Escorting patients Amber Lodge or forensic service procedure

1 Aim

The forensic service recognise that escorted leave is an important part of a patient’s recovery and enables clinical decisions to be made regarding a patient’s progress through their care pathway. Therefore, the aim of this document is to provide guidance for all colleagues, to ensure that the service is fully compliant with the standards of escorting, as detailed in the Standards for Low Secure Service, Royal College of Psychiatrists (2023). Providing a consistent approach and practice standards will ensure that managing of risks when escorting patients detained under the Mental Health Act (MHA) will be safe for patients, colleagues and the general public.

2 Scope

This document applies specifically to the forensic service and provides procedural guidance for use of colleagues working in this service including agency, bank and students. It applies to all colleagues who may be required to escort patients detained under the MHA for the purposes of recreation, home visits, leisure, hospital appointments, hospital transfers, court appearances or other possible reasons for leave.

3 Link to overarching policy

This procedure is overarched by the forensic service manual and should be read in conjunction with the forensic security procedural document, the trust policy of clinical risk assessment and management, and the lone working policy.

4 Procedure and implementation

Each patient’s individual escorted outing will differ and requirements for the outings to be escorted safely will be risk assessed and robust risk management plans implemented as required.

The trust and forensic service have specific duties under Section 11 of the Children Act 2004 to make arrangements to safeguard and promote the welfare of children and is committed to these responsibilities.

The MHA 1983 and its Code of Practice (Department of Health, 1999, draft revision 2007) set out the requirement for local policies to safeguard children’s rights in relation to private and family life and to promote good practice.

The decision to allow or deny the presence of children during a planned visit will be based on risk assessment. Where risk assessment identifies concerns, detailed planning will be required, involving all possible agencies. In accordance with the Children Acts (1989 and 2004) the welfare of the child is paramount and takes primacy over the interests of any and all adults.

4.1 Risk assessment

In line with standards 24 and 25 of CCQI, *The team and patient jointly develop a leave plan, which is shared with the patient, that includes:
- the aim and therapeutic purpose of section 17 leave that clearly links to the overarching plan for the care pathway
- a risk assessment and risk management plan that includes an explanation of what to do if problems arise on leave
- conditions of the leave
- contact details of the ward or unit and crisis numbers
- colleagues agree leave plans with carers where appropriate, allowing carers sufficient time to prepare
It is important that the patient is included in all discussions regarding leave and engaged with the escorted leave care planning agreeing with decisions. Patients are to be given opportunity to express their views and participate in the formulation of their care plans, to agree to comply with the conditions and stipulations that have to be applied.
All patients will have formal risk assessments completed on admission which will include identification of their risk of absconding and any other relevant factors whilst on escorted leave. The risk assessment will identify whether the patient falls into a low, medium or high-risk category.
The risk assessment must be documented in their individualised care plan, where appropriate detailing gender and number of colleagues required for the escort.
The risk assessment and care plan will be subject to regular review and updated as appropriate at each Multidisciplinary team (MDT) meeting and also when clinical need is identified.
Medium and High-risk patients must on admission have escorted leave care plans in place to ensure unplanned leave such as medical emergencies, court attendance and hospital appointments are managed safely.
Before any escorted leave can be undertaken the responsible clinician (RC) will complete a section 17 leave form reflecting risk assessment requirements and Ministry of Justice restrictions and stipulations if in place.
Restrictions on escorted leave such as times of leave, means of transport and communication requirements will be reviewed by the MDT and will only be in place where clinically indicated for safety.
All patients will receive verbal and written confirmation of any restrictions that will need to be imposed on them as part of the section 17 leave and will be included in the leave care plan.
Identified restrictions, such as random pat down searches or random drug and alcohol testing for example will be included in the patient care plan.
Any restrictions in place must be shared with escorting colleagues prior to Section 17 leave being undertaken.

4.1.1 Low risk

Patients assessed as being low risk will have no recent history of absconding or of threats to abscond and will be assessed as presenting with no immediate danger to themselves or others if they do abscond.
They will not be detained by the courts on remand and will currently have a stable mental state.
They may also have unescorted leave authorised.
They will be able to undertake escorted leave as a group activity with a ratio of a minimum of 1:2, one colleague to 2 patients, as well as 1:1 leave, one colleague to one patient.
A driver may be the escorting colleague for low-risk patients.
Colleagues undertaking 1:1 escorting leave duties must be conversant with the trust’s lone working policy and have completed all relevant lone working risk assessment. Use of RDaSH mobile phones are also to be used when lone working.

4.1.2 Medium risk

Patient identified as medium risk will have been assessed as having a history of absconding with threats to abscond or may be assessed as having some impulsive behaviour that poses a risk to themselves or to others if they do abscond.
Their mental state may currently be in a state of flux.
They will have no unescorted leave authorised.
Only 1:1, one colleague to one patient, escorted leave will be authorised.
Group escorted leave can only be taken if the patient has an identified colleague to fulfil the 1:1 requirement whilst on the group leave.
A driver cannot be included in the escorting colleague

4.1.3 High risk

Patient identified as high risk will have been assessed as having a history, recent and historical, and threats to abscond.
They may pose an immediate risk to themselves or to others if they should abscond.
They may exhibit a marked deterioration in mental state.
They may have no authorised leave.
May be detained or restricted by the courts.
There may be significant political, or media interest attracted.
Leave for leisure purposes will not be authorised, leave will only be for essential purposes, such as:
- transfer to another hospital
- attendance at court
- attendance at a police Station
- hospital appointments
All leave must be agreed and authorised by the full MDT, consideration to be given if secure transport would be required (see Safe transportation of patients and staff (adult and older person’s mental health and learning disability))
A minimum of 3 colleagues trained in reducing restrictive interventions (RRI) techniques will be required to undertake the leave. The lead escort must be a registered nurse.
Drivers will not be included in the number of the escorting colleague.
Police manager involvement may be appropriate with additional supportive measures such as CCTV coverage whilst on leave.

5 Assessment and standards for escorted leave

There are minimum standards which apply to all three categories of risk, with additional requirements for the medium and high categories.
All escorting colleagues are expected to adhere to the minimum standards for all categories of leave.
All patients undertaking leave must have an escort status risk assessment (appendix e).
If the patient is visiting their family in a home environment a home risk assessment (appendix f) must be completed in addition to the section 17 leave risk assessment. The home risk assessment must be discussed and agreed in the MDT prior to leave being authorised.

5.1 Standards for escorted leave

To ensure that a pre-brief is completed with the patient prior to every leave and to ensure that this is documented on SystmOne.
Be aware of all items of patient property taken on leave, for example, money, clothing, food. Ensure that the amount taken is agreed on a person-centred basis around individual risks.
To be fully briefed about the patient(s) undertaking the leave and the conditions and stipulations that have been applied to the leave.
To adhere to the plan of leave and section 17 documentation.
To know of the patient’s individual care plans and any specific instructions to be followed throughout the leave, such as use of toilet areas and what needs to be supervised.
To encourage the patient to take full advantage of any escorted leave and engage with planned activities.
To intervene if the patient displays any undesirable behaviours as highlighted in risk assessments and care plans.
Keep the patient safe at all times.
Try to prevent the patient from absconding, utilising pre-briefing and care planning guidance, using reasonable means.
To be conversant with the procedures to be undertaken in any eventuality or emergency.
To make every effort to return safely to the ward.
To be able to observe the patient and engage appropriately with them at all times and remain in close proximity during the leave period.
To undertake a debrief following the leave with the patient and the nurse in charge or shift co-ordinator, and to record details of the leave as appropriate, and ensure that this is documented on the electronic patient record SystmOne.

6 Roles of colleagues for escorted leave

6.1 Nurse in charge or shift co-ordinator

Will determine the colleagues to escort the patient, taking into account the number of escorts required, identified factors required such as gender of colleagues and skill mix, as identified by the MDT.
If more than one patient is being escorted staffing will be assigned as per individual patient leave status and associated qualifying factors highlighted in risk assessments and care plans.
Escorts will be allocated to be responsible for named patients prior to leaving the ward, and the lead escort will have overall responsibility for the group.
On occasion there may be specific clinical reasons for the patient’s leave to be reconsidered such as concerns about their mental state or increased risk of absconding.
If the decision is made to postpone or cancel leave the patient must be informed and a full explanation offered. Any decision must be recorded in the patient’s electronic notes, SystmOne.
Notification of the leave cancellation must be given to the responsible clinician and senior nursing colleagues as soon as practicable.
Discussion of the cancelled leave will be held at the next MDT meeting.
Any identified escorts will have a full briefing from the nurse in charge or shift co-ordinator regarding the patient’s individual specific requirements, conditions and stipulation for their leave as highlighted by the MDT, risk assessments and care plans.
The nurse in charge or shift co-ordinator also holds the responsibility for briefing the patient of any such conditions prior to undertaking the escorted leave.
Particular attention should be given to briefing escorts on any action to be taken, by means of prevention of absconding, or if the patient should abscond.
Any relevant information concerning emotional, physical or social factors for the patient should be given to the escorting colleagues to ensure that the care and wellbeing of the patient whilst on leave is effective and therapeutic.
Full debrief upon return from leave for the escorts is to be undertaken, and all documentation completed as required.
The patient should also complete a full debrief of leave with the escorting colleague and details of this recorded in the care plan and also the MDT notes.
Any leave facilitated for faith purposes, colleagues should seek support and advice and work with faith leaders through the trust chaplaincy department.

6.2 Lead escorts

Where more than one colleague is designated to escorting a patient, or a group outing is taking place, it is important that one colleague is designated lead escort by the nurse in charge or shift co-ordinator.
The lead escort is to ensure they have a full briefing about the patient(s) undertaking the leave and are fully aware of all conditions that must be applied. The briefing is not limited to, but issues covered should include, the following:
- the purpose of escorted leave
- details of transport and expected time of return
- the conditions, stipulations of the leave, to cover issues such as location, behaviour boundaries, meeting specified individuals, intake of alcohol
- familiarity with the patient and their individual needs and care plans.
- medications required during leave, including PRN medication for physical health issues
- if a detained patient fails to return to the ward at the agreed time they are classed as absent without leave (AWOL) and must be returned under section 18 of the MHA 1983. Employees should refer to the trust wide patients missing or absent without leave (AWOL) policy for detailed guidance. Arrange the method of communication with the ward whilst undertaking the leave
- ward mobile phones are to be signed out for leave purposes to ensure communication is facilitated to notify of return timings or to alert the nurse in charge or shift co-ordinator of any problems with the leave
- any information or documentation required for the leave is to be taken as necessary, for example, medical notes, prescription card and appointment cards for hospital appointments.
- a full discussion with the patient to ensure clarity on conditions and stipulations of leave will be held prior to leaving the ward.
- documentation of the leave and any outcomes must be recorded in SystmOne appropriately and a handover provided to the nurse in charge or shift co-ordinator and documented in the care plan and MDT update notes.

6.3 Escorts

When patients are on an individual 1:1 escorted leave, the escorting colleague will be the lead escorts as detailed in section 6.2 and must ensure they are compliant with the briefing as detailed in this section.
Escorts must be in possession of a trust staff identity card and carry this at all times as proof of authority to act as an escort to the patient. In the trust grounds this can be worn visibly however for community escorting it must NOT be on show.
Colleague belts and key pouches must NOT be worn for any escorting leave.
The use of wearing RDaSH uniform will be agreed and shared within the patients individualised care plan.
The overall organisation and planning of escorted leave is mainly within the role and function of the lead escort and the nurse in charge or shift co-ordinator.
All escorted colleagues must be clear on their role and responsibilities and maintain the required practice standards in this procedure.

6.4 The patient

It can be assumed that, because leave is to be escorted, the patient has not yet reached the point in their treatment to be granted full unescorted leave and that legal constraints eliminate unsupervised leave as an option.
All Section 17 leave documentation must have the leave care plan attached and be given to the patient and identified carer as/if appropriate.
Accompanied care and leave maybe considered as an option for patients. This would be discussed and agreed within the MDT meeting and if appropriate agreed section 17 leave care plan devised between carer, patients and MDT, which would include all necessary guidance and support.
Arrangements are to be made for a contact number to be given for them to seek advice and guidance if needed.
The patient can expect to receive a briefing by the colleagues escorting the leave prior to and following the escorted leave activity.
Patients are to be encouraged to express their views, relate their experiences and make comments through the briefing period’s pre-leave and post-leave.

7 Preparation for high risk leave

The lead escort, registered staff nurse, is/are responsible for making the appropriate transport bookings and confirming arrangements.
The driver must not be counted in the escort team.
The escorting colleagues must be adept at implementing RRI techniques and be up-to-date with training requirements.
The lead escort must check that all the requirements and arrangements specified in the care plan are confirmed, for example appointment times.
The lead escort must obtain a copy of any care plan introduced for the high risk leave and take this on the escorted leave and ensure it is fully adhered to.
The lead escort must maintain communication with the ward through the ward mobile phones utilised for escorted leave.
The lead escort will brief all escorts and the driver before commencing the high risk escorted leave with the patient.
Only when all members of the Escort team are satisfied that they are conversant with all the conditions and requirements of the escorted leave (as detailed in the fully completed section 17 leave and care plan documentation) will the high risk escorted leave be considered/recorded as undertaken.

8 Contingency plan

In the MHA Code of Practice 1983 colleagues who are escorting patients detained in accordance with the MHA are expected to prevent the absconding of a patient under their care using every reasonable means at their disposal.
A detained patient on any escorted leave who absconds from their escorting colleagues or refuses to return to ward when required to do so can be deemed to have absconded. In this case it is lawful for the escorting colleagues, as the person who had the patient’s custody immediately before absconding, to retake them, but only if colleagues feel it was safe to do so.
Prior to escorted leave, especially high risk, all escorts will be briefed by the nurse in charge or shift co-ordinator as to what action they should take, if the patient absconds.
The trust wide patients missing or absent without leave (AWOL) policy should be adhered to for section 17 leave. Section 6 authorises restraint provided that the officer or colleague reasonably believes that it is necessary to do the act in order to prevent harm to the patient. And that restraint is a proportionate response to:
- the likelihood of patient’s suffering harm
- the seriousness of that harm

Contingency plans can include the following:

In the event of an AWOL please follow the trust wide patients missing or absent without leave (AWOL) policy seeking support from the ward via phone alongside informing the police.
There must not be changes to the content of the planned escorted leave unless an emergency situation arises, which should be reported to the nurse in charge or shift co-ordinator as soon as possible. Advice should be given regarding any required changes to the leave.
It is not recommended that a single escort follows a patient who absconds in order to keep them in view. A minimum of 2 colleagues should follow the patient, with one being in contact with the patient’s ward and/or the police to update on the patient’s location. Colleagues must ensure that their safety will not be compromised to follow the patient.
Colleagues need to understand that they must not put their safety at risk or that of others in taking measures in order to prevent a patient from absconding,
Escorting colleagues who have any concerns about their ability to return the patient safely should request assistance from the police.
Any incidences of absconding will be reported at the earliest opportunity to the RC and all relevant documentation will be completed, including a completion of an IR1 form.
In the event that the patient does not return to the ward by midnight on the first day of absence complete and email the CQC AWOL notification form to the CQC. Then send the original to the service manager or matron or MHA office.
- Notify the Mental Health Act office of the AWOL.
- Complete the required, this is needed for any AWOL incident going past midnight (do not complete on-line print and send to the relevant areas, scan and save to SystmOne)

9 References

CCQI Standards for Inpatients Mental Health Services, fourth edition (2022)

10 Appendices

Appendices can be found on the forensic service manual’s page on the trust website.

Appendix E: Escort status risk assessment
Appendix F: Home risk assessment
Appendix O: Unauthorised absence of a person detained or liable to be detained under the Mental Health Act 1983

Document control

Version: 3
Unique reference number: 532
Date ratified: 2 July 2024
Ratified by: Clinical policies review and approval group
Name of originator: Forensic ward manager
Name of responsible individual: Chief nurse
Date issued: 9 July 2024
Review date: 31 July 2027
Target audience: All colleagues working in forensic services.
Description of change:
- 4.1.1 Amend sentence to: they will be able to undertake escorted leave as a group activity with a ratio of a minimum of 1:2 one colleague to 2 patients.
- 5.1 Add in: To ensure that a pre-brief is completed with the patient prior to every leave and to ensure this is documented on system one. Amend: To undertake a debrief following the leave with the patient and the nurse in charge or shift co-ordinator and record details of the leave as appropriate and document this on system one.

Page last reviewed: December 12, 2024
Next review due: December 12, 2025

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