PFD report

Jack Stephen TAYLOR · Prevention of Future Deaths report

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Issued 28 Jan 2022•West Sussex

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
9

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
19

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised9

  1. Mismatch between AWOL and missing-person risk assessment grading criteria
    Part of recurring concern: Unreliable missing-person responsePart of recurring concern: Unsafe management of inpatient leave and absence
  2. Unavailability of patient transport for absconding-patient returns
  3. Inadequate monitoring and progression of missing-person investigations
    Part of recurring concern: Unreliable missing-person response
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.12

  1. Action

    Escalate medium-risk missing-person reports without an assigned officer within two hours to G99 and, if necessary, the Critical Incident Manager.

    Stated by Sussex PoliceStated completedThe respondent said that this action was complete when they made their response on 3 February 2022.
  2. Action

    Have the Duty Inspector support sergeants by dip-checking threat assessments and the quality and sufficiency of lines of enquiry for medium-risk cases from mental health facilities.

    Stated by Sussex PoliceStated completedThe respondent said that this action was complete when they made their response on 3 February 2022.
  3. Action

    Co-develop a Missing Persons Template and accompanying action plan to improve information sharing and joint risk assessment.

    Stated by Sussex PoliceStated in progressThe respondent said that this action was in progress when they made their response on 3 February 2022.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    Sussex Partnership Foundation Trust is responsible for addressing S18 powers and Mill View Hospital matters.

    Stated by Sussex PoliceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Mismatch between AWOL and missing-person risk assessment grading criteria

Wider context from the report

“2. The joint Sussex Partnership NHS Trust & Sussex Police ‘Absent Without Leave (AWOL) Policy’ I heard evidence that the risk assessment grading criteria set out in Appendix B of this policy did not match the risk assessment grading criteria for missing persons as defined by the College of Policing. I heard evidence that the policy did not require the PICU staff to provide a copy of an up-to-date risk assessment document or their completed AWOL forms at an early stage when reporting a patient as having absconded. I heard evidence that the PICU staff did not routinely discuss the clinician’s assessment of the grading of the level of risk (i.e. high, medium, low) with the police call-taker nor ask for the police call-taker’s decision on such risk level despite it being a requirement of the policy document. I am concerned that the lack of effective joint working may hamper the swift return of high risk patients to the secure environment of the ward which is necessary for their own and others protection. ”

Is this part of a recurring concern?

Yes — Unreliable missing-person response; Unsafe management of inpatient leave and absence.

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

Unavailability of patient transport for absconding-patient returns

Wider context from the report

“1. s.18 Mental Health Act 1983 powers & Mill View Hospital. During the inquest Mill View Hospital accepted that it was their responsibility to secure the return of a patient who was detained under s.3 of the Mental Health Act 193 and who had absconded. However I heard that they were often not able to do so without the support of the police. The evidence I heard was that the Psychiatric Intensive Care Unit (PICU), known as the Pavilion Ward, rarely had sufficient staff resources to allow them to send the required minimum of 2 staff members to try and negotiate a return of an absconding patient. I also heard that, if the Hospital considered that the patient would be unwilling to return, it would require them to send at least 5 appropriately trained staff members. This would mean that the staffing of other wards would be impacted and also that the Prevention and Management of Violence and Aggression (PMVA) trained team might not be available for any other incidents. In addition the evidence was that the Hospital had no means of transporting a patient in these circumstances. The Pavilion Ward Matron informed me that the ward relied on assistance from the police in relation to all patients who absconded from the PICU. The matron was not aware of any circumstances where Mill View Hospital had utilised its powers under s.18(1) of the Mental Health Act 1983 to authorise in writing ‘any other person’ to exercise their powers to seek the return of an absconding patient. I am concerned that Mill View Hospital rely solely upon the police to assist them when the police have their own resourcing issues. I am further concerned that the Hospital has not considered the full range of their powers to secure the return of PICU patients who might pose a significant risk of harm, or death, to themselves and/or others after absconding. ”

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

Inadequate monitoring and progression of missing-person investigations

Wider context from the report

“3. Sussex Police’s use of their Missing Persons Policy I heard evidence that the trigger for the interventions required by this policy is that the missing persons report should be transferred onto the Niche system within 2 hours of a unit being assigned to take initial details. In this inquest no units were available to be assigned for over 9 hours due to the high level of demand on both the Brighton and Worthing response teams. Throughout this time the control of the investigation remained with the duty response team. I am concerned that the missing persons investigations are not adequately monitored and progressed due to other demands on the duty response teams attention. I am concerned that opportunities to swiftly locate and return a vulnerable or high risk missing person to the secure ward will be missed when the interventions of specialist officers are not triggered. ”

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 to discuss and confirm AWOL risk grading with police call-takers

Wider context from the report

“2. The joint Sussex Partnership NHS Trust & Sussex Police ‘Absent Without Leave (AWOL) Policy’ I heard evidence that the risk assessment grading criteria set out in Appendix B of this policy did not match the risk assessment grading criteria for missing persons as defined by the College of Policing. I heard evidence that the policy did not require the PICU staff to provide a copy of an up-to-date risk assessment document or their completed AWOL forms at an early stage when reporting a patient as having absconded. I heard evidence that the PICU staff did not routinely discuss the clinician’s assessment of the grading of the level of risk (i.e. high, medium, low) with the police call-taker nor ask for the police call-taker’s decision on such risk level despite it being a requirement of the policy document. I am concerned that the lack of effective joint working may hamper the swift return of high risk patients to the secure environment of the ward which is necessary for their own and others protection. ”

Is this part of a recurring concern?

Yes — Unreliable police-hospital exchange of risk information during mental-health patient supervision.

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 require early provision of current risk assessments and completed AWOL forms

Wider context from the report

“2. The joint Sussex Partnership NHS Trust & Sussex Police ‘Absent Without Leave (AWOL) Policy’ I heard evidence that the risk assessment grading criteria set out in Appendix B of this policy did not match the risk assessment grading criteria for missing persons as defined by the College of Policing. I heard evidence that the policy did not require the PICU staff to provide a copy of an up-to-date risk assessment document or their completed AWOL forms at an early stage when reporting a patient as having absconded. I heard evidence that the PICU staff did not routinely discuss the clinician’s assessment of the grading of the level of risk (i.e. high, medium, low) with the police call-taker nor ask for the police call-taker’s decision on such risk level despite it being a requirement of the policy document. I am concerned that the lack of effective joint working may hamper the swift return of high risk patients to the secure environment of the ward which is necessary for their own and others protection. ”

Is this part of a recurring concern?

Yes — Unreliable sharing of information about absent mental-health patients with police; Unsafe management of inpatient leave and absence.

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 trigger specialist-officer interventions for vulnerable or high risk missing persons

Wider context from the report

“3. Sussex Police’s use of their Missing Persons Policy I heard evidence that the trigger for the interventions required by this policy is that the missing persons report should be transferred onto the Niche system within 2 hours of a unit being assigned to take initial details. In this inquest no units were available to be assigned for over 9 hours due to the high level of demand on both the Brighton and Worthing response teams. Throughout this time the control of the investigation remained with the duty response team. I am concerned that the missing persons investigations are not adequately monitored and progressed due to other demands on the duty response teams attention. I am concerned that opportunities to swiftly locate and return a vulnerable or high risk missing person to the secure ward will be missed when the interventions of specialist officers are not triggered. ”

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

Insufficient appropriately trained staffing to secure the return of absconding PICU patients

Wider context from the report

“1. s.18 Mental Health Act 1983 powers & Mill View Hospital. During the inquest Mill View Hospital accepted that it was their responsibility to secure the return of a patient who was detained under s.3 of the Mental Health Act 193 and who had absconded. However I heard that they were often not able to do so without the support of the police. The evidence I heard was that the Psychiatric Intensive Care Unit (PICU), known as the Pavilion Ward, rarely had sufficient staff resources to allow them to send the required minimum of 2 staff members to try and negotiate a return of an absconding patient. I also heard that, if the Hospital considered that the patient would be unwilling to return, it would require them to send at least 5 appropriately trained staff members. This would mean that the staffing of other wards would be impacted and also that the Prevention and Management of Violence and Aggression (PMVA) trained team might not be available for any other incidents. In addition the evidence was that the Hospital had no means of transporting a patient in these circumstances. The Pavilion Ward Matron informed me that the ward relied on assistance from the police in relation to all patients who absconded from the PICU. The matron was not aware of any circumstances where Mill View Hospital had utilised its powers under s.18(1) of the Mental Health Act 1983 to authorise in writing ‘any other person’ to exercise their powers to seek the return of an absconding patient. I am concerned that Mill View Hospital rely solely upon the police to assist them when the police have their own resourcing issues. I am further concerned that the Hospital has not considered the full range of their powers to secure the return of PICU patients who might pose a significant risk of harm, or death, to themselves and/or others after absconding. ”

Is this part of a recurring concern?

Yes — Unreliable response to patient absconding.

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

Reliance solely on police assistance to secure the return of absconding PICU patients

Wider context from the report

“1. s.18 Mental Health Act 1983 powers & Mill View Hospital. During the inquest Mill View Hospital accepted that it was their responsibility to secure the return of a patient who was detained under s.3 of the Mental Health Act 193 and who had absconded. However I heard that they were often not able to do so without the support of the police. The evidence I heard was that the Psychiatric Intensive Care Unit (PICU), known as the Pavilion Ward, rarely had sufficient staff resources to allow them to send the required minimum of 2 staff members to try and negotiate a return of an absconding patient. I also heard that, if the Hospital considered that the patient would be unwilling to return, it would require them to send at least 5 appropriately trained staff members. This would mean that the staffing of other wards would be impacted and also that the Prevention and Management of Violence and Aggression (PMVA) trained team might not be available for any other incidents. In addition the evidence was that the Hospital had no means of transporting a patient in these circumstances. The Pavilion Ward Matron informed me that the ward relied on assistance from the police in relation to all patients who absconded from the PICU. The matron was not aware of any circumstances where Mill View Hospital had utilised its powers under s.18(1) of the Mental Health Act 1983 to authorise in writing ‘any other person’ to exercise their powers to seek the return of an absconding patient. I am concerned that Mill View Hospital rely solely upon the police to assist them when the police have their own resourcing issues. I am further concerned that the Hospital has not considered the full range of their powers to secure the return of PICU patients who might pose a significant risk of harm, or death, to themselves and/or others after absconding. ”

Is this part of a recurring concern?

Yes — Unreliable Mental Health Act detention arrangements.

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 consider the full range of powers to secure the return of absconding PICU patients

Wider context from the report

“1. s.18 Mental Health Act 1983 powers & Mill View Hospital. During the inquest Mill View Hospital accepted that it was their responsibility to secure the return of a patient who was detained under s.3 of the Mental Health Act 193 and who had absconded. However I heard that they were often not able to do so without the support of the police. The evidence I heard was that the Psychiatric Intensive Care Unit (PICU), known as the Pavilion Ward, rarely had sufficient staff resources to allow them to send the required minimum of 2 staff members to try and negotiate a return of an absconding patient. I also heard that, if the Hospital considered that the patient would be unwilling to return, it would require them to send at least 5 appropriately trained staff members. This would mean that the staffing of other wards would be impacted and also that the Prevention and Management of Violence and Aggression (PMVA) trained team might not be available for any other incidents. In addition the evidence was that the Hospital had no means of transporting a patient in these circumstances. The Pavilion Ward Matron informed me that the ward relied on assistance from the police in relation to all patients who absconded from the PICU. The matron was not aware of any circumstances where Mill View Hospital had utilised its powers under s.18(1) of the Mental Health Act 1983 to authorise in writing ‘any other person’ to exercise their powers to seek the return of an absconding patient. I am concerned that Mill View Hospital rely solely upon the police to assist them when the police have their own resourcing issues. I am further concerned that the Hospital has not considered the full range of their powers to secure the return of PICU patients who might pose a significant risk of harm, or death, to themselves and/or others after absconding. ”

Is this part of a recurring concern?

Yes — Unreliable Mental Health Act detention arrangements; Unreliable lawful decision-making for mental health patient detention and return.

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

Escalate medium-risk missing-person reports without an assigned officer within two hours to G99 and, if necessary, the Critical Incident Manager.

Verbatim wording from the response

“3.1 – Escalation if resources prevent allocation within 2 hours”

Source location

2022-0029-Response-from-Sussex-Police_Published
Page 2 · response
Published 3 February 2022

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

Have the Duty Inspector support sergeants by dip-checking threat assessments and the quality and sufficiency of lines of enquiry for medium-risk cases from mental health facilities.

Verbatim wording from the response

“Consideration has been given to whether command responsibility should be transferred to the Divisional Inspector, rather than remain at Sergeant level. However, the demand on the Inspector that this would generate could result in oversight actually being lost rather than improved, so the responsibility will remain at Sergeant level. The Duty Inspector will now instead support sergeants who have command of medium risk persons reported missing from mental health facilities by reviewing threat assessments and the quality and sufficiency of lines of enquiry that are set. This will be done as a dip-check, with random sampling to ensure consistency and quality.”

Source location

2022-0029-Response-from-Sussex-Police_Published
Page 3 · response
Published 3 February 2022

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

Co-develop a Missing Persons Template and accompanying action plan to improve information sharing and joint risk assessment.

Verbatim wording from the response

“Developing a Missing Persons Template (including an action plan)”

Source location

2022-0029-Response-from-Sussex-Police_Published
Page 1 · response
Published 3 February 2022

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

Review the Missing Person Team’s terms of reference to identify enhancements to its support during the initial response phase.

Verbatim wording from the response

“3.4 Missing Person Team Terms of Reference to be reviewed The terms of reference to which the missing person team works is to be reviewed by the Force ‘Missing Persons Working Group’.”

Source location

2022-0029-Response-from-Sussex-Police_Published
Page 3 · response
Published 3 February 2022

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

Embed the completed Missing Persons Template, protocol and joint action plan into the revised multi-agency AWOL policy and practice.

Verbatim wording from the response

“Work will take place to move towards having a final draft in May 2022, when the completed template and accompanying protocol surrounding it will then be embedded into the multi-agency Absence Without Leave (AWOL) policy which is currently subject to multi-agency review and revision.”

Source location

2022-0029-Response-from-Sussex-Police_Published
Page 2 · response
Published 3 February 2022

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

Review Sergeants’ existing missing-person training to include obtaining and assessing information and intelligence.

Verbatim wording from the response

“3.5 Training provided to Sergeants The existing training that is currently provided to Sergeants who oversee missing person investigations will be reviewed by our Learning & Professional Development Team, who are responsible for preparing and delivering training. Current training includes the function of command, assessing threat, risk & harm, setting and monitoring of proportionate lines of enquiry and handover processes. We intend to include now additionally obtaining and assessing information & intelligence (as referred to in 3.3 above). Where the training can be enhanced, additional formal training and/or Continued Professional Development will be introduced.”

Source location

2022-0029-Response-from-Sussex-Police_Published
Page 4 · response
Published 3 February 2022

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

Notify the investigation officer when a missing person’s location is identified and escalate cases without an assigned officer to G99 or the Critical Incident Manager.

Verbatim wording from the response

“When information is received relating to the location of a missing person and attendance by an officer is necessary, an officer will be assigned to that location in line with the threat, harm and risk presented.”

Source location

2022-0029-Response-from-Sussex-Police_Published
Page 3 · response
Published 3 February 2022

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

Co-develop a missing persons template and accompanying protocol for timely information-sharing and joint risk assessment.

Verbatim wording from the response

“Developing a Missing Persons Template (including an action plan)”

Source location

2022-0029-Response-from-Sussex-Partnership-NHS-Foundation-Trust_Published
Page 2 · response
Published 3 February 2022

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

Co-develop a joint missing persons action plan defining proportionate actions and tasks for finding missing patients.

Verbatim wording from the response

“Additionally, to improve information flow and the overall response to missing persons, it was agreed that work would commence on co-developing a joint missing persons action plan so both agencies can agree actions and tasks in relation to finding a missing person proportionate to the presenting risks.”

Source location

2022-0029-Response-from-Sussex-Partnership-NHS-Foundation-Trust_Published
Page 2 · response
Published 3 February 2022

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

Revise the multi-agency AWOL Policy and embed the missing persons template, protocol and action plan into policy and practice.

Verbatim wording from the response

“Work will take place to move towards having a final draft in May, when the completed template and accompanying protocol surrounding it will then be embedded into the multi-agency Absent Without Leave (AWOL) Policy which is currently subject to multi-agency review and revision.”

Source location

2022-0029-Response-from-Sussex-Partnership-NHS-Foundation-Trust_Published
Page 2 · response
Published 3 February 2022

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

Implement an escalation process clarifying site-wide colleague support when additional resources are needed for patient return.

Verbatim wording from the response

“In addition, an improved escalation process has been implemented and added to the AWOL Policy so that SPFT staff are clear about site-wide support available from colleagues when additional resource is required to facilitate a patient's return.”

Source location

2022-0029-Response-from-Sussex-Partnership-NHS-Foundation-Trust_Published
Page 3 · response
Published 3 February 2022

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

Improve vehicle access and availability arrangements so staff can return patients when police involvement is unnecessary.

Verbatim wording from the response

“SPFT recognises that police involvement in the return of a patient may be or may become unnecessary and, at times, a patient's return by SPFT staff, rather than the police, can be preferable to some patients. Alternatively, there will be cases where risk is such that the police must be involved in the return, hence the importance of robust risk assessments, clear communication and a dynamic joint action plan.”

Source location

2022-0029-Response-from-Sussex-Partnership-NHS-Foundation-Trust_Published
Page 3 · response
Published 3 February 2022

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

Sussex Partnership Foundation Trust is responsible for addressing S18 powers and Mill View Hospital matters.

Verbatim wording from the response

“This relates to our partners at Sussex Partnership Foundation Trust (SPFT) and therefore we are unable to comment on it. In the work we have completed in response to your concerns, we have worked closely with our SPFT partners and are advised that they will, of course, be addressing this in their response to you.”

Source location

2022-0029-Response-from-Sussex-Police_Published
Page 1 · response
Published 3 February 2022

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The Missing Person Team cannot take all investigations from first report because it is small and lacks 24/7 cover.

Verbatim wording from the response

“The team has specialist expertise and effective working relationships with many of our partners, providing real benefit to investigations. However, as a small team, cover is not 24/7 so it would not be possible for the team to take on all investigations from first report. The review will consider what, if any, enhancements can be made to assist their colleagues. We anticipate this review will be completed and presented to our Vulnerability Board in April 2022 and any changes that result will take effect immediately.”

Source location

2022-0029-Response-from-Sussex-Police_Published
Page 4 · response
Published 3 February 2022

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

Command responsibility for medium-risk missing persons will remain with sergeants because transferring it could reduce oversight through increased inspector demand.

Verbatim wording from the response

“Consideration has been given to whether command responsibility should be transferred to the Divisional Inspector, rather than remain at Sergeant level. However, the demand on the Inspector that this would generate could result in oversight actually being lost rather than improved, so the responsibility will remain at Sergeant level. The Duty Inspector will now instead support sergeants who have command of medium risk persons reported missing from mental health facilities by reviewing threat assessments and the quality and sufficiency of lines of enquiry that are set. This will be done as a dip-check, with random sampling to ensure consistency and quality.”

Source location

2022-0029-Response-from-Sussex-Police_Published
Page 3 · response
Published 3 February 2022

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

S18 Mental Health Act powers and Mill View Hospital matters fall outside the respondent’s remit.

Verbatim wording from the response

“This relates to our partners at Sussex Partnership Foundation Trust (SPFT) and therefore we are unable to comment on it. In the work we have completed in response to your concerns, we have worked closely with our SPFT partners and are advised that they will, of course, be addressing this in their response to you.”

Source location

2022-0029-Response-from-Sussex-Police_Published
Page 1 · response
Published 3 February 2022

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.7

  1. 1

    Write the escalation and location-notification changes into the revised missing persons policy and obtain sign-off.

    Stated by Sussex PoliceStated plannedThe respondent said that this action was planned when they made their response on 3 February 2022.
  2. 2

    Adopt proactive joint meetings between the Missing Person Team and Mill View Hospital about patients at heightened risk of going missing.

    Stated by Sussex PoliceStated completedThe respondent said that this action was complete when they made their response on 3 February 2022.
  3. 3

    Communicate internally about the enhanced missing-person practice and training content before formal training rollout.

    Stated by Sussex PoliceStated plannedThe respondent said that this action was planned when they made their response on 3 February 2022.
  4. 4

    Conduct proactive joint meetings about patients at heightened risk of going missing or becoming absent without leave.

    Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 February 2022.
  5. 5

    Roll out AWOL reduction interventions, including the evidence-based rating tool, across the Trust.

    Stated by Sussex Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 February 2022.
  6. 6

    Use an evidence-based rating tool in Eastbourne to identify patients at greatest AWOL risk and support risk mitigation.

    Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 February 2022.
  7. 7

    Monitor improvements from the measures and respond to further changes needed to improve the response to missing patients.

    Stated by Sussex Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 3 February 2022.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Formal training enhancements may be delayed because rewriting and integrating additions into existing training cycles takes time.

    Stated by Sussex PoliceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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

Write the escalation and location-notification changes into the revised missing persons policy and obtain sign-off.

Verbatim wording from the response

“This change, and that outlined in 3.1 above, will also be written into policy, which is currently under review. We anticipate it being signed-off and update within the next two months.”

Source location

2022-0029-Response-from-Sussex-Police_Published
Page 3 · response
Published 3 February 2022

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

Adopt proactive joint meetings between the Missing Person Team and Mill View Hospital about patients at heightened risk of going missing.

Verbatim wording from the response

“Proactive approach to managing Missing Patients Work has been identified to improve how both Sussex Police and SPFT take a more proactive approach to managing patients who could go missing.”

Source location

2022-0029-Response-from-Sussex-Police_Published
Page 2 · response
Published 3 February 2022

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 internally about the enhanced missing-person practice and training content before formal training rollout.

Verbatim wording from the response

“We anticipate this review to be completed by the end of April 2022. Any additions to training programme can take some time to implement due to re-writing of and building into existing training cycles. Accepting this, we will be communicating internally about many of these aspects as soon as possible, and whilst not as comprehensive as structured training, it will provide an overview and guidance prior to formal training roll-out.”

Source location

2022-0029-Response-from-Sussex-Police_Published
Page 4 · response
Published 3 February 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Conduct proactive joint meetings about patients at heightened risk of going missing or becoming absent without leave.

Verbatim wording from the response

“Proactive Approach to Managing Missing Patients”

Source location

2022-0029-Response-from-Sussex-Partnership-NHS-Foundation-Trust_Published
Page 2 · response
Published 3 February 2022

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

Roll out AWOL reduction interventions, including the evidence-based rating tool, across the Trust.

Verbatim wording from the response

“Finally, more generally, SPFT has an ongoing AWOL reduction project which has been led by the team at the Department of Psychiatry in Eastbourne. That team introduced a number of interventions, including an evidence-based rating tool which identifies those most at risk and enables improved risk mitigation. The measures have led to a sustained reduction in AWOLs in Eastbourne, and are being rolled out across the Trust.”

Source location

2022-0029-Response-from-Sussex-Partnership-NHS-Foundation-Trust_Published
Page 3 · response
Published 3 February 2022

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 an evidence-based rating tool in Eastbourne to identify patients at greatest AWOL risk and support risk mitigation.

Verbatim wording from the response

“Finally, more generally, SPFT has an ongoing AWOL reduction project which has been led by the team at the Department of Psychiatry in Eastbourne. That team introduced a number of interventions, including an evidence-based rating tool which identifies those most at risk and enables improved risk mitigation. The measures have led to a sustained reduction in AWOLs in Eastbourne, and are being rolled out across the Trust.”

Source location

2022-0029-Response-from-Sussex-Partnership-NHS-Foundation-Trust_Published
Page 3 · response
Published 3 February 2022

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

Monitor improvements from the measures and respond to further changes needed to improve the response to missing patients.

Verbatim wording from the response

“I am confident that the above measures and ongoing collaborative working between SPFT and Sussex Police will result in an improved response when patients go missing. We will monitor the improvements and respond to any further changes needed, to best meet our patients' needs. I envisage that it would be helpful to you to see the updated AWOL Policy so, once ratified, I will arrange for a copy to be sent to you. In the meantime, I hope that the content of this letter provides you with the assurances you need to address your concerns.”

Source location

2022-0029-Response-from-Sussex-Partnership-NHS-Foundation-Trust_Published
Page 3 · response
Published 3 February 2022

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

Formal training enhancements may be delayed because rewriting and integrating additions into existing training cycles takes time.

Verbatim wording from the response

“We anticipate this review to be completed by the end of April 2022. Any additions to training programme can take some time to implement due to re-writing of and building into existing training cycles. Accepting this, we will be communicating internally about many of these aspects as soon as possible, and whilst not as comprehensive as structured training, it will provide an overview and guidance prior to formal training roll-out.”

Source location

2022-0029-Response-from-Sussex-Police_Published
Page 4 · response
Published 3 February 2022

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026