Mental health informal leave guidance
Lack of robust criteria and clear guidance for staff making decisions about informal ground leave for mental health patients.
Source spread
Where this theme appears
This theme appears across 9 independent accountability sources, so the source mix matters as much as the headline total.
79 PFD reports
2 committee recs
2 CQC actions
3 IOPC recs
12 IMB recs
2 DHR recs
10 PHSO decisions
12 LGO/SPSO decisions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Prevention of Future Deaths reports(79)— showing 50 strongest matches
Keward Guy Domonic Harding
Concerns: 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.
Overdue
Christopher James Morgan
Concerns: 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.
Overdue
Linda Hudson
Concerns: Concerns were raised regarding the hospital's discharge process, specifically that the deceased was discharged with limited medication requiring daily collection due to self-harm risk, her family was not contacted, and the first follow-up nurse visit was scheduled too long after discharge.
Overdue
Yousef Shokri-Gharab
Concerns: The coroner noted Mersey Care's informal patient leave policy is outdated, unreviewed since 2007, and inconsistent with current practice.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.
Response (Mersey Care NHS Foundation Trust): • The Corporate Governance Team was tasked with ensuring all policies are reviewed and updated. • The policy identified by the coroner was reviewed and updated. • 50 policies were … (AI summary)
Responded
Maureen Leaver
Concerns: 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.
Overdue
Andrew Hall
Concerns: 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.
Response (HM Prison and Probation Service): • The prison stated that ACCT reviews include recorded information from the mental health team, and mental health staff receive ACCT training, with further courses arranged for visiting psychiatrists. • … (AI summary)
Overdue
Danuta Corbett
Concerns: 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.
Response (Sussex Partnership NHS Trust): • The consultant psychiatrist stated she now carefully reviews notes taken during ward reviews. • The Trust reinforced with staff the requirement to complete retrospective notes in specific circumstances. • … (AI summary)
Responded
Alexander Holt
Concerns: The coroner noted insufficient challenge to Mr Holt's minimised suicidal intent and poor information flow, notably staff being unaware of his recent self-harm attempt. This led to inadequate risk assessment and disrupted care continuity.
Overdue
Leah Levine
Concerns: 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.
Response (Greater Manchester West NHS): • The Salford Directorate developed a procedure for granting leave to informal patients. • The procedure outlines multidisciplinary team considerations for leave, including medication management, supervision, and crisis plans. • … (AI summary)
Responded
Tommy Faisali
Concerns: 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.
Overdue
Charlotte Bevan and Zaani Malbrouck
Concerns: 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.
Response: • Dr Kathryn Bundle has been tasked to review perinatal pathway arrangements against NICE guidelines, with draft algorithms developed and being consulted on. • The Trust plans to prepare and … (AI summary)
Responded
Brian Shillinglaw
Concerns: The provided text is incomplete and does not contain specific concerns.
Overdue
Helen England
Concerns: 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.
Response (Helen England): • The Community Treatment Order Procedure has been amended. • A process for communicating the amended procedure to staff is underway. (AI summary)
Responded
Tracey Lynch
Concerns: No specific concerns are provided in the truncated text.
Overdue
Lee Grimes
Concerns: 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.
Response (Next Stage): • The communications policy was revised to detail procedures for reporting client concerns. • All staff receive training on this policy during initial induction, and it will be added to … (AI summary)
Response (Response 5 Borough Partnership NHS Trust): • A review of procedures for processing referrals to Wigan Recovery North was undertaken. • The team's correct contact details, including the telephone number, were re-circulated to partner agencies. • … (AI summary)
Responded
Leslie Morrison
Concerns: 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.
Response (MORRISON Leslie): • The Trust stated it would implement a Trustwide initiative to develop a policy or pathway for proactively gathering information for complex and vulnerable patients. • The Trust is piloting … (AI summary)
Overdue
Danny Sweet
Concerns: 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.
Response (Cornwall NHS Trust): • The Trust stated it would launch a review into the clinical risk assessment of people presenting with suicidal thoughts or acts, to be completed by the end of February … (AI summary)
Responded
Pamela Gressman
Concerns: The coroner noted insufficient consideration of potential physical effects from reported ingestion of foreign bodies and the lack of a clear treatment and observation plan, which might contribute to similar deaths.
Response (Tees Esk amd Water Valleys NHS Trust): • The Trust has shared findings and lessons learned from the internal investigation and inquest with the ward multidisciplinary team and across the Trust. • A review of the observation … (AI summary)
Responded
Rohan Fitzsimons
Concerns: 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.
Response (Avon and Wiltshire NHS Trust): • The Section 17 procedure was amended to require a mental state examination by a registered practitioner and authorisation of leave prior to commencement, with a new recording template developed. … (AI summary)
Overdue
Anthony Preston
Concerns: 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.
Overdue
Oliver Ford
Concerns: The coroner raised concerns regarding the telephone triage process, noting a need to include a risk assessment within it and ensure all risk assessments are documented. There were also concerns about the weekend cover for the PCLS service to prevent delays in patient follow-up.
Response (Avon and Wiltshire NHS Trust): • The telephone triage process now incorporates an Access Trigger Tool to conduct in-depth risk assessments. • Clinicians are required to document a full rationale for decision-making on RIO following … (AI summary)
Responded
Micael McMonigle
Concerns: 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.
Overdue
Margaret Richardson
Concerns: The coroner noted the need for a robust and comprehensive action plan with timescales, to be implemented following a Serious Incident Investigation and inquest findings.
Overdue
John Jones
Concerns: The coroner identified a suboptimal therapeutic environment where a patient admitted for group therapy remained largely isolated and did not engage with available sessions. Concerns were raised about ensuring patient engagement when their condition makes accepting help difficult.
Response (Nightingale Hospital): • The hospital reviewed, reconfigured, and formalised the multidisciplinary team (MDT) meeting for general psychiatric patients. • The hospital will develop and introduce a decision-making pathway for MDT discussions, including … (AI summary)
Overdue
John Jones
Concerns: The coroner noted a delay of approximately one week in notifying Mr. Jones' GP of his discharge from the Crisis Team, which meant he lacked community support. There was also no clear provision in the Crisis Team's protocols for immediate GP notification.
Overdue
Peter Usher
Concerns: Inadequate detailed assessment of Mr Usher included a failure to obtain information from family, GP, and emergency services. Concerns were also noted regarding non-compliance with Trust policies for Section 136 assessments and medical staffing levels.
Response (North East London NHS Foundation Trust): • The Trust has committed to addressing the issues identified in the Regulation 28 report. • An action plan detailing these commitments has been provided. (AI summary)
Response (Borough Mental Team): • The Borough Mental Team implemented a new system to scan and digitally store all Section 136 paperwork, cross-referencing it with intelligence reports. • A streamlined flowchart was created to … (AI summary)
Responded
Wendy Telfer
Concerns: 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.
Response (Northern Eastern and Western Devon NHS Trust): • The CCG monitors delayed discharge data from mental health wards through local boards and contract review meetings. • Devon Partnership NHS Trust (DPT) has temporarily repurposed rehabilitation unit capacity … (AI summary)
Response (Royal Devon and Exeter NHS Trust): • The Royal Devon and Exeter NHS Trust stated that its Liaison Psychiatry Team provided formal training on the Mental Health Act (MHA) to at least 496 staff in 2016, … (AI summary)
Response (Devon Partnership NHS Trust): • The Trust established a central bed management team, secured additional contracted bed capacity, and extended the operational times of Crisis Resolution and Home Treatment teams. • The Trust implemented … (AI summary)
Responded
Jonathan Zucker
Concerns: 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.
Response (PSYCH): • The Royal College of Psychiatrists stated that its Professional Practice and Ethics Committee would consider issues related to consultant accountability, ownership during transitions, and care involving multiple teams. • … (AI summary)
Response (Department of Health): • Department of Health officials liaised with the Royal College of Psychiatrists regarding the concerns raised. • The Royal College of Psychiatrists intends to ask its Professional Practice and Ethics … (AI summary)
Responded
Janet Muller
Concerns: 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.
Overdue
Sabrina Walsh
Concerns: The coroner noted the absence of CCTV in corridors and communal areas at Woodlands Acute Care, which hindered the rapid location of vulnerable patients. Installing CCTV could save valuable minutes in such situations.
Response (NHS England): • The Sussex Partnership NHS Foundation Trust is reviewing its policies regarding CCTV use. • The Trust committed to installing CCTV in the entrance areas of its 12 psychiatric intensive … (AI summary)
Response (Sussex NHS Trust): • The Trust consulted with patients, families, and staff regarding the installation of CCTV. • The Trust confirmed it is implementing CCTV in the entrance areas of all 12 Acute … (AI summary)
Responded
Khuong Lam
Concerns: 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 across Wales.
Overdue
Andrew Codling
Concerns: 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.
Response (East London NHS Trust): • A new protocol has been developed and implemented within the Community Mental Health Teams (CMHTs). • The protocol provides guidance to staff on the use of mobile phones in … (AI summary)
Responded
Rastislav Petrisko
Concerns: 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.
Overdue
Keith Heatley
Concerns: 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.
Response (Swansea Bay Health Board): • The Health Board implemented a checklist to ensure multi-disciplinary team members and the patient's family are involved in leave decisions for informal patients. • A ward clerk was appointed … (AI summary)
Responded
Patricia Chambers
Concerns: 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.
Overdue
David Squire
Concerns: 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.
Response (NHS England): • NHS England stated it would raise the complexity of the issue regarding smoking and Section 17 leave with the Department of Health & Social Care. • NHS England indicated … (AI summary)
Responded
John Richardson
Concerns: 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.
Response (Sussex Partnership NHS Trust): • The Trust decided to incorporate guidance on voluntary patients' leave into its new Acute Care Operational Policy. • The guidance addresses principles for voluntary patients and s.17 leave. • … (AI summary)
Responded
Thomas Wedrychowski
Concerns: 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.
Overdue
David Fowler
Concerns: 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.
Response (Transitional Rehabilitation Unit): • A comprehensive review of policies and procedures for care planning, decision-making, and communication with families was completed. • Revised policies, including the MH28 Care Planning and Care Coordination policy … (AI summary)
Responded
Lewis Francis
Concerns: 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.
Response (Wiltshire Police): • Wiltshire Police is working with other force areas and the South West Provider Collaborative to develop a proposed Memorandum of Understanding. (AI summary)
Response (Avon and Somerset Police): • Avon and Somerset Police confirmed its Inspector is engaging with the South West Provider Collaborative to develop a Memorandum of Understanding for transferring mentally ill prisoners. • The South … (AI summary)
Responded
Kimberley Smith
Concerns: 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.
Response (Surrey and Borders Partnership NHS Foundation Trust): • The Trust stated it would develop a standalone written policy for informal patient leave, incorporating risk assessments, monitoring, and reporting missing persons. • The Trust confirmed it had completed … (AI summary)
Responded
Katy Samuels
Concerns: 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.
Response (Coventry and Warwickshire Partnership NHS Trust): • The Trust amended its Section 17 Leave Policy to include clear definitions of leave types and ensure patients are collected and returned by identified persons. • Reporting forms were … (AI summary)
Responded
Antony Schofield
Concerns: Inadequate risk review and care planning were identified before discharge and during Home Based Treatment Team care, particularly for managing suicidal thoughts. The coroner also noted HBTT staff did not sufficiently assess risk changes, and found deficiencies in the trust's audit system and SUI investigation.
Response (Greater Manchester Mental Health NHS Foundation Trust): • The Trust updated Standard Operating Procedures for inpatient wards and the Home Based Treatment Team (HBTT) to clarify requirements for risk assessments and discharge planning. • New processes include … (AI summary)
Responded
Jude Lloyd
Concerns: 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.
Response (Greater Manchester Mental Health NHS Foundation Trust): • The Trust has implemented an eLearning training package for staff on physical health, including diabetes management, and employs physical health nurses within CMHTs to conduct annual assessments. The physical … (AI summary)
Responded
Alexandra Tolley
Concerns: 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.
Response (Leeds and York Partnership NHS Foundation Trust): • The Trust stated it would develop new Prevention, Management of Violence and Aggression (PMVA) training for all staff, including bank staff, to address decision-making and legal principles during patient … (AI summary)
Responded
Marshall Metcalfe and Jane Ireland
Concerns: 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.
Overdue
James Forryan
Concerns: The coroner raised concerns about the easy accessibility of websites and forums that openly promote suicide methods, noting insufficient regulation and enforcement action against such platforms.
Response (Department of Health and Social Care): • The Government confirmed that the Online Safety Bill will require in-scope companies to remove illegal content, including that which encourages or incites suicide, and will list encouraging or assisting … (AI summary)
Responded
Mena Terefi
Concerns: 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.
Overdue
William Savory
Concerns: 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.
Overdue
Thomas Smith
Concerns: 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.
Response (Responses from NHS England): • NHS England reported that East London NHS Foundation Trust (ELFT) delivered training to staff on "Spice" awareness and engaged local drug and alcohol service providers. • NHS England stated … (AI summary)
Overdue
Select committee recommendations(2)
#8 —
Recommendation: 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 …
Response attribution not verified
#1 —
Recommendation: 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 …
Response attribution not verified
CQC inspection actions(2)
Bushey Fields Hospital
Identify ways in which informal patients can leave the ward and understand their rights to leave.
Should Do
Personal Security Service
The provider must ensure staff responsible for care and treatment have access to suitable documents justifying use of Mental Health Act and Deprivation of Liberty prior to delivering the service.
Must Do
IOPC learning recommendations(3)
Operation Hotton recommendations - Metropolitan Police Service, September 2021
The IOPC recommends that the MPS should review whether frontline roles, particularly response policing of busy areas such as Leicester Square, are assessed as roles which carry greater risk of stress and trauma, and apply the College of Policing psychological …
Operation Hotton recommendations - Metropolitan Police Service, September 2021
The IOPC recommends that the MPS should take steps to ensure there is effective supervision and quality assurance in place for officers where there is little measurable work output to review, to ensure the maintenance of policing standards and officers’ …
Operation Hotton recommendations - Metropolitan Police Service, September 2021
The IOPC recommends that the MPS should assure itself that sufficient steps have been taken to ensure appropriate supervision and welfare is in place to prevent officers becoming isolated through their duties. This follows an investigation into allegations of misconduct …
IMB individual recommendations(12)
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.
Ministry of Justice
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).
Home Office
Isle of Wight (2020)
In 2020 there have been a number of remand prisoners requiring immediate admission to inpatient healthcare facilities in the prison and urgent referral to secure units. Are there any actions planned with HM Courts and Tribunals Service to provide appropriate psychiatric assessment in the court setting, to ensure prisoners who are significantly mentally unwell are diverted to psychiatric hospital rather …
Ministry of Justice
In Progress
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 HMIP recommendations …
Ministry of Justice
In Progress
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)
HMPPS
In Progress
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 psychiatric hospitals …
HMPPS
In Progress
Bronzefield (2024)
The number of women sent to Bronzefield under a ‘Place of Safety’ warrant has nearly doubled this year. What are the Minister’s plans to address this issue? (6.3)
Ministry of Justice
In Progress
Norwich (2022)
The Board requests again that the Prison Service looks at the care of prisoners who are located in the segregation unit for long periods of time.
HMPPS
In Progress
Heathrow Immigration Removal Centre (2022)
The Home Office needs to consider different ways of dealing with detainees who, for physical or mental reasons, feel incapable of sharing a room and should avoid using the CSU as a punishment for detainees who resist a request to share.
Home Office
Swaleside (2025)
Again, the length of time spent in the care, separation and reintegration unit (CSRU) by a number of prisoners remains too long and far exceeds regular recommendations. The Board notes the response last year about exit strategies, but there has been no improvement. What actions and strategies have been implemented to reduce the time prisoners spend in the CSRU, why …
HMPPS
Lindholme (2025)
The Board asks that the Governor considers monitoring the population of the CSU as currently many prisoners are being held there in excess of 42 days.
Governor / Director
Humber (2020)
The Board has grave concerns about the potential for long-term damage to the prisoners. We are keen to hear from the minister about the proposals he has to address this, as restrictions are removed.
Ministry of Justice
Health investigations(12)
Independent investigation: John Stevens, Woking (2001) — Rec 4
We recommend that the North West Surrey Mental Health Partnership NHS Trust review the Informal Leave Policy.
south_east
Independent investigation: John Curran, Highbury & Islington (2006) — Rec R35
The trust should review the patient leave policy and procedures on Conolly ward as a matter of urgency to ensure that the current practice is safe and compliant with CPA.
london
An independent review of the care and treatment received by … — Rec R7
The trust should review all Mental Health Act section 17 leave policies, procedures, assessments and good practice guidance to assure themselves that the requirements are scrupulously carried out. Systems need to be in place to provide evidence-based assurance that all section 17 leave on the acute admission ward conforms to …
north_east_yorkshire
An independent investigation into the care and treatment of mental … — Rec 3
The Trust AWOL policy should be amended to ensure that any decision to discharge an AWOL patient in their absence is explicitly risk assessed, supported by a detailed decision making tool, and reported on centrally to ensure practice is monitored.
Greater Manchester Mental Health NHS Foundation Trust
north_west
Accepted
An independent inquiry into the care and treatment of Ms … — Rec 7
We recommend that OHFT review its policy and guidance in respect of patients who are AWOL or missing from hospital. We further recommend that this policy and guidance be developed with partner agencies including TVP. OHFT and TVP should agree how expert advice should be sought and how concerns should …
south_east
An independent inquiry into the care and treatment of Ms … — Rec 7
Medical leave to be better co-ordinated and a standardised system of handover of care during these periods to be developed in the CMHT, with consultants making better use of the leave folder in the shared drive.
south_east
An independent inquiry into the care and treatment of Ms … — Rec 6
The “Patients who are absent without leave or who are missing from hospital” policy (CP17) needs reviewing following clarification between the police and the Trust and the crisis service and the inpatient wards on the respective responsibilities for returning patients to hospital.
south_east
Independent investigation: Shamim Akhtar, Birmingham (2000) — Rec 12
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all patients are fully assessed prior to any period of leave from hospital, and that the assessment includes a full risk assessment, a full social history, and a full medical history.
midlands
An independent inquiry into the care and treatment of Ms … — Rec 9
The review recommends that the Oxfordshire Safeguarding Adult Board consider producing a joint protocol concerning the management of vulnerable adults who become missing persons that could be applied across the TVP area.
south_east
An independent inquiry into the care and treatment of Ms … — Rec 7
The review recommends that the Oxfordshire Safeguarding Adult Board consider replicating the OSCB escalation protocol to promote better inter-agency working when responding to vulnerable persons reported missing from mental health care settings.
south_east
Independent investigation into the care and treatment of Mr G — Rec 2.10
The Independent Investigation Team recommends that the Trust address the prescribing of Section 17 leave in Mental Health Act training. The Trust must ensure that its staff and clinicians comply with the requirements relating to “leave” as set out in section 17 Mental Health Act 1983. The Trust shall provide …
Mr G who committed a homicide in 2012. Mr G was in receipt of services from Camden and Islington NHS Foundation Trust
london
Accepted
Independent investigation: Anthony Rigby, Blackburn (2002) — Rec 11
Nursing staff should assess the value of leave taken by patients on their return before further leave is planned, with a positive leave assessment acting as the main consideration for further leave.
north_west
PHSO casework decisions(10)
P-003684 — An independent provider in the Hammersmith and Fulham …
Mrs D complained staff failed to notice her brother's pneumonia, perform a risk assessment before leave, and delayed action when he didn't return, which she believed led to his death.
NHS in England
Partly Upheld
Jul 2025
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.
NHS in England
Partly Upheld
Apr 2021
P-003805 — Berkshire Healthcare NHS Foundation Trust
Mr R complained the Trust inappropriately requested a Deprivation of Liberty Safeguards (DoLS) instead of a Section 3 for his mother and failed to communicate effectively with family.
NHS in England
Aug 2025
P-004375 — Hampshire and Isle of Wight Healthcare NHS Foundation …
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.
NHS in England
Upheld
Nov 2025
P-004702 — Central and North West London NHS Foundation Trust
Ms S complained about a community nurse breaching confidentiality, delayed/missed medical reviews, false imprisonment, neglect, and defamation by Trust staff, causing distress and missed opportunities.
NHS in England
Jan 2026
P-003249 — West London NHS Trust
Ms K complained the Trust made false allegations, forced medication, and unlawfully detained her, causing fear for her freedom and inability to report crimes.
NHS in England
Dec 2024
P-002030 — Somerset NHS Foundation Trust
Mrs E complained her father was not admitted under the Mental Health Act and that the Trust pressured her family into private care. She also alleged unauthorized treatment after DoLS expired.
NHS in England
Jun 2023
P-002520 — South London and Maudsley NHS Foundation Trust
Ms H complained about the Trust's deliberate lack of care, forced medication, and negligence from 2008-2014, including wrongful detention and racial discrimination in housing, causing reputational damage.
NHS in England
Mar 2024
P-002901 — West London NHS Trust
Ms L complained she was injected against her will and falsely accused of medical fraud and violence by Trust staff while an inpatient.
NHS in England
Aug 2024
P-004426 — South West Yorkshire Partnership NHS Foundation Trust
Mrs H complained about the Trust's lack of mental health treatment despite referrals, being discharged for complaining, inaccurate information, and a staff member's inappropriate comment.
NHS in England
Nov 2025
LGO / SPSO decisions(12)
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 …
LGO (Local Government & …
Health
Apr 2024
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 …
LGO (Local Government & …
Health
Upheld
Sep 2024
19-018-519c — Brighton & Hove Clinical Commissioning Group (19 018 …
Summary: The complainant, Ms B, said she learnt in 2020 the Council, the Trust and two Clinical Commissioning Groups did not properly consider her daughter’s, Miss G’s, entitlement to free aftercare following her detainment under the Mental Health Act 1983. She also complained about the care and support provided to …
LGO (Local Government & …
Health
Upheld
Mar 2022
19-018-519b — NHS East Sussex Clinical Commissioning Group (19 018 …
Summary: The complainant, Ms B, said she learnt in 2020 the Council, the Trust and two Clinical Commissioning Groups did not properly consider her daughter’s, Miss G’s, entitlement to free aftercare following her detainment under the Mental Health Act 1983. She also complained about the care and support provided to …
LGO (Local Government & …
Health
Not Upheld
Mar 2022
22-002-419 — Staffordshire County Council
Summary: We will not investigate this complaint about a refund of care home fees and the person’s eligibility for free care under s117 of the Mental Health Act 1983, as the issue has now been resolved.
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2022
22-002-185 — Leeds City Council
Summary: We will not investigate this complaint about the Council’s decision to detain him under the Mental Health Act 1983. This is because there is insufficient evidence of fault to justify an investigation.
LGO (Local Government & …
Adult Care Services
Jul 2022
22-006-560 — Bristol City Council
Summary: We will not investigate this complaint about information provided by the Council about voting rights for people who are detained in hospital under the Mental Health Act. This is because there is insufficient evidence of injustice.
LGO (Local Government & …
Other Categories
Sep 2022
23-012-217 — Kent County Council
Summary: There was delay in revising Mr Y’s care and support plan after a review in April 2023 and a change of placement in August and a failure to complete a mental capacity assessment in line with the Code of Practice to the Mental Capacity Act. This caused avoidable confusion. …
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2024
25-000-113 — Liverpool City Council
Summary: Ms X complains the Council, Trust and ICB are not providing her with section 117 aftercare support which she is entitled to after being detained under Section 3 of the Mental Health Act 1983. We will not investigate this complaint because we have seen evidence all the organisations have …
LGO (Local Government & …
Adult Care Services
Jul 2025
24-021-630 — Bath and North East Somerset Council
Summary: We will not investigate Ms X’s complaint about the Council’s involvement in her detention under the Mental Health Act. There is not enough evidence of fault to justify our involvement. Some of Ms X’s concerns are matters for other bodies to consider.
LGO (Local Government & …
Adult Care Services
Jun 2025
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 …
SPSO (Scottish Public Se…
Scottish Government and Devolved Administration
Partly Upheld
Jul 2012
23-011-009 — Cornwall Council
Summary: We investigated a complaint about the section 117 aftercare provided to Ms A by the Council, the Trust and the ICB after she was detained under section 3 of the Mental Health Act 1983. We found no fault by any of the organisations.
LGO (Local Government & …
Adult Care Services
Not Upheld
Jun 2024
Domestic Homicide Reviews(2)
Lincoln — recommendation 3b
The Safer Lincolnshire Partnership should ensure that the University encourages all students to ‘opt in’ and when sharing information do share with the ‘nominated person’ the risk of harm to themselves and others.
Safer Lincolnshire Partnership
Lincolnshire Partnership NHS Foundation …
Lincoln — recommendation 4
The Safer Lincolnshire Partnership should ensure that the risks of increased aggression involved with watching violent films is communicated in learning bulletins. (Although fully acknowledged that the perpetrator watching violent films wasn’t known by professionals until the criminal trial, it is good learning from practitioners to be aware of this …
Safer Lincolnshire Partnership
Lincolnshire Partnership NHS Foundation …