Assessing bronchopneumonia symptoms
25. In her complaints to us and the Provider, Mrs D said the pathologist who conducted Mr E’s post-mortem said he died of fatal bronchopneumonia. She said the pathologist concluded the illness was likely to have started several days before he died.
26. She acknowledged his symptoms may have started as mild ones. However, around 28 and 29 March 2022, she considered he would have been displaying noticeable respiratory symptoms. She complained staff did not notice them, and instead of starting treatment they let Mr E out on leave from hospital on 29 March.
27. In its investigations, the Provider said the Provider’s Health Monitoring Policy explains the frequency in which staff needed to offer Mr E ongoing physical health assessments. However, the Provider did not say how frequently staff should have done these assessments.
28. We found the Provider’s staff acted in line with relevant policy on this matter.
29. Section 1.2 in the NMC Code says staff must make sure they deliver the fundamentals of care effectively for their patients. Our nurse said this meant staff needed to have a care plan in place focused on maintaining Mr E’s physical health.
30. We saw the Provider’s Health Monitoring Policy gave staff more practical guidance on how to do this. Section 2.1.1 says medical staff should prescribe the frequency and type of physical observations the staff looking after a patient should complete.
31. Around the time of events, we saw Mr E’s care records show medical staff updated his physical health care plan (‘keeping healthy’) on 26 March.
32. To detect early signs of any respiratory illness, noting COVID-19 as the most likely risk, they asked care staff to monitor his physical health daily. They asked these staff to observe him for any changes in his physical health which may suggest an illness like COVID-19. If they had any concerns about his physical health, these staff should contact Mr E’s GP.
33. In line with section 2.1.1 of the Provider’s Health Monitoring Policy, we saw this care plan explained the steps staff needed to take in respect to monitoring Mr E’s physical health. That is, how often they should observe him and what to look for. Our nurse said this care plan met the standard they would expect to see in delivering the fundamentals of care set out in the NMC Code.
34. Mr E’s daily notes show, in documenting whether he was ‘keeping healthy’, staff recorded their daily observations about his physical health. Close to the time he left the Provider, we saw the following examples of this.
35. On 26 March, staff recorded they took Mr E’s temperature. They saw it was within the normal range. On 27 March, staff noted they did not have concerns about his physical health and Mr E did not report any.
36. Staff made two entries about his physical health on 28 March. In those entries staff noted they took Mr E’s temperature. He had good food and fluid intake. He did not report any physical health concerns. Staff recorded he did not report feeling unwell in their entry about his health on the morning of 29 March.
37. Our nurse said these assessments met the required standard they would expect to see to observe and monitor Mr E’s physical health in line with the NMC Code.
38. Having considered the evidence and advice, we saw the Provider had a care plan in place to monitor Mr E’s physical health which was in line with the standards and policies we refer to. The staff looking after him did what this care plan directed them to do. This means we found they acted in line with relevant standards and policy in monitoring and assessing Mr E for any physical health problems, including any respiratory illnesses.
39. Given the pathologist’s conclusions, we recognise why Mrs D has concerns about whether staff should have seen signs of respiratory illness. We hope our findings give her some assurance about the monitoring the Provider’s staff had in place.
Risk assessment before Mr E left hospital
40. In her complaints to us and the Provider, Mrs D explained factors she felt staff should have assessed in considering the risk of allowing Mr E to leave the Provider’s hospital. She said staff did not do so at the time they let him leave. She said these factors included:
• from January 2022, Mr E telling the Provider’s doctors he felt depressed and consistently low in mood • from around 20 March, he told doctors this was causing him stress and agitation • by late March, he was more irritable and increasingly talking about his religious beliefs.
41. Mrs D said these were noticeable changes in Mr E’s behaviour and signs of mania staff should have seen. She added he had not been sleeping much at night. This included him staying up all night prior to leaving the Provider’s hospital the morning of 29 March.
42. She considered at least some of these factors should have indicated his vulnerable state and the risk he might make poor decisions. This in turn posed a risk to his own safety and the safety of other people. On this basis, she said staff should not have allowed him to leave on 29 March.
43. The Provider’s investigations explained the Provider’s Leave Signing In and Out Policy was relevant on this matter. It said this prompts staff to do a risk assessment prior to authorising any leave for a patient. The assessment directs staff to assess a patient’s mental state before they leave hospital. Staff only need to do this once for patients who have different periods of leave throughout a day.
44. The Provider said staff allowed Mr E to go into the local area at 8.42am. Staff did not do the risk assessment they should have before he left. He returned to hospital at 9.14am. When staff authorised his leave at 10.22am, they did not do a risk assessment either. The Provider explained the staff looking after Mr E were not aware of this requirement.
45. We found the Provider’s staff did not do what they should have on this matter.
46. Section 27 in the Mental Health Code of Practice gives guidance staff should follow in planning a patient’s leave from a mental health facility. This includes assessing risk.
47. Regarding short-term leave (for a few hours), the clinician responsible for the patient’s care needs to set out the terms of this leave. For example, the place(s) the patient can visit during their leave and any restrictions on the time of day the leave can take place. The clinician should set out any circumstances in which staff should not authorise their leave.
48. Further to this, the Provider’s Leave Signing In and Out Policy gives its staff guidance on the risk assessments they should do in authorising or refusing short-term leave at the point the patient is trying to leave hospital.
49. This policy says staff should review the leave plan their responsible clinician has made and check the patient is using leave they are authorised to have as part of their plan. As part of the risk assessment the Provider referred to in its investigation, staff should also consider:
• whether the patient has shown aggressive behaviour in the last 24 hours or whether they have self-harmed • the patient’s mental state, and whether their appearance, behaviour, speech content, and mood suggest their state of mind poses a risk • whether there have been changes in the patient’s interactions with staff or others, or they have shown any suspicious behaviours • whether the patient has complied in taking their medication in the last 48 hours, for example, any psychotropic medication or medicines they take for physical health conditions.
50. For patients who have different periods of short-term leave they take throughout a day, staff should complete this assessment once daily prior to their first period of leave that day. If staff have reason to believe a patient’s mental state or the risks have changed before any later periods of leave in the day, they should complete a new risk assessment.
51. When Mr E left the Provider’s hospital on 29 March, his leave plan shows he had a range of unescorted leave options, including:
• up to one hour and 15 minutes three times per day to go off site for a walk/fresh air • up to 30 minutes once a day to go to a local shop • up to 90 minutes once per week to go to a local shop to get money • up to three hours and 15 minutes three times per week to go to the local town centre • up to two hours to attend a local café four times per week • up to two hours to attend church services twice a week, either when the church had a service on Tuesday, Thursday, or Saturday.
52. Regarding when Mr E might not have such leave authorised, the psychiatrist responsible for his care explained staff should assess his mental state at the time he wanted to take leave. That is, by doing the risk assessment we explained in paragraph 49.
53. Having considered such factors, and whether Mr E had been involved in any incidents during their shift, it would be at the discretion of the staff on shift whether they permitted the leave he wanted to take.
54. So, we saw the Provider planned what staff should have done at the point Mr E wanted to take any leave in line with the Mental Health Code of Practice. Primarily, this instructed them to do the risk assessment we described in paragraph 49. However, we saw staff did not follow these instructions on 29 March before they let Mr E leave the Provider’s hospital.
55. As the Provider acknowledged, staff did no such risk assessment when Mr E went out for a walk at 8.42am. After returning from his walk, staff let him leave again at 10.22am to go to church without doing a risk assessment.
56. We saw his leave records and daily notes also reflect this, and there is no documentation to show staff considered factors from paragraph 49. Staff only recorded when he left, the type of leave they allowed, and what Mr E was wearing.
57. Our nurse said they also saw this omission from Mr E’s records. They added the lack of any risk assessment at the times he left the Provider’s hospital on 29 March fell short of what they would expect to see according to the standards and policy we explained above.
58. Therefore, having reviewed this advice and evidence, we saw staff did not do the risk assessments they should have about Mr E going out on leave prior to letting him leave the Provider’s hospital. The Mental Health Code of Practice and the Provider’s Leave Signing In and Out Policy says they should have done such assessments.
59. Regarding the impact of this failing, we appreciate Mrs D told us the lack of risk assessment meant staff did not detect factors indicating Mr E might make bad decisions. This included not returning to hospital. Had staff done risk assessments, she considers this should and would have resulted in him remaining in hospital on 29 March.
60. We saw the Provider’s investigation said, while Mr E did not have leave to go to church at the time, he had other valid unescorted leave options available. For example, to go into the local area to visit a café or shops. Had staff realised the error in permitting leave to attend church, they could have permitted him other approved unescorted leave at the time.
61. Had staff done risk assessments on 29 March, the Provider added it is likely its staff would and could still have approved Mr E to take leave. It said staff had no concerns about his presentation that morning.
62. We did not find the sequence of events are likely to have been different had staff done a risk assessment at the point Mr E left the Provider’s hospital. This meant we could not link the lack of risk assessment to the impact Mrs D describes or conclude that had staff done a risk assessment this would have resulted in Mr E remaining in hospital.
63. Section 27 of the Mental Health Code of Practice says while leave of absence can be a time of risk, it is also an important part of the patient’s care plan. Therefore, we would have expected the Provider to allow Mr E to use unescorted leave options he had valid at the time unless they saw clear risks meaning they should not let him leave hospital.
64. From review of his care records, our nurse saw no risk factors which precluded staff letting Mr E out on unescorted leave the morning of 29 March. Our nurse did not consider the observations staff recorded about his mental state and behaviour that morning should have given staff cause for concern. They added staff could not have predicted the events which later took place through a risk assessment.
65. We note, and our nurse saw this too, Mr E’s records show he reported no physical health concerns to staff. While staff noted he had little sleep, they deemed his mood manageable. He spoke to his psychiatrist that morning and said he was feeling better than he had been and felt well. Staff noted he had been polite. His medication charts show he had been taking his prescribed medicines.
66. This meant we did not see clear evidence Mr E met criteria (which we explained in paragraph 49) from the Provider’s risk assessment documentation which meant staff should not have let him leave hospital.
67. Therefore, having considered the evidence and advice, had staff acted in line with policy and done the risk assessment this indicated, we did not find this would have changed what happened.
68. We concluded, albeit under a different type of unescorted leave Mr E’s psychiatrist had permitted, staff would and could still have allowed him to leave hospital. Given the Mental Health Code of Practice says leave is an important part of a patient’s care, we saw no robust reason staff should have denied Mr E such leave on 29 March.
69. Even when we cannot see an injustice stemming from an organisation’s failings, we may recommend an organisation acts to try and prevent a recurrence of failings we see.
70. We looked at whether the Provider already acted like this to learn lessons from what went wrong on this matter and improve. Having done so, we found it had.
71. In its investigations, the Provider acknowledged staff did not do the risk assessment we saw they should have when they authorised Mr E’s leave. This acknowledgment is in line with our Principles for Remedy. The Provider also explained this happened because the staff on duty were not aware they needed to do the risk assessment.
72. To learn lessons from this omission, through internal learning forums, staff training, team meetings and governance meetings, managers explained the Provider’s Leave Signing In and Out Policy to staff. They told staff they should use the risk assessment proforma included within this policy before a patient commences any leave from hospital.
73. This proforma, which supports the policy, directs staff to conduct the risk assessment we described in paragraph 49, and when they should do one.
74. Our Principles for Remedy say, to prevent the same failings happening again, organisations can:
• revise policies and procedures • train or supervise their staff • do any combination of these things.
75. The evidence shows the Provider took actions like this. By making staff aware of the procedure they should follow, and the proforma assisting them to follow it, we considered it is less likely staff will repeat the omission we saw in Mr E’s care. This meant we found the Provider had taken all the action we would expect to improve.
76. We hope we have clearly explained our findings on this matter. We also hope they provide Mrs D some assurance about improvements the Provider has made. We appreciate it is important to her that the Provider acknowledges any failings and makes improvements to prevent them happening again.
Issues Mrs D says made it harder for staff to find Mr E after he left hospital
77. Mrs D says the remaining three concerns she has meant it took staff longer to find Mr E after he left hospital than it would have had they acted in line with policies.
78. In paragraphs 79 to 137, we explain why we found staff got things wrong on each of these matters. In paragraphs 138 to 158 we give our findings on the impact this had. From paragraph 159 we give our findings on whether the Provider did enough to address the impact we found and whether it acted to learn from the events and improve.
Staff checks on the purpose of Mr E’s leave
79. Mrs D told us staff mistakenly allowed Mr E out on leave to go to church on the morning of 29 March. She said staff had information available confirming the church had no service at that time, and they should not have let him leave on this basis.
80. The Provider’s investigations found staff authorised Mr E two hours of leave to attend church. It said this was not an authorised leave option he had under his care plan. He had leave to attend church on Thursday morning, and Tuesday and Saturday evenings for church services. It noted 29 March was a Tuesday, but staff let him leave at 10.22am.
81. The Provider said staff had last updated his leave arrangements on 16 March and they uploaded these arrangements to his care notes. It noted Mr E had several leave options. It said having so many may have caused staff uncertainty. This likely explained the incorrect leave staff authorised.
82. We found staff did not act in line with relevant policy on this matter.
83. As we explained in paragraph 46 and 47, the Mental Health Code of Practice says, regarding short-term leave, the clinician responsible for a patient’s care needs to set out the terms of this leave.
84. When a patient requests to take leave, the Provider’s Leave Signing In and Out Policy says staff should review the patient’s leave plan their responsible clinician has made. They should check the patient is using leave they are authorised to have at that time.
85. As the Provider acknowledged, Mr E’s leave plan did not allow him to take leave to go to church on Tuesday mornings. Despite this, as we saw in his care records, staff authorised him to go out on leave for this purpose the morning of 29 March.
86. To act in line with the standards and policies above, our nurse said they would have expected staff to check Mr E’s leave plan to ensure he was taking leave in line with what his psychiatrist authorised. Instead, staff mistakenly allowed him to go to church at a time his psychiatrist had not authorised. Our nurse said this was an error and fell short of the standard they would expect to see.
87. This means, having reviewed the evidence and advice, we found the checks staff did on the type of leave they authorised and whether they should have authorised it were not in line with the policies we identified. Staff failed to see they should not have permitted Mr E leave to go to church the morning of 29 March.
Staff checks on whether Mr E had charged his mobile phone
88. In her complaints to us and the Provider, Mrs D said Mr E’s mobile phone ran out of battery after he left hospital. This meant staff lost the main means of contacting him if he did not return, and this made it harder for them to find him. She said staff could have avoided this had they checked whether his phone was charged before he left.
89. The Provider’s investigations said when staff realised Mr E was away without leave, they tried calling his phone. The calls staff made went straight to his voicemail. The Provider acknowledged staff did not check his phone had sufficient charge prior to his leave. According to its own policies, it said staff should have done this.
90. We found staff did not act in line with relevant policy on this matter.
91. Our nurse said there are no national guidelines on whether staff must check a patient’s mobile phone is charged before they take any leave from their mental health facility. That said, we note section 8.19 of the Mental Health Code of Practice says such facilities should have their own policies about the possession and use of mobile phones.
92. We saw the Provider’s Leave Signing In and Out Policy said staff should confirm a patient’s mobile phone is charged at the point they allow them to leave hospital. Our nurse said this procedure made practical sense and it is in line with the recommendations from the Mental Health Code of Practice.
93. On this basis, we saw staff should have acted in line with this policy. This meant they should have performed the checks required so they could confirm Mr E’s phone had sufficient charge to last for the duration of the leave they granted (two hours).
94. As the Provider acknowledged, and we saw this reflected in Mr E’s records, staff did not check his phone to see whether it had sufficient charge to last the duration of his leave. This was not in line with the Provider’s Leave Signing In and Out Policy.
The time it took staff to notice Mr E’s absence and act to find him
95. In her complaint to us, based on the leave staff permitted Mr E, Mrs D said he should have returned to hospital by 12.22pm. She said staff failed to notice he was missing and take any action about this until 1.30pm.
96. She said there were actions she expected staff to promptly take. This included:
• searching the church • contacting the police • contacting local taxi firms.
97. Respectively, Mrs D said staff took these actions at 2.45pm, 5.17pm, and 6pm. She complains this took too long.
98. The Provider’s investigations said it was around 12.30pm when one of its healthcare assistants noticed Mr E had not returned from his leave. It said this member of staff needed to notify the registered mental health nurse in charge about Mr E not returning.
99. The Provider said it could not conclude exactly when this happened, but the healthcare assistant had told the nurse in charge by 1.35pm at the latest. Assuming they alerted the nurse around 1.35pm, the Provider said this should have happened earlier.
100. It said the nurse commenced the Provider’s missing patient action checklist. At this point staff started searches within the hospital and local area. They tried calling Mr E, but his phone went straight to voicemail.
101. The Provider acknowledged staff could have escalated the matter to its senior manager on site earlier. Staff did not do so until 4.35pm. The manager was conducting recruitment interviews, and colleagues did not want to disturb them.
102. The Provider said staff called the local police service at 5.17pm and appropriately shared their concerns about Mr E. It added staff could have done this earlier because:
• Mr E was due to return at 12.22pm • staff had tried calling his phone, but all their calls went to his voicemail • he had not called the ward to tell staff he would be late, which was unusual for him.
103. That said, regarding these escalations, the Provider said staff did not feel overly concerned, given Mr E’s previous history of returning from leave late. Staff had no concerns about his behaviour or presentation that day or in the days before 29 March. It added staff completed the actions they should have that evening. This included contacting the police.
104. We found staff did not take some of the actions they needed to at the time they should have.
105. Section 28 of the Mental Health Code of Practice says facilities like the Provider should have clear written policies about the action staff should take if a patient does not return from their leave. This includes, in relation to locating the patient:
• the immediate action staff should take when they become aware a patient has not returned, but as a requirement they must inform the professional in charge of the patient’s ward, who should in turn ensure they inform the patient’s responsible clinician • the circumstances in which staff commence a search of a hospital and its grounds • the circumstances in which staff notify other local agencies • the circumstances in which staff inform the police.
106. Following on from this, we saw the Provider had a policy like this. That is, the Provider’s Absent Patient Policy.
107. Section six says when staff cannot account for a patient and they have no granted leave, staff on shift should alert the nurse in charge of the patient’s ward. The nurse should then instigate a search of the patient’s bedroom, en-suite facilities, and other likely areas. Staff should promptly search the ward area and hospital grounds, unless this search is unwarranted.
108. After taking the above steps, the Provider’s Absent Patient Policy says, based on the risk staff perceive, they can allow varying amounts of time to take further steps like contacting the police. If the initial searches commenced by the nurse in charge are not successful, they should then alert the senior manager on site and the patient’s responsible clinician.
109. As we described in paragraphs 95 to 100, we saw conflicting accounts and uncertainty about when the Provider’s staff noticed Mr E’s absence and started acting on it. This includes when staff told the nurse in charge of his ward and when the nurse commenced actions to try and locate Mr E.
110. Therefore, we considered the evidence available to reach a view about what happened based on the balance of probability. Using that view, we went on to consider whether the Provider’s staff carried out the steps from the Provider’s Absent Patient Policy at the times they should have.
111. Beyond what Mrs D told us and what the Provider said in its investigations, we identified four key pieces of evidence about the events. These include:
• Mr E’s care records • the Provider’s incident report and staff incident review meeting • the missing patient checklist staff filled in when Mr E did not return from his leave • statements from the staff involved for the Provider’s investigations.
112. The main entry in Mr E’s care records about the Provider’s response the afternoon of 29 March comes in an entry staff began to input at 4.59pm. This was a summary of actions they took during the afternoon to inform the incident report the Provider made. At 12.25pm, staff had noted they saw Mr E was due back. However, he had not returned.
113. We saw staff started a missing patient checklist. The first time they recorded in this document was 12.30pm. We considered this shows staff noticed Mr E had not returned around 12.25pm and they then commenced paperwork on this. The Provider’s Absent Patient Policy encourages staff to start such paperwork when a patient does not return from leave. So, we saw staff promptly realised Mr E had not returned when his period of leave expired.
114. The Provider’s Absent Patient Policy says the staff on duty should then have informed the nurse in charge of Mr E’s ward he had not returned at this point.
115. In the missing patient checklist, where it asks staff to tick a box to say they have alerted the nurse in charge, staff on shift ticked this box and recorded they took this action at 12.30pm. They also recorded they told the senior manager on site at that time too (the director of clinical services).
116. That said, the timings in this document about when staff escalated concerns to senior colleagues are not consistent with other evidence.
117. In the staff incident review meeting held about the events on 4 May, which the nurse in charge of Mr E’s ward attended, the nurse explained colleagues told them he had not returned to hospital at 1.35pm.
118. The nurse’s written statement they gave on 20 May corroborates this. The nurse again said colleagues told them Mr E had not returned at 1.35pm. The nurse recalled what they were doing at the time (giving another patient their medication). They also noted staff told them they had tried to call Mr E, and his phone went straight to voicemail.
119. We saw, elsewhere in his records, staff had tried to call Mr E at 1.30pm. This means staff could only have told the nurse about the attempted call after 1.30pm. This detail supports the nurse’s account about when colleagues told them Mr E had not returned.
120. We also saw the director of clinical services said in their statement colleagues told them about Mr E not returning around 4.35pm, not 12.30pm. They recalled they had been doing interviews until 4.30pm and only spoke to staff about events of the day after that.
121. So, we saw there are consistent accounts with detail on what these more senior staff were doing at the time colleagues told them Mr E had not returned. We consider these are more compelling, and they show the details recorded in the missing patient checklist about when staff contacted senior colleagues are not accurate.
122. We also saw the healthcare assistant who informed the nurse in charge gave a handwritten statement about the events and when they informed colleagues about Mr E not returning. For the reasons we explain below, we did not consider their statement compelling evidence about what happened.
123. We saw the healthcare assistant made corrections to the timings of events in their statement. We considered this indicated they lacked certainty or struggled to remember what happened and when.
124. They recorded they realised Mr E had not returned at 12pm. They noted they told the nurse in charge at 12.15pm. We considered this could not be true because Mr E’s leave records indicate he had leave until 12.22pm. Therefore, staff could not have deemed he failed to return until this time.
125. The healthcare assistant also gave their statement on 20 September. This is much later than the evidence we described in paragraphs 117 to 121, which were from May. As they were trying to recall events at such a later date, and based on what we said above, we did not consider this a reliable account about what happened.
126. Therefore, we considered the most consistent and compelling evidence about what happened to be the accounts documented in the team incident review and the statement given by the nurse in charge. As this explains staff told the nurse in charge Mr E had not returned at 1.35pm, we concluded this is what happened. This was around 65 to 70 minutes after staff realised Mr E had not returned.
127. When staff saw Mr E had not returned, the Provider’s Absent Patient Policy says they should have told the nurse in charge of his ward. Our nurse said staff delayed telling the nurse in charge and they would have expected staff to alert them straightaway. We note there is an immediate requirement that they do so under the Mental Health Code of Practice.
128. On this basis we found staff did not act in line with the Provider’s Absent Patient Policy in escalating Mr E’s absence to the nurse in charge.
129. Our nurse said this also delayed the searches the Provider’s Absent Patient Policy says the nurse in charge should then have commenced. That is, searches of the hospital grounds and areas Mr E was likely to be. In this case, the local area including the church.
130. We saw the nurse in charge started organising these searches from 1.35pm. The nurse’s statement and the incident review records indicate, when staff returned from their searches by 5pm, they did not find Mr E.
131. The Provider’s Absent Patient Policy says staff should have commenced these searches around 65 to 70 minutes earlier. Therefore, we found the Provider delayed doing initial searches.
132. Noting what we explained in paragraph 108, we did not see failings regarding the later actions staff took and when they took them. This includes when they called external agencies like the police, and when the nurse in charge informed the director of clinical services and Mr E’s responsible clinician (his psychiatrist) he had not returned to hospital.
133. The staff statements and incident review records explain staff told Mr E’s psychiatrist and the director of clinical services about him not returning by 4.35pm. We note this was before concluding their initial searches of the local area.
134. Based on the perceived level of risk, the Provider’s Absent Patient Policy gives staff leeway in when they contact other organisations like the police or taxi firms. Regarding the time staff took to take this action in Mr E’s case, our nurse said this was reasonable given he had a history of returning late from his leave. The Provider’s Absent Patient Policy allowed this leeway.
135. In considering risk and when they should call the police, as we set out in paragraph 102 and 103, staff were mindful of reasons for and against calling the police. Mr E’s history of returning from leave late meant they called the police around 5.15pm, rather than earlier, after their searches for him had not been successful. Around 45 minutes later, they also called local taxi firms.
136. Given the Provider’s Absent Patient Policy allows this leeway here, and our nurse saw reasons staff could apply this leeway, we did not see a failing in when staff took later actions like calling the police and local taxi firms.
137. This means, having reviewed the evidence and advice, we found delays of around 65 to 70 minutes in staff alerting the nurse in charge that Mr E did not return from leave. This also delayed the initial searches of the hospital grounds, church, and local area the nurse started organising when they learnt Mr E had not returned.
Our findings about the impact the previous three matters had
138. We appreciate Mrs D says the failings on these matters meant staff lost the opportunity to find Mr E earlier. This meant he was out of hospital for longer. Therefore, she believes he lost the opportunity to receive earlier care for bronchopneumonia that may have saved his life.
139. Specifically on checking the purpose of his leave, Mrs D told us, when Mr E got to church and saw no service taking place, this would have caused him confusion. She said this would have impacted on the next steps he decided to take.
140. We could not link the injustice Mrs D described to these failings.
141. In the first instance, we could not robustly conclude whether staff would have located Mr E earlier had they acted in line with policy. This meant we could not say with any certainty whether he missed the chance to return to hospital any sooner. In turn, this meant we could not say whether he missed the opportunity to receive earlier care that may have prevented his death.
142. We explain the reasons for this below. That said, we recognise this uncertainty about what impact the Provider’s failings had is in itself an injustice. We acknowledge this will be distressing for Mrs D as it leaves her with unresolved questions about Mr E’s death and whether staff may have prevented it. This injustice stems from the Provider’s failings.
143. Our nurse said they did not think it possible to conclude with any accuracy or evidence what might have happened in locating Mr E had staff acted in line with policy. However, they considered it was unlikely to have made any difference.
144. Other than from Mr E himself, we have no way of reliably knowing why he took the next steps we know about (which we describe below) after he arrived at the church.
145. From his care records, we saw the Provider’s staff spoke to a member of the church during their afternoon searches for Mr E. This person said they saw him at the church in the morning.
146. As there was no service, they said Mr E asked them to call him a taxi to go to the marketplace in the local town centre. He could not do so himself because he said his phone had no battery. This person called him a taxi and did not see him again.
147. Rather than going to the town centre, we considered Mr E could have asked for the church member to call him a taxi to take him back to hospital. We could not find other evidence available about what he intended to do and why, and whether the absence of a church service had anything to do with this. So, we did not see we could conclude what impact a lack of a service had on his next steps.
148. Had staff checked his phone’s battery, we did not see this guaranteed staff a means of contacting Mr E. He may have chosen not to answer his phone. Through the church member’s phone call, he had a chance make contact or return to the Provider’s hospital he decided not to take. This raises the possibility he may have ignored phone calls.
149. Regarding the delayed searches, had staff started them from 12.22pm, we could not reliably conclude whether this may have enabled them to find Mr E. Soon after he arrived at the church and realised there was no service, we saw evidence he went to the local town centre. Therefore, in retracing where Mr E went, staff would have been around two hours behind him.
150. The main information we saw about his actions in the town centre and afterwards come from the police reports for the coroner’s inquest. The police’s financial enquiries found Mr E made two cash withdrawals totalling £285 at a bank branch in the local town centre. He made no further bank card transactions.
151. When the police found him on 1 April at the railway station in east London, he had £59.10 in cash on his person. Therefore, he made any purchases after withdrawing money from the bank in cash. The police also found he had train tickets from a railway station in central London and a valid ticket for all the zones of the London Underground.
152. We appreciate the railway station in the local town centre is a short walk from the bank Mr E withdrew cash from. The station has frequent train services travelling east towards London, and various places in the southwest of England going in the opposite direction. The tickets Mr E had, and where the police found him, show he went to London.
153. So, even had staff started their searches soon after Mr E failed to report back to the Provider’s hospital, he could potentially have left the local town centre earlier than 12.22pm on a train. In these circumstances, the searches of the local area recommended by the Provider’s Absent Patient Policy would not have resulted in staff locating him. Given the evidence of train tickets he had purchased, he could already have been in London or on the way.
154. As we saw no further evidence available on what Mr E did and when, this meant we could not reliably conclude what the outcome of any search may have been had staff started searching earlier.
155. While it is likely he may already have left the local town centre, we could not see a way to robustly exclude the possibility he may still have been there during the period of delay we saw, and that this meant the searches staff did stood a chance of finding him. For example, if Mr E was waiting for later transport leaving the town centre, staff may have spotted him before he departed.
156. Because we could not reliably reach a conclusion about this, and there remains uncertainty on whether staff might have found Mr E through searches performed at the right time, we recognise this uncertainty will be distressing for Mrs D. This will leave her with unanswered questions on what difference prompter action in line with policy might have made.
157. Because we could not reliably reach conclusions about this, this means we can never know whether Mr E lost the opportunity to be in hospital and potentially seek earlier medical care that may have avoided what happened at the railway station on 1 April.
158. This again will be a source of uncertainty for Mrs D. We appreciate these unresolved questions and uncertainty about Mr E’s death and whether it may have been prevented will be distressing for her.
The Provider’s actions to address the injustice we found and make improvements
159. When we see injustice arising from any failings, we use our Principles for Remedy in considering the appropriate remedy. We also have regard to the outcome the person complaining wants.
160. Mrs D wants the Provider to acknowledge the things it got wrong on these matters and apologise about the impact they caused. She also wants it to make service improvements. As these are things our Principles for Remedy also say the Provider should do, we looked at whether it had taken action like this already on these issues.
161. In its investigations and during its complaint process, the Provider acknowledged staff made a mistake in not checking whether Mr E was taking appropriate leave. Staff authorised him to go to church when they should not have. It explained the range of leave options he had made the matter confusing for staff.
162. It acknowledged staff should have checked his mobile phone had sufficient charge to contact him while he was away from hospital, but they did not do so. The Provider also said the healthcare assistant who first noticed Mr E’s absence should have alerted the nurse in charge of his ward as soon as they realised his absence. This would have been around 12.30pm, so the nurse could commence searches.
163. These are the same failings we found. Therefore, in line with our Principles for Remedy, we saw the Provider acknowledged the failings we saw.
164. That said, the Provider’s investigations and responses to Mrs D’s complaint did not consider the impact of these events. As we explain from paragraph 166, the Provider focused on explaining what it did to improve.
165. This meant we did not see the Provider recognised the injustice we found, or it apologised about this. As this is something our Principles for Remedy say it should do, we have recommended the Provider takes this action. We explain this recommendation further in the recommendations section at the end of our report.
166. To try and ensure the errors the Provider acknowledged did not happen again, in its investigations, it explained action it took to improve. Through shared learning forums, staff training, team meetings and governance meetings, the Provider:
• simplified how staff record leave arrangements in patient leave documentation to avoid staff confusion, help staff authorise the correct leave, and prevent a patient inappropriately using any consecutive leave allowances they may have • explained to staff they must use the Provider’s risk assessment proforma before a patient commences any leave from hospital • explained to staff they must document contingency plans in a patient’s leave records to include any actions staff should take if a patient fails to return from leave • made its missing patient action checklist proforma accessible for all staff to use in the event a patient does not return from leave • trained staff on how to use its missing patient action checklist through missing patient simulation training.
167. Therefore, we saw a mixture of staff training and revisions to the Provider’s procedures that will help reduce the risk of the failings we found happening again. These measures seek to reduce the chance of staff wrongly letting a patient leave hospital and they aim to ensure more robust actions to find and return them to hospital if they breach conditions of their leave.
168. We considered simplifying the documentation about a patient’s leave arrangements will help staff identify what leave patients are allowed and when. This will reduce the risk of staff authorising a patient out on incorrect leave like they did with Mr E because they were unclear about his entitlements.
169. The Provider’s risk assessment proforma prompts staff to check and confirm the patient’s phone has battery life at the point they authorise them to go out on leave. As the Provider made its staff aware they need to use this proforma (we described the proforma in paragraph 73), we saw how this may reduce the chance of them allowing a patient out on leave when their phone has little or no battery again.
170. The other actions we listed in paragraph 166 seek to make it clearer to staff what they should do if a patient goes missing. The Provider has empowered a greater range of its staff to have access to and use the resources they need to start exercising its procedures to find a missing patient. This is through making guidance proformas more accessible to staff and providing training on their use.
171. We saw how these measures are likely to improve how quickly and thoroughly the Provider responds to find a missing patient should this happen in the future. As the Provider had taken the kind of action our Principles for Remedy recommend, we could not see further action it should take to improve its service.
172. We appreciate our findings on the events and how they influenced Mr E’s death will leave Mrs D with unresolved questions. We recognise this will be distressing, and we are sorry there are questions we cannot resolve.
173. We hope we clearly explained our findings and they assure Mrs D we only reached them following careful consideration of the evidence. We hope they help assure her about improvements the Provider made. We also hope our recommendations help to bring her closure on her complaint.