recent cases; reminder of protocols; revision of relevant legislation and case law.” Source location 2014-0511-Response-by-Surrey-Police
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing Missing Person Policy comprehensively provides risk assessment criteria and clearly allocates responsibility for enquiries.
Verbatim wording from the response “The Force’s Missing Person Policy (MPP) is currently under review. The existing MPP, a policy jointly produced with NHS partners, is a comprehensive document setting out the way in which risk can be assessed and appropriate levels of responsibility:” Source location 2014-0511-Response-by-Surrey-Police
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The communication failure concerned notification of an absent classification, not mental health issues in the wider context.
Verbatim wording from the response “8. “Ineffective communications between police and Elgar Ward”” Source location 2014-0511-Response-by-Surrey-Police
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing police training arrangements are comprehensive, and probationary officer training was reviewed and found fit for purpose.
Verbatim wording from the response “• The Force has in place a comprehensive program of training and is developing and enhancing this as an on-going matter.” Source location 2014-0511-Response-by-Surrey-Police
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing policies and procedures are considered fit for purpose and consistent with current professional guidance.
Verbatim wording from the response “Summary” Source location 2014-0511-Response-by-Surrey-Police
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