In the circumstances it is my statutory to report to you: The MATTER OF CONCERN is as follows. The responsible clinician (RC) assessed the patient as low risk on granting an hour's unescorted leave in the local area from 13th: He said that he was not mentally unstable; which would trigger an escort: He was no expressing suicidal thoughts. The RC did not consider that Mr Petrisko was an immediate risk to himself; although the past medical history established a higher term risk He had already taken leave several times without selfharming (although unknown to the doctor he had returned drunk on 8h whilst in another unit)_ Although there was reference to recent or pending testing there was no record of the result of any screening on return from leave in this admission. A nurse indicated that being high risk made no difference to the likelihood of screening and the RC indicated that he may still be given leave if he was high risk However a mental health nurse on the ward said that he was given leave as he was low risk The risk assessments were guided by the statutory guidance of the Mental Health Act and were not subject to further local guidance: In retrospect the RC did not change his risk assessment: A missing persons form Was completed by the ward. His risk was described as concern he would take amount of and alcohol; which would affect his mental state and that it was not out of character_ In answer to the question whether he was likely to commit suicide, was written: Was admitted with overdose cocaine and medication with suicidal intent" The police were called at 21,56 and attended at 23.30, by which time emergency services were already in attendance to him in the car park, following 999 call: As he was low risk the local policy on handling patients who had absconded at the time indicated that he could be given a period of grace before the police were notified, if he not return at the allotted time. This was given as he had a history of being late back from The ward notified the police hour 49 minutes after he was due back, a period of time acknowledged to be too long: The policy in place made clear that a high risk patient should be reported immediately: The revised Trust policy continues that requirement; removes the period of grace but it to the discretion of the clinicians when to call the policy, if the patient is deemed not to be high risk: duty longer long drug drug drug large drugs did leave. leaves

The DI from the Metropolitan Police Service indicated on reviewing the case, that he would be classed as medium risk, not low risk. High risk is an immediate risk to life, when a DI is deployed immediately to investigate and search: Medium Risk is that the risk to life is not immediate, but is a concern. An investigation and search is begun within the hour: Low risk is where there are no immediate concerns. The investigation may not begin straight away but take a few She further said that an immediate action would be to identify the places from which he had been admitted before. The medical records indicated that of the last three admissions he had been brought in from the Calderwood Street Car Park on two occasions (13.12.16 and 05.01.17). That was the site where he took the final fatal overdose_ Thus if the police had been rung immediately, and assuming took no action for the whole of the first hour, would have had at least 49 minutes tO find him in this site, which on the facts of the present case would enable an inference to be drawn that his life would have been saved: Thus the risk assessment by the police seem to some deaths to be prevented, which would not necessarily on application of the assessment of the responsible physician, as immediate reporting only occurs if the patient is high risk It is of concern that there are two different methods of assessing the risk when a vulnerable patient is granted leave; both in operation; one with greater potential of saving his life than the other_ ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths I believe that the NHS Trust has the power to take such action recognize that to do so may involve other organizations am therefore copying this to the Metropolitan Police Service and Royal College of Psychiatrists and attaching Oxleas Procedure for missing /absconding patients who are absent without leave, version 3.2. YOUR RESPONSE You are under a to respond to this report within 56 of the date of this report; namely by Monday April 30*, 2018. 1, the coroner, may extend the period. Your response must contain details of action taken O proposed to be taken, setting out the timetable for action. Otherwise you must why no action is proposed: If you require any further information or assistance about the case_please contact the case officer days: they they would enable duty days explain