South London and Maudsley NHS Foundation Trust
NHS / Health Body
Action Taken
South London and Maudsley NHS Foundation Trust will mandate MDT risk assessments after AWOL incidents, require consultation with on-call managers out-of-hours, deliver refresher training on the AWOL policy, and document Section 17 leave conditions in care plans. They will also remind wards of the requirement for staff to accompany police when returning patients and reinforce joint action planning with police. (AI summary)
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Dear Sian Reeves, Thank you for your letter dated 7th of April 2025 regarding the Prevention of Future Death Report. We acknowledge the concerns raised during the inquest and are committed to addressing each point thoroughly and constructively. Below is the Trust’s formal response and the actions we are implementing to prevent similar incidents in the future.
1. Individualised Assessment Following AWOL Incidents It was noted that staff working on the NPU lacked a clear understanding of the South London and Maudsley NHS Foundation Trust (SLAM) policy on AWOL, Missing and Absent Persons. There was no evidence of an individualised risk assessment prior to the suspension of Section 17 leave in Mr McDonald’s case, contrary to policy expectations. Action: AWOL Policy – Strengthened Measures to Prevent Future Incidents
• The Trust’s AWOL Policy now mandates that a Multi-Disciplinary Team (MDT) risk assessment must be conducted following every Absence Without Leave (AWOL) incident. The Responsible Clinician is required to promptly review the patient's leave status thereafter.
• During out-of-hours periods, staff must consult the on-call manager, Specialist Registrar, or Consultant to ensure appropriate clinical oversight and risk management.
2
•Bespoke Refresher training on all aspects of the AWOL Policy will be delivered to the National Psychosis Unit. Attendance will be monitored to ensure consistent understanding and application of the policy.
• All wards must ensure that Section 17 leave conditions are explicitly documented in each patient’s individualised care plan. Compliance will be monitored through Mental Health Act Audits via the Trust’s electronic audit system, Tendable.
• These actions will be shared and cascaded via Trust-wide through a blue light bulletin. Each directorate will be required to provide formal confirmation of full implementation to ensure accountability.
2. Staff Accompaniment During Police Return of Patients The policy states that Trust staff must accompany the police when the police are returning a patient from home. This did not occur when Mr McDonald was located at his mother’s residence on 24 February 2023, and there was no evidence that staff considered this requirement. Actions:
• All wards will be reminded of the requirement for staff to accompany the police when patients are returning to the ward with the police as per Trust’s AWOL Policy.
• Emphasis will be placed on collaborative working between clinical staff and the police in guidance and staff briefings which will be shared by the 16th of June 2025.
3. Joint Action Planning with Police The policy requires a jointly agreed action plan between police and Trust staff if police involvement is anticipated in returning a patient to hospital. This was not undertaken in Mr McDonald’s case. Actions:
• The current AWOL Policy (updated November 2023) explicitly includes the requirement for a jointly agreed action plan between police and Trust staff if police involvement is anticipated in returning a patient to hospital.
• The NPU will receive refresher training and all other Trust wards will receive a briefing/bulletin to reinforce the policy's procedures, including joint action planning.
• This will include a requirement that for all patients on Section 17 leave, an MDT-developed care plan will outline steps to be followed in the event of non- return.
3 We are taking these matters extremely seriously and are committed to ensuring staff are fully equipped to implement policy requirements in practice. We remain focused on improving the safety and quality of care for all service users.
1. Individualised Assessment Following AWOL Incidents It was noted that staff working on the NPU lacked a clear understanding of the South London and Maudsley NHS Foundation Trust (SLAM) policy on AWOL, Missing and Absent Persons. There was no evidence of an individualised risk assessment prior to the suspension of Section 17 leave in Mr McDonald’s case, contrary to policy expectations. Action: AWOL Policy – Strengthened Measures to Prevent Future Incidents
• The Trust’s AWOL Policy now mandates that a Multi-Disciplinary Team (MDT) risk assessment must be conducted following every Absence Without Leave (AWOL) incident. The Responsible Clinician is required to promptly review the patient's leave status thereafter.
• During out-of-hours periods, staff must consult the on-call manager, Specialist Registrar, or Consultant to ensure appropriate clinical oversight and risk management.
2
•Bespoke Refresher training on all aspects of the AWOL Policy will be delivered to the National Psychosis Unit. Attendance will be monitored to ensure consistent understanding and application of the policy.
• All wards must ensure that Section 17 leave conditions are explicitly documented in each patient’s individualised care plan. Compliance will be monitored through Mental Health Act Audits via the Trust’s electronic audit system, Tendable.
• These actions will be shared and cascaded via Trust-wide through a blue light bulletin. Each directorate will be required to provide formal confirmation of full implementation to ensure accountability.
2. Staff Accompaniment During Police Return of Patients The policy states that Trust staff must accompany the police when the police are returning a patient from home. This did not occur when Mr McDonald was located at his mother’s residence on 24 February 2023, and there was no evidence that staff considered this requirement. Actions:
• All wards will be reminded of the requirement for staff to accompany the police when patients are returning to the ward with the police as per Trust’s AWOL Policy.
• Emphasis will be placed on collaborative working between clinical staff and the police in guidance and staff briefings which will be shared by the 16th of June 2025.
3. Joint Action Planning with Police The policy requires a jointly agreed action plan between police and Trust staff if police involvement is anticipated in returning a patient to hospital. This was not undertaken in Mr McDonald’s case. Actions:
• The current AWOL Policy (updated November 2023) explicitly includes the requirement for a jointly agreed action plan between police and Trust staff if police involvement is anticipated in returning a patient to hospital.
• The NPU will receive refresher training and all other Trust wards will receive a briefing/bulletin to reinforce the policy's procedures, including joint action planning.
• This will include a requirement that for all patients on Section 17 leave, an MDT-developed care plan will outline steps to be followed in the event of non- return.
3 We are taking these matters extremely seriously and are committed to ensuring staff are fully equipped to implement policy requirements in practice. We remain focused on improving the safety and quality of care for all service users.