Mental health informal leave guidance
75 items
1 source
Lack of robust criteria and clear guidance for staff making decisions about informal ground leave for mental health patients.
Cross-Source Insight
Mental health informal leave guidance has been flagged across 1 independent accountability source:
75 PFD reports
This theme has been identified in one data source. As more data is added, cross-references may emerge.
PFD Reports (75)
Tony Duncan
Concerns: A psychiatric liaison team failed to conduct a proper risk assessment, overlooking suicidal ideation and acute mental health deterioration, leading to inappropriate discharge without medication review or escalation.
Response: The Trust has strengthened its psychiatric liaison service at King's College Hospital ED by extending hours to 24/7, introducing comprehensive training, increasing staff, and launching a new ED Low Intensity …
Responded
Hilary Chapman
Concerns: The updated section 17 leave policy does not reflect the new processes for discussing and prescribing leave, creating a gap between practice and documented policy, with no review expected until 2026.
Pending
Charles Stonley
Concerns: Limited resources and a severe shortage of mental health beds mean vulnerable patients in crisis are left in Emergency Departments for prolonged periods, increasing their risk of self-harm and death.
Overdue
Chloe Barber
Concerns: Critical gaps exist in transitional care pathways from CAMHS to adult services, along with unclear guidelines for administering antipsychotic depots and a poor understanding of Mental Health Act aftercare provisions.
Overdue
Jacob Wooderson
Concerns: Concerns exist about the fatal cardiac side effects of Elvanse, especially with remote prescribing relying on potentially unreliable patient-reported observations and verbal advice that ADHD patients may forget.
Responded
Jacqueline Potter
Concerns: Families of psychiatric patients on leave are not provided with codified risk and safety plans. Furthermore, secure unit Wi-Fi lacks filters, allowing vulnerable patients access to self-harm websites, increasing suicide risk.
Responded
Christopher McDonald
Concerns: Psychiatric unit staff lacked understanding and adherence to the 'AWOL - Missing & Absent Persons Policy,' failing in individualized assessments, police accompaniment, and joint action planning.
Responded
Jan Raciborski
Concerns: The consistent failure to document risk assessments in contact records hinders information sharing, impedes investigations into deaths, and risks obscuring future threats to life.
Responded
Huw Erasmus
Concerns: There was a lack of documented post-leave assessments for a patient with a known risk of ingesting vegetation, alongside staff confusion regarding assessment requirements and documentation standards.
Responded
Yemisi Cielto-Opaleye
Concerns: Inadequate patient consent regarding Olanzapine depot injection risks, insufficient observation protocols post-injection, and failures in medication change approval processes including SOAD checks, risked fatal Post Injection Syndrome.
Responded
Matthew Gale
Concerns: Carers were not informed of Section 17 leave conditions or provided forms, and compliance audit data is inconsistent. Removing the requirement for carer signatures in a new policy increases future risks.
Responded
Kieran Lavin
Concerns: Critical suicide risk information was not recorded or shared effectively due to busy shifts. Post-death guidance for informal patient transport risk assessment remains inadequate, lacking specific questions for comprehensive evaluation.
Responded
Hayley Cowan
Concerns: There is a critical lack of consistent and clear national guidance for Mental Health Trusts on defining and implementing Section 17 leave for detained patients, leading to inconsistent policies and practical instructions for staff.
Overdue
Nicholas Harrison
Concerns: The Approved Mental Health Practitioner service repeatedly failed to conduct legally compliant Mental Health Act assessments, including insufficient collateral information gathering and inadequate medical attendance, despite family requests.
Responded
Rosie Young
Concerns: Trust employees lacked familiarity and specific training on the Mental Health Act Transportation Policy, leading to inadequate risk assessment and delegation during patient transfers.
Responded
Tammy Watkins
Concerns: Persistent failures in physical healthcare within mental health settings, including staff not recognizing deteriorating patients, non-adherence to NEWS2 policy, and confusion in emergency call procedures, led to preventable deaths.
Responded
Nicholas Dymond
Concerns: Independent mental health assessors lack mandated access to full patient records, while staff misunderstand voluntary admission and the "least restrictive option," potentially hindering appropriate care.
Responded
Sasha Mishabi
Concerns: St. Andrew's Healthcare displayed chronic non-compliance with its pressure ulcer prevention policy, including failures in assessments, daily skin inspections, and incident reporting. This indicates systemic governance and quality assurance deficiencies.
Responded
Ian Darwin
Concerns: Tees Esk and Wear Valleys NHS Foundation Trust routinely fails to conduct timely serious incident investigations, allowing hazards to persist and compromising learning, despite past assurances and national guidelines for 60-day completion.
Responded
Kirsty Taylor
Concerns: Fragmented mental and physical health services lack seamless connectivity for neurodivergent patients, particularly those with ADHD. Additionally, communication with families of mental health patients remains ineffective, and the Personality Disorder Pathway development is too slow.
Responded
Girmaye Guyo
Concerns: There's a risk of patients being discharged under the Nearest Relative Power despite still meeting detention criteria, due to a lack of clear procedures and legal tests for clinicians to apply.
Overdue
Vaughan Whalley
Concerns: Deficient suicide and self-harm risk assessments upon release from detention, coupled with poor communication to police and inadequate practitioner-detainee interaction, compromised effective risk management. A manager's review also lacked critical analysis or learning identification.
Responded
Nicholas Stout
Concerns: Mental health crisis assessments are often delayed, essential Triage Tools and Safety Plans are not consistently completed, and safeguarding referrals for children are frequently missed.
Responded
Heather Findlay
Concerns: Staff are unprepared for patients absconding, with policies lacking clear guidance on following or police engagement, leading to confusion and potential non-attendance by police for distressed patients.
Responded
Hilary Guedalla
Concerns: Multiple communication failures meant staff were unaware of a patient's high suicide risk and allowed unescorted leave. Inadequate record-keeping, brief un-noted risk assessments, and delayed, confused responses to a missing patient compounded the risk, exacerbated by short-staffing.
Responded
Brenda Shields
Concerns: The patient was discharged without planned follow-up or family involvement, and promised referrals were not made. Inadequate consideration of her alcohol problems led to an incorrect low-risk assessment, mirroring concerns from previous reports.
Responded
Christopher Ryan
Concerns: The trust tolerated a blurring of therapeutic escorted leave with unsecure smoking breaks, where one staff member supervised multiple patients in an unsecure car park. This lack of clear boundaries and a safe smoking area allowed patients to abscond with catastrophic consequences.
Responded
Thomas Smith
Concerns: Mental health staff lacked critical knowledge and training on "Spice" dangers. Flawed Section 17 leave risk assessments meant escorts were unaware of recent drug-related risks or patient care plans, compromising safety.
Overdue
William Savory
Concerns: There was a significant two-hour delay in initiating the missing persons protocol for an informal patient, as staff were unaware of the requirement to act immediately. This lack of awareness poses a risk of future delays and deaths.
Overdue
James Forryan
Concerns: Easily accessible websites openly promote and provide guidance on suicide methods, contributing to deaths. There is a lack of sufficient regulation and enforcement against such harmful online content.
Responded
Marshall Metcalfe and Jane Ireland
Concerns: Children's Social Care disengages during mental health admissions, leading to a lack of social worker input in discharge planning and continuity of care, which increases patient risk upon leaving the facility.
Overdue
Alexandra Tolley
Concerns: The care plan's instruction not to restrain or follow a high-risk patient absconding under Section 2 was incompatible with safety duties. Informal decisions for ground leave lacked criteria and proper risk assessment.
Responded
Jude Lloyd
Concerns: Inadequate care planning and communication between inpatient, CMHT, and GP services led to unmanaged diabetes and missed mental capacity assessments. The Trust's internal investigation was also flawed and incomplete.
Responded
Antony Schofield
Concerns: Inadequate risk assessments, poor communication during patient transfer, and a lack of professional curiosity by community mental health staff led to missed opportunities to address escalating suicidal risk, compounded by poor audit and flawed investigation.
Responded
Katy Samuels
Concerns: The Section 17 Leave Policy lacked clear guidance on escorted leave and escort identity verification, enabling a detained patient to leave unobserved, return intoxicated, and subsequently self-harm.
Responded
Kimberley Smith
Concerns: The Trust lacks clear written policies for managing informal patients' leave requests, including risk assessments and monitoring. A vital recommendation for a comprehensive alcohol detoxification protocol also remains unimplemented.
Responded
Lewis Francis
Concerns: A lack of mechanisms for transferring serious crime suspects in police custody to mental health facilities and insufficient understanding of autistic prisoners' needs pose significant risks.
Responded
David Fowler
Concerns: The patient's family was not informed or invited to an MDT meeting before his Mental Health Act section was lifted. Staff lacked clarity on who was responsible for family communication, and no formal policy was in place.
Responded
Thomas Wedrychowski
Concerns: Annual monitoring for diabetes in patients on antipsychotics may be insufficient for high-risk individuals, and there is a critical lack of physical healthcare information sharing between primary and secondary care providers.
Overdue
John Richardson
Concerns: Confusion among staff regarding voluntary patients' leave status highlighted the absence of a specific leave policy for voluntary patients, unlike those sectioned under the Mental Health Act.
Responded
Keith Heatley
Concerns: There was a lack of documented multidisciplinary decision-making and policy guidance regarding leave for informal patients, coupled with inconsistent recording of MDT meetings and no clinical review before high-risk patient leave.
Responded
David Squire
Concerns: Smoke-free hospital guidance forces detained mental health patients who smoke into unescorted 'off-grounds' leave without staged assessment, significantly increasing risks of absconding, self-harm, and harm to others.
Responded
Patricia Chambers
Concerns: Concerns were identified regarding practices at West London Mental Health Trust, indicating a risk of future deaths if appropriate action is not taken.
Overdue
Rastislav Petrisko
Concerns: Inconsistent risk assessment and classification of a patient, combined with a delayed police notification policy for absconding low-risk patients, led to an unacceptable delay in emergency response.
Overdue
Khuong Lam
Concerns: Mental health guidance lacks provisions for reviewing Section 17 leave upon ward transfer, and there's a need for better communication to clinicians and consideration of two escorts for patient safety.
Overdue
Sabrina Walsh
Concerns: The absence of CCTV in corridors and communal areas at the acute care facility delayed locating vulnerable patients, risking timely intervention.
Responded
Janet Muller
Concerns: Deficient nursing records, risk assessments, and care plans, coupled with inadequate staffing and persistent issues allowing Mental Health Act patients to abscond, increased patient risk.
Responded
Jonathan Zucker
Concerns: A lack of a lead clinician or systemic coordination between private and NHS mental health services resulted in fragmented patient care oversight.
Responded
Andrew Codling
Concerns: A community health team's voicemail to a patient missed an opportunity to reinforce crisis support numbers, potentially contributing to a missed chance to prevent self-harm over a weekend.
Responded
Wendy Telfer
Concerns: Inadequate training for physical healthcare staff on mental health needs and Mental Health Act application is a concern. A severe national shortage of psychiatric beds also caused critical delays in patient transfer, contributing to preventable deaths.
Responded
Peter Usher
Concerns: Inadequate mental health assessments failed to gather comprehensive patient information from various sources, lacked proper staffing support, and indicated a lack of clinical insight from the duty doctor.
Responded
John Jones
Concerns: A significant delay in notifying the GP of patient discharge from the Crisis Team left the patient without community support. Crisis Team training lacked clear communication protocols for such handovers.
Overdue
John Jones
Concerns: The hospital failed to ensure an unwell patient engaged with crucial group therapy, despite it being the reason for admission, leading to isolation and a suboptimal therapeutic environment.
Overdue
Margaret Richardson
Overdue
Oliver Ford
Concerns: The telephone triage process lacked a robust risk assessment, and any assessments were often undocumented. Insufficient PCLS weekend cover led to crucial follow-up delays for patients triaged on Fridays.
Responded
Micael McMonigle
Concerns: Critical failures in managing informal patient leave, including lack of staff policy knowledge, inadequate risk assessment updates, and severe delays in responding to a patient's absence, contributed to significant safety concerns.
Overdue
Anthony Preston
Overdue
Rohan Fitzsimons
Concerns: Insufficient inpatient mental health beds, influenced by funding, led to significant delays in Mental Health Act assessments, posing a risk of individuals taking their own lives while awaiting necessary detention.
Overdue
Pamela Gressman
Concerns: There was insufficient consideration of physical effects from reported foreign body ingestion, leading to an absence of a clear treatment and observation plan for physical symptoms.
Responded
Danny Sweet
Responded
Leslie Morrison
Overdue
Lee Grimes
Concerns: Home health care failed to act on overdose disclosures and ensure follow-up with mental health services, compounded by inadequate staff training in managing overdose reports.
Overdue
Tracey Lynch
Concerns: No specific concerns are provided in the truncated text.
Overdue
Helen England
Concerns: No protocol or guidance exists for Mental Health Nurses regarding doctor referral decisions when discharging self-harm patients, particularly those on a Community Treatment Order, creating a significant risk.
Responded
Charlotte Bevan and Zaani Malbrouck
Concerns: There was no mandatory multi-disciplinary team meeting or widely circulated care plan for pregnant women with known mental health conditions, risking fragmented and uncoordinated care.
Responded
Leah Levine
Concerns: Lack of clearly written conditions for temporary hospital leave, including supervision levels and observation regimes, led to conflicting staff understanding and poor communication with caregivers.
Responded
Alexander Holt
Concerns: Failures included not challenging minimised suicidal intent, providing intended treatment, ensuring continuity of care, and maintaining information flow, leading to inadequate risk assessment and a broken referral process.
Overdue
Danuta Corbett
Concerns: The hospital's leave policy for informal patients was not followed, and inadequate risk assessment for escorted leave, using an untrained agency worker, resulted in critical safety failures.
Responded
Andrew Hall
Concerns: Inadequate communication and documentation of mental health risks, failure to administer prescribed medication, and insufficient patient observation within the prison healthcare unit were identified. Training gaps for staff in risk assessment and ACCT procedures also contributed to concerns.
Overdue
Maureen Leaver
Concerns: Inadequate medical supervision and ineffective systems for investigating acutely ill elderly patients in a psychiatric ward were identified, alongside a lack of understanding of legal duties for patient transfers.
Overdue
Christopher James Morgan
Concerns: The Trust lacks clear policies for communicating risk level changes and leave access with family, and has no defined staff-to-patient ratio for escorted leave from psychiatric wards.
Overdue
Yousef Shokri-Gharab
Concerns: An outdated and unreviewed policy for informal patient leave failed to reflect current practice, risking patient safety due to lack of multidisciplinary consensus and proper documentation.
Response: Mersey Care NHS confirms that the specific policy of concern regarding leave for informal patients has already been reviewed and updated. The Corporate Governance Team has completed reviews for 117 …
Pending
Linda Hudson
Concerns: Hospital discharge of a high-risk patient without family notification, inadequate communication regarding medication protocols, and a delayed nurse follow-up visit created significant safety risks.
Overdue
Keward Guy Domonic Harding
Concerns: An urgent mental health assessment was significantly delayed for over two weeks, potentially preventing detection of a decline in physical health that could have been treated.
Overdue
Mena Terefi
Concerns: Mental health services face demand far exceeding capacity following a transformation, with referrals over 100% above anticipated levels and insufficient resources, risking future deaths.
Overdue