Mental health informal leave guidance
Lack of robust criteria and clear guidance for staff making decisions about informal ground leave for mental health patients.
115 items
6 sources
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
97match
Keith Heatley
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.
Matched on
terms: guidance, informal, leave
PFD report
93match
David Squire
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.
Matched on
terms: guidance, health, leave, mental
PFD report
93match
Thomas Smith
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.
Matched on
terms: health, leave, mental
PFD report
89match
Helen England
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.
Matched on
terms: guidance, health, mental
PFD report
89match
Khuong Lam
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.
Matched on
terms: guidance, health, leave, mental
PFD report
89match
John Richardson
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.
Matched on
terms: health, leave, mental
PFD report
87match
Alexandra Tolley
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.
Matched on
terms: informal, leave
PFD report
81match
Tommy Faisali
Psychiatric GP referrals are handled by unqualified staff, and risk assessments are not consistently completed or documented, leading to uncommunicated patient risks and a lack of care continuity within mental health teams.
Matched on
terms: health, mental
PFD report
81match
Micael McMonigle
Staff showed a lack of knowledge and failure to follow policy regarding leave for informal patients, risk assessments were not updated, and the response to the patient's absence was delayed and did not conform with procedures; staff knowledge of leave policy was inadequate.
Matched on
terms: informal, leave
PFD report
81match
Peter Usher
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.
Matched on
terms: health, mental
PFD report
81match
David Fowler
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.
Matched on
terms: health, mental
PFD report
81match
Kimberley Smith
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.
Matched on
terms: informal, leave
PFD report
81match
Katy Samuels
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.
Matched on
terms: guidance, leave
PFD report
81match
Antony Schofield
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.
Matched on
terms: health, mental
PFD report
77match
Yousef Shokri-Gharab
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.
Matched on
terms: informal, leave
PFD report
77match
Andrew Hall
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.
Matched on
terms: health, mental
PFD report
77match
Wendy Telfer
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.
Matched on
terms: health, mental
PFD report
77match
Jonathan Zucker
A lack of a lead clinician or systemic coordination between private and NHS mental health services resulted in fragmented patient care oversight.
Matched on
terms: health, mental
PFD report
77match
Janet Muller
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.
Matched on
terms: health, mental
PFD report
77match
Marshall Metcalfe and Jane Ireland
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.
Matched on
terms: health, mental
PHSO casework decision
76match
P-003684 - An independent provider in the Hammersmith and Fulham area
Mrs D complains staff allowed Mr E to leave his mental health facility. Mrs D also complains staff did not take the action they should have to find Mr E when he did not return from his leave.
Matched on
terms: health, leave, mental
PFD report
74match
Maureen Leaver
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.
Matched on
terms: leave
PFD report
73match
Christopher James Morgan
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.
Matched on
terms: leave
PFD report
73match
Danuta Corbett
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.
Matched on
terms: informal, leave
PFD report
73match
Lee Grimes
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.
Matched on
terms: health, mental
PFD report
73match
Leslie Morrison
No formal mental capacity assessment or consideration of a DoLS authorisation was undertaken in the community, and details of the patient's mental health condition did not accompany him to the hospital; the coroner suggests policies to ensure up-to-date information is provided upon admission or discharge.
Matched on
terms: health, mental
PFD report
73match
Rohan Fitzsimons
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.
Matched on
terms: health, mental
PFD report
73match
Lewis Francis
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.
Matched on
terms: health, mental
LGO / SPSO decision
73match
23-009-939b - Barts Health NHS Trust (23 009 939b)
Summary: We will not investigate this complaint about the decision to detain a patient under the Mental Health Act, because of concerns they were refusing treatment for their physical health. This is because there was a right to appeal the assessment outcome through a tribunal and it would have been reasonable to use this.
Matched on
terms: health, mental
PFD report
69match
Keward Guy Domonic Harding
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.
Matched on
terms: health, mental
PFD report
69match
Leah Levine
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.
Matched on
terms: leave
PFD report
69match
Charlotte Bevan and Zaani Malbrouck
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.
Matched on
terms: health, mental
PFD report
69match
Patricia Chambers
Concerns were identified regarding practices at West London Mental Health Trust, indicating a risk of future deaths if appropriate action is not taken.
Matched on
terms: health, mental
PFD report
69match
Mena Terefi
Mental health services face demand far exceeding capacity following a transformation, with referrals over 100% above anticipated levels and insufficient resources, risking future deaths.
Matched on
terms: health, mental
PFD report
69match
William Savory
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.
Matched on
terms: informal
IMB recommendation
68match
Isle of Wight (2020)
Again the issue of prisoners experiencing significant mental health issues has been overlooked. The HMIP recommendation to Her Majesty’s Prison and Probation Service (HMPPS) to ensure that mentally ill prisoners are transferred to appropriate facilities, in line with national guidance, was rejected. What plans are in place to ensure that mentally ill prisoners are managed in line with...
Matched on
terms: guidance, health, mental
PFD report
65match
Thomas Wedrychowski
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.
Matched on
terms: health
IMB recommendation
65match
Heathrow Immigration Removal Centre (2021)
The policy which results in people with severe mental health issues being held in IRCs should be reviewed. Despite the introduction of a new Detention Service Order (DSO) published in June 2020 on ‘mental vulnerability and immigration detention’, the Board feels that further action is necessary as the problem remains.
Matched on
terms: health, mental
LGO / SPSO decision
64match
201104524 - Mental Welfare Commission for Scotland
Mrs C complained that the Mental Welfare Commission for Scotland (the Commission) failed to respond appropriately to a letter sent to them by her son. The letter contained her son's concerns about his detention and treatment under Mental Health legislation. In addition, Mrs C complained that the Commission failed to tell her or her husband about the letter,...
Matched on
terms: health, mental
Committee recommendation
63match
#1 - Fourth report: Unequal impact? Coronavirus, disability and access to services: full Report
We welcome the Government’s decision to discontinue the Coronavirus Act’s Mental Health Act provisions, which potentially relaxed requirements for sectioning, against the grain of overdue and much-needed reforms, and which thankfully proved to be unnecessary in England. We will continue to push for progress towards implementation of our recommendations on Care Act and Children and Families Act provisions...
Matched on
terms: guidance, health, mental
PFD report
61match
Andrew Codling
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.
Matched on
terms: health
PFD report
61match
Jude Lloyd
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.
Matched on
terms: mental
PFD report
61match
James Forryan
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.
Matched on
terms: guidance
IMB recommendation
60match
Gatwick IRC/RSTHF (2022)
Increase the Detention Gatekeeper’s threshold(s) for bringing men with mental health issues into detention and improve facilities and support to enhance the prospect of release from detention for men exhibiting deterioration of their mental health in detention (section 4.4).
Matched on
terms: health, mental
PHSO casework decision
60match
P-001067 - Essex Partnership University NHS Foundation Trust
Mr and Mrs A complain that Essex Partnership University NHS Foundation Trust (the Trust) did not communicate with or invite Mr A to any review meetings including the discharge meeting and discharged Mrs A from Hospital too soon. They also complain that when Mrs A went back into the mental health hospital, the Trust stripped Mrs A naked...
Matched on
terms: health, mental
LGO / SPSO decision
60match
23-014-778a - Lewisham & Greenwich NHS Trust (23 014 778a)
Summary: We consider London Borough of Lewisham and Lewisham and Greenwich NHS Trust did not appropriately seek the views of Mrs Y’s supported accommodation before deciding she could not return there from hospital. Also, the Council did not carry out a Mental Capacity Act assessment and best interest decision in line with the relevant guidance. That caused Mrs...
Matched on
terms: guidance, mental
PFD report
57match
Anthony Preston
The discharge system lacked robustness, with no documentary proof of a telephone call to the Crisis Team, and no immediate follow-up notification of discharge; the coroner noted this left a high-risk patient without support.
Matched on
classifier match
PFD report
57match
Oliver Ford
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.
Matched on
classifier match
PFD report
57match
John Jones
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.
Matched on
classifier match
IMB recommendation
56match
Swaleside (2021)
The Board has concerns regarding the mental health of residents who have suffered long-term lock-down. (see sections 5 and 6.2)
Matched on
terms: health, mental