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This document has been recently updated to ensure that it is compliant with the new Association of Chief Police Officers (ACPO) guidelines: This has been shared with the Surrey Adult Safeguarding Board and feedback will be provided and discussed at the next meeting in January 2015. The Force continues to work with its partners to ensure compliance with existing policy: Once the review of the MPP is complete, training and a familiarisation programme will be implemented for officers and mental health/medical staff (which may even include consideration for joint enterprise) to ensure that all staff understand and implement the policy and work effectively together to dellver successful outcomes for missing individuals The policy will be subject to regular and on-going reviews, In with Force process for all existing policies/procedures: "Critical Information _required_to moke_gn informed risk assessment_as_to whether WOS missing or gbsent was omitted Response; The omission of certain information that would have better informed the risk assessment, and thus whether the subject was 'Absent' or 'Missing' _ was a specific of this case. It was as result of a call handler failing to pass on particular detalls to the Duty Inspector at the material time: Guidance has since been circulated to all appropriate personnel to emphasise ad ensure, so far as is possible, that all necessary details are provided in order for an accurate risk assessment to be made: The risk of this happening will also be significantly mitigated by the full introduction of Mobile Data Terminals (M.D.Ts) This will ensure that officers receive the necessary documented inforation first hand and do not have to rely on Information being verbally relayed to them:
3. "The_declslon_to re-closslfy from missing_to_obsent_wos_not_communicated to_the hospital" Response; This was an error on behalf of the operator and, therefore, case specific: The procedure includes a full list/flowchart of the process. The requirement to notify the hospital following the re-classification was ignored on this occasion; the operator did not act In accordance with procedure: The operator has been given subject to misconduct process and given '"words of advice' as a formal sanction. line again

"Asgesult no enquiries_ Or investiggtions were_made bY_any_agency_ to_ascertaln Mr Hafele'$ whereabouts ~ Response: It is correct that this was the result and is a specific failing in this case:
5. "Adequgte trgining_on the Surrey Wide Response Agreement and the Surrey _ Person Procedure did not take place_
6. "Inrelation to the Police_specific training with regards torsk assessments for_ mental heolth was lacking_ Response; The Force has In place comprehensive program of training ad Is developing &d enhancing this as an on-going matter: All officers and staff are required to complete the NCALT (College of Policing) e-learning package on National Declsion Maklng Model: A review of the initial training provided to Probationary police officers was carried out in accordance with peer review recommendations. This Is now complete ad the training has been found to be fit for purpose_ The Force'$ Mental Health Liaison Officers (MHLOs) are a group of 21 officers and staff from across the Force and from various roles who have opted to 'up skill' in this area and develop their knowledge The MHLOs are available to advise colleagues on mental health querles, including Sections 135 ad 136 of the Mental Health Act 1983, the Mental Capacity Act 2005, policies and procedures and information about local mental health charities and organisations These Individuals, where possible, also play part in building and maintaining relationships with local partners and voluntary organisations charities The MHLOs received an initial 2 input whereby they were briefed on topics which included legislation, the role, current policies and procedures, specialist topics eg: children and young people, and inputs from local mental health charities and support services. The MHLOs also receive 6 monthly updates and have received their first one of these in November 2014. These updates are produced taking into account requests made by the MHLOs and any operational updates required. The Force is aiming to increase the number of MHLOs across the force in the future; however there are no plans to recrult to thls role currently: Missing key day

Mental Health Briefings to Supervisors will begin in February 2015 ad will include a overview of issues and learning from recent cases; reminder of protocols; revision of relevant legislation and case law: Two Back to Basics e-briefing/learning packages; Mental Capacity Act: Practical Guide to Dealing with Mental Ill Health_ are to be rolled out Force wide at the beginning of February 2015 and priority will be given to front line officers and staff, The Metropolitan Pollce Force has recommended the Vulnerability Assessment Framework for introduction to Surrey: This model still needs to be agreed/adapted for Surrey before training can be rolled out: This will potentially form part of a Force wide training update programme on omni-competence commencing in March 2015. The Force reviewed all its (internal and external) mental health policies and procedures within the last 6 months and this review will be an on-going process alongside Crisis Care Concordat partners: New policles and procedures have been drafted where a requirement was identified as a need, for example the 'Conveyance of Mental Health Patients' and 'Restraint of Mental Health Patients within a Mental Health or medical environment . Other materials have been and are being produced to assist officers to properly and effectively support individuals in mental health crisis. For example, s136 information is now available on MDTs s0 that officers can complete approprlate 5136 paperwork but also have access to relevant data and legislation to assist them: Mental health booklets are being drafted to enhance the awareness of officer and staff knowledge about mental health issues: #t is proposed that this information will be made available in an interactive format, avallable on officers MDTs. "Surre Police_TPT_brieflng_training_did not_correspond to the definition of_Absent given_in the Surrey Police Wisslng Person Procedure Response: This was noted by the Force and the TPT briefing training will be modified to take account of this and ensure consistency in the future: 8 "Ineffective communications between police ond Elggr Ward" Response; This was in the context of the communication between the Contact Centre and Elgar Ward and specifically related to the ward not being informed that the individual was being treated as 'Absent' rather than 'Missing: Thls does not relate dlrectly to mental health In the wider has

context and will be addressed through the review which is taking place into the wider issues relating to missing persons. Summary HM Coroner does not express concern to the contrary but, nonetheless, it is worth noting that we remaln of the vlew that our policies and procedures are fit for purpose and take into account matters referred to in current ACPO and College of Policing guidance: The Force will endeavour to remain vigilant in ensuring that these policies are maintained and up to date, compliant with statutory provisions and relevant guidance: The Force will continue in its endeavours to ensure staff and officers are trained appropriately in order to minimise the risk of breaches in procedure: The Force Is aware that there may be occasions where there are policy breaches and these will be dealt with under appropriate management and conduct procedures, as in this case The Force is committed to working with NHS and other medical partners to ensure effective channels of communication and consistent response and handling of mental ill health issues Should HM Coroner require further assistance or darification of matters set out in this letter, we will be pleased to assist as necessary:

Dear Mr Travers Inquest into the Death of Mr William Hafele Regulation 28 Report Action to Prevent Future Deaths Response Further to the conclusion of the inquest into Mr William Hafele's death on 10th November 2014, you wrote to Surrey and Borders Partnership NHS Foundation Trust in accordance with Regulation 28 report to prevent future deaths, stating that during the course of the inquest the evidence revealed matters giving rise to concern We would, firstly , like to take this opportunity to offer our sincere condolences to Mr Hafele's family for their loss_ The areas of concern you raised that relate to our Trust and our responses are detailed below: Training procedures, in respect of the Police and hospital staff on Elgar Ward; in the case of reports of missing persons: Critical information required to make an informed risk assessment as to whether HW was missing or absent was omitted: There was a lack of understanding of areas of responsibility and appropriate actions. We have further emphasised the importance of the Missing Persons (MISPER) process to all our staff on these units, including making this part of our improvement work in the reduction of the numbers of people who may be Absence Without Leave (AWOL): A member of Clinical Assurance team is specifically assigned to wards with the view to ensure compliance with the MISPER agreement is tested. Staff have been further clearly instructed to complete Appendix A of the MISPER agreement: This outlines details such as name and location of the unit reporting the missing person, the risk assessment zoning and clear justification for category, personal details of the person who may have gone missing with an option to attach a For abetter life Trust Headquarters, 18 Mole Business Park, Leatherhead, Surrey KT22 7AD T_0300 55 55 222 F_01372 217111 WWWsabp nhs.uk the the

photo and description of general appearance_ To ensure that relevant information is recorded and reported to the Police as part of the missing persons report, it is now expected practice for all staff to ensure that upload this document onto our Electronic Patient System (RiO) in timely manner: This will now be audited for completeness The decision to reclassify from missing to absent was not communicated to the hospital, as result no enquiries Or investigations were made by any agency to ascertain Mr Hafele's whereabouts. Ineffective communications between the Police and Elgar Ward: A flow chart clearly outlining the process to make inquiries further to missing persons report to the Police has been developed. It contains clear directions on the process that needs to be undertaken when someone has not returned to the ward_ This standardisation of approach will support staff in making enquiries Or investigations when person using our services goes missing from the wards Adequate training on the Surrey Wide Response Agreement and Surrey Police Missing Person Procedure did not take place. We have enhanced our focus on reducing the number of people who go missing from our wards and we believe the work we are doing through our improvement team as outlined in our Quality Improvement Plan will start to show positive results We have a close working relationship with Surey Police which has further been strengthened through the Crisis Concordat work we are doing: This is also providing the opportunity for us to learn together on aspects on which we can improve_ The MISPER agreement has been widely discussed in teams and presented at our managers meetings on a number of occasions. In addition mandatory training has now been arranged for all staff within the unit to be completed by the end of February 2015. To further ensure embedding of the process, we will now require our ward managers to undertake a quarterly audit on MISPER forms Appendix A & B and any emerging issues are discussed at our Acute Care Forum meeting: We have included the concerns you have raised in our corporate action plan to ensure that there is ongoing leaming from these. We would like to offer our sincere condolences again to the Hafele family for their loss and hope that the steps we have taken as outlined above assures you and them, that we have leamt and continue to leam from this event Please do not hesitate to contact me or Director of Quality (DoN) if you require any further information: