Mental health informal leave guidance
Lack of robust criteria and clear guidance for staff making decisions about informal ground leave for mental health patients.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
99match
Alexandra Tolley
The coroner noted that the patient's care plan prioritized self-management over safety in absconding situations, which appeared incompatible with Mental Health Act detention duties. Concerns were also raised about informal decision-making for ground leave and unclear definitions of physical interventions for staff.
Matched on
terms: health, informal, leave, mental
PFD report
98match
Maureen Leaver
The coroner identified a lack of medical supervision for inpatients and inadequate systems for managing acutely ill elderly patients with complex conditions. There were also concerns about an insufficient understanding of legal duties under the Mental Health Act 1983 and Mental Capacity Act 2005 during patient transfers.
Matched on
terms: health, leave, mental
PFD report
93match
Lee Grimes
The coroner identified a lack of action by Next Stage staff following overdose disclosures, insufficient follow-up with mental health services, and inadequate staff training. Concerns also relate to the mental health trust's unclear guidance for managing such disclosures.
Matched on
terms: guidance, health, mental
PFD report
93match
Thomas Smith
The coroner identified insufficient staff knowledge and training on synthetic cannabinoid dangers in mental health settings. Additionally, the system for assessing risks during s.17 leave was inadequate, as escorting staff lacked access to vital patient information.
Matched on
terms: health, leave, mental
PFD report
89match
Helen England
The coroner noted the absence of a protocol or guidance for Mental Health Nurses on when to refer a discharge decision to a doctor for patients who self-harmed, particularly those under a Community Treatment Order.
Matched on
terms: guidance, health, mental
PFD report
89match
David Squire
The coroner raised concerns that NHS England's smoke-free hospital guidance impedes the proper staging of Section 17 leave for mental health patients who smoke, potentially increasing absconding risk. The guidance also fails to adequately consider the distinct needs and risks of mental health hospitals.
Matched on
terms: guidance, health, leave, mental
PFD report
89match
John Richardson
The coroner noted confusion among staff regarding a voluntary patient's leave status and the absence of a specific leave policy for voluntary patients, unlike those sectioned under the Mental Health Act.
Matched on
terms: health, leave, mental
PFD report
89match
Kimberley Smith
The coroner identified no clear written policy for informal patients requesting leave from an Acute Care Unit, specifically regarding risk assessments and risk management. Concerns also included outstanding aspects of a protocol for managing alcohol detoxification on mental health wards.
Matched on
terms: health, informal, leave, mental
PFD report
85match
David Fowler
The coroner identified a lack of family involvement and communication regarding the decision to remove a patient from a Mental Health Act section. There was no formal policy for informing families or inviting them to MDT meetings, leading to confusion among staff regarding responsibilities.
Matched on
terms: health, mental
PFD report
81match
Micael McMonigle
The coroner identified gaps in staff knowledge and adherence to policies for informal patient leave, leading to inadequate risk assessments and unclear communication of leave conditions. Significant delays and non-compliance with missing patient procedures were also noted.
Matched on
terms: informal, leave
PFD report
81match
Wendy Telfer
The coroner noted insufficient training for physical healthcare staff regarding mental health needs and the application of the Mental Health Act. Concerns were also raised about the persistent lack of available psychiatric beds, which caused delays in patient transfer.
Matched on
terms: health, mental
PFD report
81match
Katy Samuels
The Coventry and Warwickshire Partnership NHS Trust's Section 17 Leave Policy for detained patients requires clearer guidance on escorted leave, including verification of escorts and confirmation that patients leave with them. The report also notes insufficient time allocated for staff handovers.
Matched on
terms: guidance, leave
PFD report
81match
Jude Lloyd
The coroner identified inadequate diabetes care planning and monitoring before discharge, alongside insufficient communication between inpatient, community mental health teams, and GPs. There was also a lack of formal mental capacity assessments and robust audit systems.
Matched on
terms: health, mental
PFD report
77match
Yousef Shokri-Gharab
The coroner noted Mersey Care's informal patient leave policy is outdated, unreviewed since 2007, and inconsistent with current practice. It requires immediate updating to include multidisciplinary consensus, patient vulnerability considerations, and clear documentation.
Matched on
terms: informal, leave
PFD report
77match
Danuta Corbett
The coroner identified gaps in the documentation and application of the leave policy for informal patients, particularly regarding risk assessments and decisions for escorted leave. Critical patient information, including risks associated with her home, was not handed over to the escort.
Matched on
terms: informal, leave
PFD report
77match
Tommy Faisali
The coroner identified insufficient qualifications for staff assessing psychiatric referrals and noted gaps in the completion and communication of risk assessments, including suicide risk, within mental health teams, exacerbated by a lack of continuity of care.
Matched on
terms: health, mental
PFD report
77match
Janet Muller
The coroner noted incomplete nursing records, handovers, and care plans, with audits failing to identify these deficiencies. Concerns were also raised about patients detained under the Mental Health Act being able to abscond due to insufficient security and inadequate staffing levels.
Matched on
terms: health, mental
PFD report
77match
Marshall Metcalfe and Jane Ireland
The coroner raises concerns about Children's Social Care closing cases for young people during mental health inpatient admissions, leading to a lack of social worker input into discharge planning, which may impede therapeutic relationships and increase risks post-discharge.
Matched on
terms: health, mental
PFD report
73match
Christopher James Morgan
The coroner raised concerns regarding the lack of communication with family and carers before changing a patient's risk level for leave, and the absence of a clear policy on staff-to-patient ratios for escorted leave from psychiatric wards.
Matched on
terms: leave
PFD report
73match
Andrew Hall
Inadequate documentation and communication among mental health, healthcare, and prison staff regarding the deceased's condition and self-harm risk were identified. Also noted were insufficient observation, unadministered medication, and deficiencies in CCTV systems and staff training.
Matched on
terms: health, mental
PFD report
73match
Charlotte Bevan and Zaani Malbrouck
The coroner noted a lack of evidence that multi-disciplinary team meetings are consistently held or that comprehensive, widely-circulated care plans are consistently developed for pregnant individuals with known mental health conditions.
Matched on
terms: health, mental
PFD report
73match
Rohan Fitzsimons
The coroner identified insufficient availability of in-patient mental health beds, leading to delays in Mental Health Act Assessments. These delays could result in individuals taking their own lives before assessment and bed provision.
Matched on
terms: health, mental
PFD report
73match
Khuong Lam
The coroner noted insufficient guidance for reviewing or revoking Section 17 leave upon ward transfer or to a PICU, and raised concerns about the need for Responsible Clinicians to be informed of such transfers for leave review. The report also suggested applying lessons from a study on the efficacy of two escorts for patients on Section 17 leave...
Matched on
terms: guidance, leave
PFD report
73match
Lewis Francis
The coroner noted a lack of a mechanism for transferring individuals in police custody with serious charges to medium secure mental health facilities, and insufficient understanding of the needs of prisoners on the autistic spectrum.
Matched on
terms: health, mental
LGO / SPSO decision
73match
23-009-939b - Barts Health NHS Trust (23 009 939b)
Summary: We will not investigate this complaint about the decision to detain a patient under the Mental Health Act, because of concerns they were refusing treatment for their physical health. This is because there was a right to appeal the assessment outcome through a tribunal and it would have been reasonable to use this.
Matched on
terms: health, mental
PFD report
69match
Keward Guy Domonic Harding
An urgent mental health assessment, requested on March 19th, 2013, was not completed before April 2nd, 2013. A timely visit by a health professional may have detected a decline in physical health, potentially allowing for active treatment to prevent death.
Matched on
terms: health, mental
PFD report
69match
Jonathan Zucker
The coroner identified the absence of a requirement or system for a lead clinician to oversee and coordinate Mr. Zucker's care, which was provided by both private and NHS mental health services.
Matched on
terms: health, mental
PFD report
69match
Keith Heatley
The coroner identified a lack of formal policy or procedure in Wales for reviewing and assessing voluntary patients before home leave, leading to reliance on undefined 'best practice'. There were also insufficient procedures for hospital staff to liaise with families and community psychiatric nurses regarding home leave preparedness and support.
Matched on
terms: leave
PFD report
69match
Patricia Chambers
The report identifies concerns regarding the West London Mental Health Trust's Discharge Medication Summary and 7-Day Follow-Up processes, noting they need to be redrawn. Issues were also raised about the system for collecting, recording, and disseminating information.
Matched on
terms: health, mental
PFD report
69match
Mena Terefi
The mental health service faces demand for direct referrals that significantly exceeds its capacity, leading to insufficient resources to meet service obligations and creating an increased risk for individuals requiring care.
Matched on
terms: health, mental
CQC action
69match
Bushey Fields Hospital
Identify ways in which informal patients can leave the ward and understand their rights to leave.
Matched on
terms: informal, leave
IMB recommendation
68match
Isle of Wight (2020)
Again the issue of prisoners experiencing significant mental health issues has been overlooked. The HMIP recommendation to Her Majesty’s Prison and Probation Service (HMPPS) to ensure that mentally ill prisoners are transferred to appropriate facilities, in line with national guidance, was rejected. What plans are in place to ensure that mentally ill prisoners are managed in line with...
Matched on
terms: guidance, health, mental
PFD report
65match
Leslie Morrison
The coroner raised concerns about the lack of formal mental capacity assessment and DoLS consideration both in the community and upon hospital admission. There was also insufficient communication between care providers, resulting in crucial patient information not being shared with the hospital.
Matched on
terms: mental
PFD report
65match
William Savory
There was a delay in initiating the missing persons protocol, and some staff were not aware of the requirement to commence procedures immediately for informal patients, creating a risk of future delays.
Matched on
terms: informal
IMB recommendation
65match
Heathrow Immigration Removal Centre (2021)
The policy which results in people with severe mental health issues being held in IRCs should be reviewed. Despite the introduction of a new Detention Service Order (DSO) published in June 2020 on ‘mental vulnerability and immigration detention’, the Board feels that further action is necessary as the problem remains.
Matched on
terms: health, mental
PHSO casework decision
65match
P-004375 - Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Mr E complained his daughter was wrongly sectioned and the Trust failed to communicate with him about her presentation before leave. This caused distress to both.
Matched on
terms: health, leave
LGO / SPSO decision
64match
201104524 - Mental Welfare Commission for Scotland
Mrs C complained that the Mental Welfare Commission for Scotland (the Commission) failed to respond appropriately to a letter sent to them by her son. The letter contained her son's concerns about his detention and treatment under Mental Health legislation. In addition, Mrs C complained that the Commission failed to tell her or her husband about the letter,...
Matched on
terms: health, mental
Committee recommendation
63match
#1 - Fourth report: Unequal impact? Coronavirus, disability and access to services: full Report
We welcome the Government’s decision to discontinue the Coronavirus Act’s Mental Health Act provisions, which potentially relaxed requirements for sectioning, against the grain of overdue and much-needed reforms, and which thankfully proved to be unnecessary in England. We will continue to push for progress towards implementation of our recommendations on Care Act and Children and Families Act provisions...
Matched on
terms: guidance, health, mental
PFD report
61match
Leah Levine
The coroner noted concerns regarding the absence of clear, written conditions for temporary hospital leave, including supervision responsibility and observation regimes, leading to conflicting expectations.
Matched on
terms: leave
PFD report
61match
Rastislav Petrisko
The coroner identified inconsistencies in risk assessment and its application to granting leave, noting a significant delay in police notification for an absconded patient due to a 'period of grace' in the existing policy.
Matched on
terms: leave
IMB recommendation
60match
Gatwick IRC/RSTHF (2022)
Increase the Detention Gatekeeper’s threshold(s) for bringing men with mental health issues into detention and improve facilities and support to enhance the prospect of release from detention for men exhibiting deterioration of their mental health in detention (section 4.4).
Matched on
terms: health, mental
PHSO casework decision
60match
P-001067 - Essex Partnership University NHS Foundation Trust
Mr and Mrs A complained about inadequate communication before Mrs A's discharge from a mental health hospital, her premature discharge, and a lack of dignity and appropriate care during a subsequent seclusion. They also cited poor complaint handling.
Matched on
terms: health, mental
LGO / SPSO decision
60match
23-014-778a - Lewisham & Greenwich NHS Trust (23 014 778a)
Summary: We consider London Borough of Lewisham and Lewisham and Greenwich NHS Trust did not appropriately seek the views of Mrs Y’s supported accommodation before deciding she could not return there from hospital. Also, the Council did not carry out a Mental Capacity Act assessment and best interest decision in line with the relevant guidance. That caused Mrs...
Matched on
terms: guidance, mental
Committee recommendation
59match
#8 - 1st Report - Unequal impact? Coronavirus, disability and access to services: interim Report on temporary provisions...
The Coronavirus Act’s emergency changes to the Mental Health Act 1983 were intended for use as a last resort should mental health staff resources be depleted by the pandemic to the extent that people needing assessment or detention in hospital become a risk to themselves or others. These provisions have not come into force in England because, through...
Matched on
terms: health, mental
PFD report
57match
Danny Sweet
The coroner identified a lack of consistent assessment and discharge decisions, noting gaps in managing patients with capacity who decline care despite family concerns. The Serious Incident Report was also found to be incomplete.
Matched on
classifier match
PFD report
57match
Anthony Preston
The discharge procedure lacked robustness, with no documentary proof of calls to the Crisis Team or immediate written notice of discharge, leaving a high-risk patient without support.
Matched on
classifier match
PFD report
57match
Andrew Codling
A community health team's voicemail message to the deceased was too brief, stating the office was closing and advising to call back Monday, thus missing an opportunity to reinforce alternative help and crisis numbers for immediate support.
Matched on
terms: health
PFD report
57match
Thomas Wedrychowski
The coroner noted that expert evidence suggested more frequent diabetes monitoring than annually for individuals with a higher baseline risk, and that physical healthcare findings were not consistently shared between primary and secondary care providers.
Matched on
terms: health
IMB recommendation
56match
Swaleside (2021)
The Board has concerns regarding the mental health of residents who have suffered long-term lock-down. (see sections 5 and 6.2)
Matched on
terms: health, mental
IMB recommendation
56match
Bronzefield (2024)
The Board remains concerned about the number of prisoners coming into the prison, having been identified as acutely mentally unwell (including some prolific self-harmers), either requiring section under the Mental Health Act or admission to a secure hospital. How does the Prison Service plan to provide support to manage these prisoners, who cannot be easily moved to secure...
Matched on
terms: health, mental