Recommendations - Sussex Police, March 2020

Sussex Police · Ref: 2019/126127

Recommendation date: 6 March 2020

Response due: 1 May 2020

Published: 4 November 2020

Death and serious injury Welfare and vulnerable people

Sussex Police were informed of a man who had left an A&E department, having been admitted the previous evening for issues of mental ill health. Sussex Police officers attended the man’s home address in order to conduct a check on his welfare. When he was not located at the property, the officers left and continued with further enquiries. The area response sergeant then assessed the man as a medium risk missing person, however, the man was sadly found deceased in his home a short while later.

View on IOPC website

Recommendations (3)

Recommendation 1 Awaiting Response

Recommendation

The IOPC recommends Sussex Police should review ‘Missing Persons Police – Appendix E – Absent Without Leave (AWOL)' policy with specific reference to the below; The ‘Missing Persons Police – Appendix E – Absent Without Leave (AWOL)’ appears to be … Read moreThe IOPC recommends Sussex Police should review ‘Missing Persons Police – Appendix E – Absent Without Leave (AWOL)' policy with specific reference to the below; The ‘Missing Persons Police – Appendix E – Absent Without Leave (AWOL)’ appears to be overdue for review. Sussex Police and Sussex NHS Trusts should review this policy document with a view to; a) ensuring that the policy is consistent with Sussex Police’s other missing persons policies and guidance and; b) considering whether this should be brought in line with APP for Missing Persons and the APP for AWOL patients, specifically relating to multi-agency protocols in relation to missing or AWOL patients. At 7.06am, a nurse from the Princess Royal Hospital, Haywards Heath, contacted Sussex Police in order to report a male patient, had left the grounds of the hospital and was uncontactable. The nurse reported the man had been admitted to the Accident and Emergency Department the previous evening. The man had expressed intent to harm himself and he had been seen by the Mental Health team who considered his condition serious enough to keep him in hospital overnight. The man was due to be seen by the Mental Health Team again that morning for further assessment. The incident was classified as a ‘concern for welfare’ and graded as a Grade 2 ‘Prompt’ response. Between 7.27am and 8.08am a discussion was had between staff within the control room and the Sussex Police response team Sergeant, as to whether NHS staff were responsible for undertaking actions to locate the man, or whether this responsibility fell to Sussex Police. As a result, the incident log relating to man was mistakenly closed for a brief period, however, at 8.08am it was re-opened and the response Sergeant assigned Sussex Police units to attend the man's address. During the course of the IOPC investigation, the following was identified in regard to the Sussex Police ‘Missing Persons Police – Appendix E – Absent Without Leave (AWOL)’ document; i) The document was last updated in December of 2015 and was set for review in November of 2017 but remained extant in October of 2019. ii) The document provided the following definition of ‘missing’; “Anyone whose whereabouts cannot be established and where the circumstances are out of character, or the context suggests the person may be the subject of crime or at risk of harm to themselves or another.” (pg. 4) This does not match the definition of missing in the main Sussex Police missing persons policy (D10), and in line with APP guidance, which is; “Anyone whose whereabouts cannot be established will be considered as missing until located and their well-being or otherwise confirmed” (p.2) Do you accept the recommendation? No Sussex Police has requested that the IOPC withdraw the learning recommendation that was made following their investigation into the actions of Sussex Police on the 4th October 2019 in response to a concern for the welfare of a man. The IOPC has agreed to withdraw the recommendations. This request by Sussex Police is for the following reasons: 1) The learning recommendation suggested that the AWOL policy was reviewed as a result of this set of circumstances. However the AWOL policy that is in place only applies to Mental health (MH) hospitals and was not applicable in this situation as the man walked out of an A and E department. 2) Sussex Police are not able to compel acute facilities to enter into a formal agreement with the organisation. In response to this incident Sussex Police has taken the following action which demonstrates our commitment to learning and continuous improvement in our service delivery: 1. Op Northwood is now in operation and this clearly indicates roles and responsibilities of the police in dealing with partner requests where there is a real and immediate threat to life. Comprehensive engagement has been undertaken with partners to ensure there is a common understanding on this policy and the roles and responsibilities are fully understood. 2. The AWOL policy has been updated and agreed with MH partners 3. Communication to the Force has been circulated which clearly explain who the AWOL policy is relevant to i.e. MH and does NOT extend to acute care providers. Show less

Recommendation 2 Accepted

Recommendation

The Sussex Police and Sussex NHS Partnerships should also review the ‘Missing Persons Police – Appendix E – Absent Without Leave (AWOL)’ with a view to establishing which agency is responsible for conducting checks to ascertain the wellbeing and whereabouts … Read moreThe Sussex Police and Sussex NHS Partnerships should also review the ‘Missing Persons Police – Appendix E – Absent Without Leave (AWOL)’ with a view to establishing which agency is responsible for conducting checks to ascertain the wellbeing and whereabouts of patients absent from hospital. A specific emphasis should be placed on instances where there is either; a) disagreement as to primacy as to which agency has responsibility to conduct the necessary checks, or, b) the status of the patient is ambiguous so as to not clearly define primacy.A contingency position whereby an agency is automatically allocated responsibility to conduct the necessary checks should be established. The Sussex Police and Sussex NHS Partnerships should also review the ‘Missing Persons Police – Appendix E – Absent Without Leave (AWOL)’ with a view to establishing which agency is responsible for conducting checks to ascertain the wellbeing and whereabouts of patients absent from hospital. A specific emphasis should be placed on instances where there is either; a) disagreement as to primacy as to which agency has responsibility to conduct the necessary checks, or, b) the status of the patient is ambiguous so as to not clearly define primacy. A contingency position whereby an agency is automatically allocated responsibility to conduct the necessary checks should be established. At 7.06am, a nurse from the Princess Royal Hospital, Haywards Heath, contacted Sussex Police in order to report a male patient, had left the grounds of the hospital and was uncontactable. The nurse reported the man had been admitted to the Accident and Emergency Department the previous evening. The man had expressed intent to harm himself and he had been seen by the Mental Health team who considered his condition serious enough to keep him in hospital overnight. The man was due to be seen by the Mental Health Team again that morning for further assessment. The incident was classified as a ‘concern for welfare’ and graded as a Grade 2 ‘Prompt’ response. Between 7.27am and 8.08am a discussion was had between staff within the control room and the Sussex Police response team Sergeant, as to whether NHS staff were responsible for undertaking actions to locate the man, or whether this responsibility fell to Sussex Police. As a result, the incident log relating to man was mistakenly closed for a brief period, however, at 8.08am it was re-opened and the response Sergeant assigned Sussex Police units to attend the man's address. During the course of the IOPC investigation, the following was identified in regard to the Sussex Police ‘Missing Persons Police – Appendix E – Absent Without Leave (AWOL)’ document; The document provided the following definition of ‘absent’ when in relation to an ‘informal’ patient; “Any informal patient who is found not to be present on the ward or in the hospital building, and grounds and who has not advised staff and is not taking agreed leave should be treated as absent for the purposes of this document.” (para 2.3, p. 6). The category of ‘absent’ is not included in the main Sussex Police missing persons policy (D10), and the guidance for call handlers (D12) specifically states: “There is no longer such a thing as an Absent/absentee status - persons will be deemed missing or not” (p. 1) The document does not offer clarification on the difference between a missing person and a concern for welfare, which is how the initial call regarding the patient was originally categorised. The document does not provide sufficient clarity as which organisation, Sussex Police or Sussex NHS Trusts, should take responsibility for locating an informal patient who has absented themselves from hospital. Do you accept the recommendation? No Show less

Force Response

Accepted action: Sussex Police has requested that the IOPC withdraw the learning recommendation that was made following their investigation into the actions of Sussex Police on the 4th October 2019 in response to a concern for the welfare of … Read more

Recommendation 3 Awaiting Response

Recommendation

If such a situation arises, a review should take place after proactive measures to allocate responsibility have been taken, as opposed to at the material time of the patient being absent in order to avoid delay in resourcing a response. … Read moreIf such a situation arises, a review should take place after proactive measures to allocate responsibility have been taken, as opposed to at the material time of the patient being absent in order to avoid delay in resourcing a response. At 7.06am, a nurse from the Princess Royal Hospital, Haywards Heath, contacted Sussex Police in order to report a male patient, had left the grounds of the hospital and was uncontactable. The nurse reported the man had been admitted to the Accident and Emergency Department the previous evening. The man had expressed intent to harm himself and he had been seen by the Mental Health team who considered his condition serious enough to keep him in hospital overnight. The man was due to be seen by the Mental Health Team again that morning for further assessment. The incident was classified as a ‘concern for welfare’ and graded as a Grade 2 ‘Prompt’ response. Between 7.27am and 8.08am a discussion was had between staff within the control room and the Sussex Police response team Sergeant, as to whether NHS staff were responsible for undertaking actions to locate the man, or whether this responsibility fell to Sussex Police. As a result, the incident log relating to man was mistakenly closed for a brief period, however, at 8.08am it was re-opened and the response Sergeant assigned Sussex Police units to attend the man's address. Do you accept the recommendation? No Sussex Police has requested that the IOPC withdraw the learning recommendation that was made following their investigation into the actions of Sussex Police on the 4th October 2019 in response to a concern for the welfare of a man. The IOPC has agreed to withdraw the recommendations. This request by Sussex Police is for the following reasons: 1) The learning recommendation suggested that the AWOL policy was reviewed as a result of this set of circumstances. However the AWOL policy that is in place only applies to Mental health (MH) hospitals and was not applicable in this situation as the man walked out of an A and E department. 2) Sussex Police are not able to compel acute facilities to enter into a formal agreement with the organisation. In response to this incident Sussex Police has taken the following action which demonstrates our commitment to learning and continuous improvement in our service delivery: 1. Op Northwood is now in operation and this clearly indicates roles and responsibilities of the police in dealing with partner requests where there is a real and immediate threat to life. Comprehensive engagement has been undertaken with partners to ensure there is a common understanding on this policy and the roles and responsibilities are fully understood. 2. The AWOL policy has been updated and agreed with MH partners 3. Communication to the Force has been circulated which clearly explain who the AWOL policy is relevant to i.e. MH and does NOT extend to acute care providers. Show less