Patients missing or absent without leave (AWOL) policy

Contents

1 Policy summary

This policy provides guidance to employees on what action to take when a patient goes missing or absent without leave (AWOL) from one of its inpatient wards.

Every effort should be made within in-patient services to ensure that staff know the whereabouts of all patients in their care, however due to the majority of in-patient areas not being locked and therefore allowing a degree of free movement, there may be times when a patient cannot be found on the ward and staff are not able to account for their whereabouts. The risk of an inpatient being missing, or AWOL is that they may either actively or passively harm themselves or others, or be exploited by others, or suffer harm due to an inability to care for themselves whilst they are away from the in-patient environment.

The policy highlights the distinction between a patient who is missing and a patient who is AWOL and when a patient is classed as missing or AWOL.

It also highlights when there should be escalation to the police, what circumstances this applies and what the internal trust escalation processes are in these situations.

It is underpinned by the Mental Health Act (MHA) Code of Practice Guidelines 2015 and sets out the trust’s approach managing the risk of missing and AWOL patients in its inpatient services.

2 Introduction

2.1 Definitions

2.1.1 Missing

This term applies to any situation where patients have absconded, are absent without agreement or planned leave or have not returned from leave and are considered likely to act in a way that may present a risk to themselves or others.

Confused or disoriented patients may also go missing if they wander away from their care setting.

This definition also applies to any patient who has identified risks, regardless of their level of capacity to make a decision, who leaves the ward without having discussed their wish to leave with the multi-disciplinary team.

For a patient subject to the Deprivation of Liberty Safeguards (DoLS) who leaves an in-patient service without the knowledge or agreement of the clinical team, the DoLS only authorises the stay on the ward so if someone leaves there is no authority to bring the patient back under the safeguard. They would be classed as a vulnerable missing person.

2.1.2 Absent without leave (AWOL)

This term is used in connection with patients who are liable to be detained under the MHA and who absent themselves from hospital without authorised leave granted under section 17 or who are subject to a community treatment order (CTO) and have failed to attend hospital when recalled. A patient would also be considered AWOL if they failed to return within the time limits allowed for authorised section 17 leave.

The MHA 1983 Code of Practice (paragraph 28.15) indicates that there are three situations that should always and immediately be reported to the police by healthcare services:

1. patients subject to part 3 MHA 1983, this means patients connected to criminal proceedings, either before or after trial or conviction
2. patients who are dangerous
3. patients who are particularly vulnerable, there is no obligation in law for hospital staff to report any other relevant matters immediately or at all

Every effort should be made within in-patient services to ensure that staff know the whereabouts of all patients in their care, however due to the majority of in-patient areas not being locked and therefore allowing a degree of free movement, there may be times when a patient cannot be found on the ward and staff are not able to account for their whereabouts.

The risk of an in-patient being AWOL or missing is that they may either actively or passively harm themselves or others, or be exploited by others, or suffer harm due to an inability to care for them whilst they are away from the in-patient environment.

3 Purpose

The purpose of this policy is to set out the arrangements for managing the risks associated with patients who are missing or AWOL from inpatient services whilst they are receiving care and treatment within the trust, or whilst on planned leave from the inpatient services.

Maintaining effective risk assessment, care planning and communication and responding in a timely and consistent manner when patients do go AWOL or are missing, liaising effectively with other relevant agencies.

This policy also applies to patients subject to a CTO recall who fail to return voluntarily to the hospital named in the recall notice (see community treatment order policy). The policy does not apply to community patients who have, or are at risk of, disengaging with services. See the disengagement policy.

4 Scope

This policy applies to all inpatient clinical staff, all AWOL or missing patients, whether they are informal or detained under the MHA1983 (Amended 2007), or subject to DoLS.

Staff working within the trust inpatient forensic services should also refer to Amber Lodge low secure service specific policies, forensic services manual for details of their area specific procedures.

For further information about responsibilities, accountabilities and duties of all employees, please see appendix A.

5 Responsibilities, accountabilities and duties

5.1 Board of directors

The board of directors has responsibility for the implementation of this policy and the monitoring of compliance. This responsibility is delegated to the trust chief executive who will delegate lead responsibility to the chief operating officer.

5.2 Care group directors

Care group directors are responsible for:

• the implementation of all policies and procedures which are in place to meet the needs of patients
• monitoring adherences to this and other related policies
• adequate resources and training being available to the clinical team

5.3 Modern matrons or service managers

It is the responsibility of the modern matrons or service managers to:

• make their staff aware of this policy and contents
• bring any issues which may affect implementation of this policy to the attention of the environmental risk in clinical areas group
• within the forensic services to audit compliance with the Care Quality Commission (CQC) reporting requirements in respect of patients detained under the Mental Health Act 1983 that go absent without leave (appendix B)
• investigate any breaches in compliance with the contents of this policy
• the provision and monitoring of operational and clinical supervision to clinical staff

5.4 Community staff

Community staff will:

• cooperate with and assist in-patient staff and the police to identify the potential whereabouts of patients known to them who are AWOL or missing

5.5 Responsible clinician

The responsible clinician will:

• be involved in the assessment of clinical risk for any patients on the wards who are admitted under their care
• review the granting of leave under section 17 for any patients detained under the Mental Health Act 1983 who have been absent without leave and then subsequently returned to the ward

5.6 The nurse or clinician in charge

The nurse or clinician in charge of the ward at the time of any patient going missing or absent without leave has a number of responsibilities under this policy and should refer to section 5 for full details.

5.7 The police

The police responsibilities are:

• all reports of missing or absent people will be managed in line with the South Yorkshire police and Humberside police standard operating procedure
• the police communications room will receive all reports of missing or absent patients on behalf of the police
• the police will manage, and co-ordinate all reports from whatever source
• the police will provide a service to receive reports 24 hours each day
• the initial police attendance will be graded in line with force missing persons policy
• the police will provide a unique reference number (URN) for each report confirming receipt
• the police will provide a reference number for those missing persons placed on the missing person data base
• the police will initiate a safe return check for all patients where there are concerns regarding if they are especially vulnerable
• in all cases a record will be made on the police national computer (PNC)

South Yorkshire police are not providers of transport for patients, detained or otherwise. While it is accepted that there is a legal basis for police to assist with the transportation of persons to hospital when detained under the Mental Health Act; the threshold for such assistance is necessarily high. On every occasion, police will only provide or assist with the transport in those circumstances where there is a risk of violence or aggression (following the RAVE risks). Any use of police resources must be risk assessed, justified and documented. Even then police constables must secure the authority of a supervisory officer unless in an emergency.

5.8 The Mental Health Act office

If a patient is detained under the MHA 1983 and goes AWOL; the MHA office will advise the responsible clinician and staff of the time limits associated with the relevant section for returning the patient as detailed in the MHA reference guide (appendix C).

5.9 Inpatient staff

Inpatient staff will:

• adhere to the relevant clinical risk assessment requirements for their clinical area as stated in section 5.2 of this policy
• adhere to guidance in section 5.7 of this policy

5.10 Staff working in locked units (Amber Lodge, Jubilee Close or Coral Lodge)

Staff working in locked units (Amber Lodge, Jubilee Close or Coral Lodge) only will:

• In the case of detained patients who go absent without leave comply with the reporting arrangements to the Care Quality Commission as detailed in sections 6.7 and 6.16 of this policy
• refer to Amber Lodge low secure service specific policies, when a Patient goes absent without leave (AWOL) SOP

5.11 Trust head of patient safety

The trust head of patient safety is responsible for the analysis of patient safety incidents and actions taken and the dissemination of learning from incident reports. This includes incidents of patients going absent without leave.

6 Procedure or implementation

6.1 Quick guide

6.1.1 Risk assessment

Classifying what the risk is, is the patient a risk to themselves or others and do they meet one of the three criteria below for reporting to the police:

1. is the patient subject to Part III MHA 1983, this means patients connected to criminal proceedings, either before or after trial or conviction (for example forensic detentions)
2. is the patient dangerous
3. is the patient especially vulnerable

6.1.2 Actions

Have we completed the following actions:

• searched the unit and grounds
• tried contacting the patient
• tried contacting the patients family or carers
• checked the patients accommodation
• looked around the local area
• informed the Access or Crisis team
• completed an IR1

6.1.3 Police

Where we need to contact the police:

• ensure that we are only contacting if the patient meets one of the 3 criteria above
• where the patient is a part 3 restricted patient, state this and the detention they are subject to for example section 37/41 or 47/49 etc
• where the patient’s vulnerability is high, highlight why the patient is significantly at risk
• where the patient is dangerous emphasise in what way, and to whom

6.1.4 In hours internal escalation

All instances of patients being missing, or AWOL should be notified to modern matron, care group triumvirate, head of service and chief operating officer immediately where:

• Ministry of Justice restrictions apply
• any patient, where the staff have concerns for the safety of the patient

For all other patients:

• the modern matron, if the patient has not returned with 30 minutes An AWOL only needs further escalation to the care group triumvirate or silver if there is a high profile case and, or incident related to the AWOL (or absent or missing person) that is likely to attract media attention and, or require high level communication with external partners

6.1.5 Out of hours internal escalation

All instances of patients being missing, or AWOL should be notified to bronze, silver and gold on-call immediately where:

• Ministry of Justice restrictions apply
• any patient, where the staff have concern for the safety of the patient

For all other patients:

• the bronze manager, if the patient has not returned within 30 minutes see section 6.7 for further details

6.1.6 On return

On the return of an AWOL patient the staff nurse should contact bronze or modern matron etc, and inform them of the patients return

• if police were informed contact police to update
• update the patient’s risk assessment and care plan
• spend time with patient to offer support and debrief

6.2 Information to patients

At the point of admission to the ward informal patients are to be advised of the fact that should they need to leave the ward for any reason they are to discuss this with a member of the clinical team. Detained patients will need to seek permission from the responsible clinician (RC) to leave the ward. In the event of any patient having leave from the ward, it is important that staff are able to account for patients whereabouts at all times.

6.3 Risk assessment

Staff should also refer to the trust clinical risk management system policy.

6.3.1 Doncaster physical health inpatient wards

A mental health clinical risk assessment will only be completed on patients who have identified cognitive impairment or mental health issues. Where it has been identified that a clinical risk assessment is required staff are to follow the guidance below.

6.3.2 Adult and older peoples mental health, leaning disability and forensic services

All patients will have a formal risk assessment completed on admission which will include identification of their risk of going AWOL or missing, including previous history and, or patterns.

The risk assessment will be reviewed and updated whenever any changes in the patient’s condition or risk profile are identified.

Known “triggers” for increasing the likelihood of a patient going AWOL or missing must be recorded for example, phone calls from particular friends and relatives. If the assessment indicates that the patient has an increased likelihood of absconding or going missing, details of their description should be recorded for instance, height and weight, other physical characteristics etc. The recording of this information must be kept in the patient’s electronic patient record.

The assessment should identify whether the risk is active or passive:

• active, patient is likely to knowingly and overtly attempt to leave the clinical area
• passive, patient may be confused and, or disorientated and may wander out of, or away from the clinical area if unsupervised.

All patients who are assessed as presenting a risk of going AWOL or being missing should have clearly recorded in their care plan appropriate levels of observation, supervision and security of the clinical environment for the level of risk assessed. When assessing the environment consideration must be given to the level of access the patient has to open windows, fire doors, or low rooflines. The care plan must be subject to regular review and must be communicated to all staff that need to be aware.

For patients who have been identified at high risk of going AWOL or being missing the following should be included in their electronic patient record:

• personal description information
• places they are likely to visit
• details of any additional actions required in the event of them going AWOL or being missing
• a photograph (see patient identification policy)

For patients who are confused and there is a risk that they may become separated from their escort, consideration should be given to the need for them to carry contact information with them when away from the wards.

6.4 When is patient classed as AWOL or being missing

Under section 18 of the MHA, patients are considered to be AWOL in various circumstances, in particular when they:

• have left the hospital in which they are detained without leave being agreed (under section 17 of the MHA) by their RC
• have failed to return to the hospital at the time required to do so under the conditions of leave under section 17
• are absent without permission from a place where they are required to reside as a condition of leave under section 17
• have failed to return to the hospital if their leave under section 17 has been revoked
• are patients on a CTO (community patients) who have failed to attend hospital when recalled
• are patients on a CTO who have absconded from hospital after being recalled there
• are conditionally discharged restricted patients whom the Secretary of State for Justice has recalled to hospital
• are conditionally discharged restricted patients who have absconded from hospital after being recalled there
• are guardianship patients who are absent without permission from the place where they are required to live by their guardian

Patients will be considered missing in the following circumstances:

• if an informal patient considered being vulnerable by the clinical team leaves the ward area without the staff being aware or has not returned from leave
• if an informal patient who has been identified as posing a significant risk to themselves or others absents themselves whilst being escorted or transported in the community

If an informal patient whose whereabouts are known, is refusing to return to the ward and there is no immediate risk to themselves or others then they are not missing. In these circumstances staff should arrange a multi-disciplinary team (MDT) review to agree if discharge is appropriate. It is important that community staff, and, or friends and family (where appropriate) are included in the MDT.

Where there is any doubt about a patient’s capacity to make the decision to return to the ward, a decision under the Mental Capacity Act (MCA) whether to return them should be made.

6.5 Required response from the police

At the time of contacting the police, staff must be clear as to which category they are from:

• patients subject to Part III MHA 1983, this means patients connected to criminal proceedings, either before or after trial or conviction (for example, forensic detentions)
• patients who are dangerous
• patients who are especially vulnerable

There is no obligation in law for staff to report any other relevant matters immediately or at all. When reporting a patient missing staff duties include:

• undertaking an immediate search of ward and surrounding area
• providing appropriate and relevant information (including the date on which a police ability to use section 18 MHA 1983 to bring the patient back expires, see appendix C)
• provide any available photographs of absent patients to assist the police in conducting missing person’s investigations.

The police should also be told immediately if a patient is found or returned.

6.5.1 Patients subject to  detention under the MHA 1983

Any patients subject to detention under the MHA 1983 who leave the hospital without a valid section 17 are to be reported as AWOL. Section 18 of the 1983 MHA provides powers to the police for retaking into custody patients who are absent without leave and returning them to hospital in the three scenarios above.

6.5.2 Patients who are subject to DOLS

If a patient subject to the DOLS leaves the hospital without the agreement of the consultant psychiatrist and, or nurse a request should be made to the police that as they are a “particularly vulnerable adult” they are located and returned to the hospital.

6.5.3 Power under the MCA to return patient

For those patients who lack capacity to agree to return to the ward, section 4 and 5 of the MCA provides powers to the police as well as staff and allows them to make a best interests decision to return the patient to the ward.

Section 6 authorises restraint provided that the officer or member of staff 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

However, the police powers under section 4 and 5 of the MCA can not to be used to obtain a MHA assessment as there is provision within the MHA1983 (Amended 2007) for when these situations arise.

6.5.3.1 Patients who are on the ward informally and are assessed as being a significant risk or dangerous to themselves or others

These patients are missing, and the police will be asked to try and locate or return the patient to the ward. Once a missing person is found safe and well the police will take appropriate action which will include:

• notifying the ward as to the patient’s location
• requesting that the patient returns voluntarily

If the patient refuses to return to the ward voluntarily, an assessment for detention under the MHA 1983 may need to be arranged, or where the person is located and lacks capacity and there is evidence via the best interest process that a return to the ward is in the person’s best interest as there is a specific and immediate threat of harm to themselves or another person, or that failure to take immediate action could result in significant harm to that person they can be returned by the police. However, any restraint used must be proportionate to the likelihood of the person suffering from or inflicting harm and the seriousness of that harm (MCA 2005).

Staff must note that police officers are not equipped to carry out assessments of capacity. If capacity is in question, then an appropriate professional should carry out such an assessment. In addition to this if the patient is in a private place (such as their home address), officers have no powers without a warrant under section 135 (1) or section 135 (2) unless there is evidence of an offence being, or about to be, committed. The Sessey case (2011) clearly states that officers do not have powers to invoke the provisions of the MCA in order to seek a mental health assessment, as would be the case for a patient who had been admitted informally and was refusing to return to the ward voluntarily.

Patients who are on the ward informally and are assessed as being a low or no discernible risk to themselves or others.

If the patient has capacity, has been assessed as not posing a significant risk to themselves or others and their whereabouts are known as staff have managed to make phone contact with them and they are felt to be safe until they agree or want to return and can be returned by relatives or friends or be picked up by clinical staff, no police response will be required.

If clinical staff have been unable to make contact with the patient by phone, a request will be made for either the patients care coordinator (if allocated) or the Crisis team (if not allocated to a care coordinator) to undertake a safe and well check.

6.6 Information required by the police

When contacting the police to report an inpatient as missing or AWOL the nurse in charge of the ward must provide the following information:

• patients’ full name and any nick names or aliases they are known to use
• age
• full physical description, including any distinguishing marks such as scars or tattoos
• a photograph (if available)
• details of clothing worn by the patient when last seen
• patients’ legal status
• patients’ mental state
• details of any cognitive or sensory disability
• detail of any known risks to self or others
• detail of any physical disability or illness or complication which may put the patient at increased risk
• any known communication problems for example, if the patients first language isn’t English
• when the patient was last seen including where, time and by whom
• what action has been taken to try and locate the patient prior to reporting the matter to the police
• the specific and level of risk posed to the patient due to them being missing or AWOL
• details of any places or addresses the patient is known to frequent

6.7 Action to take if an informal inpatient goes missing or a patient detained under the MHA 1983 goes AWOL (including anyone subject to DOLS)

Staff must immediately notify the nurse in charge who will:

1. organise a search of the surrounding wards and other facilities in line with area specific procedures
2. attempt to contact the patient using all relevant contact details available (mobile phone number, landline, email) to ascertain where they are and request that they return to the ward
3. notify the patient’s next of kin or nearest relative who may be able to offer information or insight regarding the patient or inform the team if they make contact, staff should also consider any support that may need to be offered to family or carers at this stage
4. if the patient is not located, inform the consultant psychiatrist or RC during normal working hours
5. inform as per the table below
6. for mental health services and detained patients, notify the Crisis team who may be asked to assess the patient should they present in the accident and emergency department or make contact with the Crisis team
7. inform the patient’s care co-ordinator and other community workers involved
8. notify switchboard as they may receive calls with regard to the missing person
9. inform the patient’s GP in case the patient presents at the surgery for medication
10. notify hospital security if available
11. if any child safeguarding issues have been identified, inform children and family services or the duty social worker if outside normal working hours
12. inform anyone who is felt may be at risk from the patient, as identified in their risk assessment and risk management plan
13. report the incident accurately using the electronic incident form (IR1) via the trusts safeguard electronic incident reporting system
14. where in use make a record on the ward’s 24-hour report
15. if the patient fails or refuses to return to the ward, discuss with their consultant the need to carry out an assessment under the MHA 1983 (amended 2007), or for the patient to be discharged in their absence with appropriate community follow-up being arranged and communicated to them. Where possible the clinical team who provided care to the patient in the community prior to admission, or the Crisis team in the case of patients not previously known to services are to be involved in this discussion
16. For locked units (Amber Lodge) only:
    • in the event that the patient does not return to the ward by midnight on the first day of absence complete and email the AWOL notification form to the CQC, then send the original to the service manager, matron, or MHA office
    • comprehensively record all actions taken in the electronic patient record
    • when the patient returns ensure that everyone notified of their AWOL or missing status is advised that they have now returned

6.7.1 Business days 9am to 5pm

All instances of patients being missing, or AWOL should be notified to modern matron, care group triumvirate, head of service and chief operating officer immediately where:

• Ministry of Justice restrictions apply
• any patient, where the staff have concerns for the safety of the patient

For all other patients:

• the modern matron, if the patient has not returned with 30 minutes
• an AWOL only needs further escalation to the care group triumvirate or silver if there is a high profile case and, or incident related to the AWOL (or absent or missing person) that is likely to attract media attention and, or require high level communication with external partners

6.7.2 Out of hours business days 5pm to 9am and non-business days

All instances of patients being missing, or AWOL should be notified to bronze, silver and gold on-call immediately where:

• Ministry of Justice restrictions apply
• any patient, where the staff have concern for the safety of the patient

For all other patients:

• the bronze manager, if the patient has not returned within 30 minutes (bronze staff can still contact silver if they want to discuss a concern or to support decision-making)
• an AWOL only needs further escalation to the silver if there is a high profile case and, or incident related to the AWOL (or absent or missing person) that is likely to attract media attention and, or require high level communication with external partners
• escalation to gold would only take place where there is an extremely high profile case or incident relating to the patient

6.8 Action to take if a patient goes absent whilst being escorted or transported within the community

• A search of the immediate area should be undertaken by the escort.
• In the event that the patient is not found, the escort will contact the ward and inform the nurse.
• The nurse or clinician in charge of the ward will implement the actions from section 6.6 of this policy.

6.9 Action if a patient absconds from an address to which they have authorised leave 14

• The member of staff who receives the information will try to obtain the following details and make a record of them:
  • date and time patient was last seen
  • here
  • who by
  • whether the patient gave any indication as to where they intended to go
  • if they took any clothing, money, or passport with them.
• Inform the relevant service manager or matron and the patients RC.
• The service manager or matron will take relevant action as detailed in section 5.6 of this policy.

6.10 Additional notification required for patients detained on court orders or subject to Ministry of Justice restriction orders

• For any patient detained under section 37 and 41, section 47 and 49, and section 48 and 49 who are AWOL the service manager or matron must notify their manager who will inform the Ministry of Justice of the patients’ absence (appendix D).
• For patients detained on sections 35, 36, 37 or 38 who have not been found following initial searches the service manager or matron will notify the courts business manager.

6.11 Return of any patient who has been AWOL or missing

• An adult with capacity (over 16 years of age) not subject to detention under the MHA 1983 (amended 2007) cannot be taken back to the ward without their consent.
• If the patient cannot be persuaded to return, staff should contact their service manager or matron and consultant psychiatrist for advice. Any 15 subsequent action is dependent on a risk assessment of the current situation and the safety of the patient and others.
• In the very exceptional circumstance of a child under 16 years of age who is not subject to detention under the MHA 1983 (amended 2007), parental authority is required prior to the return of the child unless the child is deemed to be “Gillick” competent”.

When deciding on the most appropriate method for conveying the patient to hospital the code of practice recommends that the following must be considered:

• transport options
• distance to be travelled
• patient’s views, age and any disability they may have
• risks associated with the method of transport
• risks of patient behaving violently or re-absconding
• safety of the people conveying and accompanying the patient

6.12 Action to be taken if a patient is located at home but is refusing entry

If the patient is detained, an approved mental health professional (AMHP), any member of the hospital staff, any police officer, or anyone authorised in writing by the hospital managers may apply for a warrant under section 135(2) of the MHA 1983 (amended 2007) which provides for the retaking of a patient who is already detained under the act and is AWOL.

For informal patients who are located in the community but refuse to return or allow entry, a request should be made for a visit to be undertaken by community staff who are involved in the patient’s care. Where patients do not have an allocated community worker, the request will be made to the Crisis team. Following the community services assessment, a decision will be made regarding further action required to support the patient.

6.13 Time limits for returning detained patients who are absent without leave

Detained patients who go AWOL can be returned to the ward for up to six months after going absent or until the expiry date of the current authority for their detention or guardianship whichever is later. Staff should refer to appendix C for specific guidance.

If at the time the person goes AWOL the authority for detention or guardianship has been renewed in accordance with section 20, but the new period has yet to begin, the renewal is ignored and the six-month limit for returning the patient applies (MHA 1983 (Amended 2007, memorandum page 27, 71).

These time limits do not apply to patients subject to restrictions under section 41 or part 3 of the MHA who continue to be liable to be returned at any time.

6.14 Specific guidance for patients subject to guardianship

Any patient subject to guardianship who is absent without permission from an address where they are required to reside by the guardianship order, may be taken into custody and returned to that place of residence by the named guardian, any member of staff of the responsible local social services authority or by any person authorised in writing by the local social services authority or private guardian.

6.15 Action to be taken when the patient returns

• It is the responsibility of the nurse or clinician in charge to inform everybody previously notified of the patient’s absence of their return. This includes out of hours the bronze, silver, gold command.
• The clinical team will review the patient’s risk assessment and update the care plan, accordingly, including consideration of the level of observations required to prevent further occurrences.
• A search may be initiated for weapons or drugs if it is felt necessary, see searching of a person or their property policy.
• Staff should only contact the on-call doctor outside of normal working hours about the return of an absent patient if there are concerns about the patients’ mental state or physical presentation and the medical attendance is needed.
• Any further periods of leave from the ward are to be suspended until a full multi-disciplinary review has been undertaken.

6.16 Specific action following the return of a detained patient

6.16.1 Notification to the Care Quality Commission (CQC)

6.16.1.1 Locked units (amber lodge)

When a detained patient who absconds has been reported to the CQC and returns, part two of the AWOL notification form is to be completed and emailed to the CQC and a copy to MHA office to them (see appendix B).

6.16.1.2 Patients returned within 28 days

If a patient is returned within 28 days and the current authority for detention or guardianship has not expired, that authority remains until its expiry date. No form is required to continue the detention or guardianship.

If a patient is returned within 28 days and the authority for detention or Guardianship has expired or has less than seven days to run, it can be extended by up to seven days beginning with the day the patient returns. During these seven days the patient must be assessed with a view to either renewing that authority for detention or guardianship or discharging the patient. The RC may renew the section in the usual way and the renewal will take effect from the date the original period ended.

6.16.1.3 Patients returned after 28 days

If a patient is returned after 28 days have elapsed, the RC must assess the patient within seven days of return to determine whether detention or guardianship is still appropriate. Where the authority for detention or guardianship has expired it can be extended by up to seven days beginning with the day the patient returns. If continued detention or guardianship is thought necessary, the RC must submit the relevant form, and the renewal will take effect from the expiry date of the original section once the forms have been received by the hospital managers.

6.16.1.4 Patients returned subject to DOLS

If a person is under an urgent authorisation or standard authorisation there is no specific legal authority under the MCA to return the patient to the hospital, they are detained to if the patient refuses or objects or resists. This would need to be discussed with the clinician in charge of the person’s care and treatment as in these circumstances it may be necessary for clinical staff to make urgent arrangements under section 135(1) to undertake a MHA assessment or for police to consider their powers under section 136 where applicable and appropriate.

If the urgent authorisation has already expired and the trust is waiting for assessments for a standard authorisation to be authorised the patient should be treated as a missing person and apply the relevant part of this policy or procedure, taking into account patients’ vulnerability and risk to self and others.

6.17 Record keeping

Throughout any instance of a patient going AWOL or missing from the ward clinical staff are to complete an IR1 and keep a full and chronological record of all action taken, and information received which is to be documented in the electronic patient record.

6.18 Reducing the incidents of missing or AWOL

Good clinical risk assessment and engagement of patients is the most effective way to reduce the instances of patients going missing or absent without leave. However, it is vital that staff consider the clinical environment and take appropriate action to reduce or eliminate opportunities for inpatients to leave the ward without staff being aware. This will also include the need to secure any windows or doors which have been used as an unauthorised exit by patients to prevent other patients leaving by the same route.

6.19 Dealing with media enquiries

Any media enquiries relating to a patient who is AWOL or missing are to be referred within hours to the trust communications department on:

• Phone: 03000 212100
• Email: rdash.rdashcommunications@nhs.net

And out of hours by ringing the trust switchboard and asking for the director on call.

Staff must not answer any enquiries themselves.

If necessary, a press statement will be issued by the trust communications department.

In the event that staff become aware that the patient’s family or friends have, or may contact the media, they are to notify the trust communications department.

7 Training implications

Whilst there are no specific training needs in relation to this policy the clinical staff to whom it applies will be made aware of its contents in the following ways:

• by the service manager or matron at local induction and when there is a change to practice
• details of the policy review will be published in the trust’s daily Bulletin on a monthly basis or via the trust intranet policy updates
• this policy is also included in the MHA training
• trust staff also receive training in respect of the following:
  • Deprivation of Liberty Safeguards
  • Safeguarding Adults
  • Mental Capacity Act 2005

8 Monitoring arrangements

8.1 Analysis of incidents and actions taken or learning from incident reports

• How: Quarterly incident report.
• Who by: Patient safety lead.
• Reported to: Environmental risks in clinical areas group meeting
  care group quality meeting.
• Frequency: Monthly.

8.2 Number of patients absent who meet the criteria for notification to the Care Quality
Commission

• How: Audit of the notification reports.
• Who by: MHA manager.
• Reported to: Mental health legislation operational group and care group MHL monitoring group meetings
• Frequency: Quarterly.

9 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

9.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, “not just clinically but in terms of dignity and respect”.

Consequently, the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity, and respect, (when appropriate this should also include how same sex accommodation is provided).

9.1.1 How this will be met

There is no requirement for additional consideration to be given with regard to privacy, dignity or respect. In respect of the reporting requirements for patients who are absent without leave staff will abide by the trusts’ information sharing protocols.

9.2 Mental Capacity Act (2005)

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals’ capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all employees working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason, all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected, and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

9.2.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act (2005) (section 1).

10 Links to any other associated documents

• Incident management policy
• Health and safety policy
• security policy
• MCA Mental Capacity Act 2005 policy
• MCA deprivation of liberty (DoL) policy
• Clinical risk management system policy
• Supportive therapeutic observation policy
• Searching of a person or their property policy
• Disengagement policy
• Patient identification policy

11 References

• Jones, Richard (2021) Mental Health Act Manual, 24th Edition, Sweet and Maxwell.
• Department of Health (2008) Code of Practice Mental Health Act 1983.

12 Appendices

To assist the police in prioritising their response to any reports of missing or AWOL patients they have asked that staff complete the following by circling all that apply. In the case of any patient with a combination of low, medium or high risk their overall rating will defer to the highest identified risk.

12.1 Appendix A Specific risk assessment for when a patient goes missing or AWOL

12.2 Appendix B Notification report to the care quality commission

• Appendix B Notification report to the care quality commission (staff access only) (opens in new window)

12.3 Appendix C Notification report to the Care Quality Commission

12.4 Appendix D Ministry of Justice, out of hours guidance

• Phone Out of hours number: 0300 303 2079

12.4.1 Restricted patients

The Ministry of Justice Mental Health Casework Section (MHCS) only deals with psychiatric patients detained under the following Mental Health legislation:

• sections 37 and 41 of the Mental Health Act 1983
• sections 47 and 49 of the Mental Health Act 1983
• sections 48 and 49 of the Mental Health Act 1983
• The Criminal Proceedings Insanity (Unfitness to Plead Act 1991 (CPI))
• section 45a of the Mental Health Act (hospital directions) MHCS does not deal with patients detained solely under sections 2 or 3 of the Mental Health Act, or any other sections not mentioned above

12.4.2 Service operating hours

The out of hour’s service runs from 5pm to 9am each weekday. The service is extended to 24 hours on Saturdays, Sundays and public holidays.

12.4.3 When to email the relevant MHCS functional mailbox out of hours

Where previously hospitals have called the Ministry of Justice out of hours service to pass on non-urgent information (but have not needed to speak to the duty officer), MHCS recommends that an email to the relevant functional mailbox is a more secure means of ensuring that such information is recorded. The types of issues that we would ask for an email about include:

• absconds (unless the patient is high profile and there is likely to be significant media interest)
• the return of an absconder
• urgent transfers to a general hospital for emergency medical treatment
• death of a patient
• informing us that the patient has, or is alleged to have, committed a criminal offence

The functional mailbox address is as follows:

• Email: mhcsmailbox@justice.gov.uk

12.4.4 When to call the out of hour’s service

MHCS operates an out of hour’s service to make urgent or emergency (non-medical) decisions for restricted patients. The service also enables hospitals and supervisory teams to seek urgent advice from the Ministry of Justice in real time. The out of hour’s officer will only provide verbal authority for any decisions made during the out of hour’s service.

The decisions or events which are likely to involve calls to the out of hour’s service include:

• urgent recalls from the community to hospital
• urgent remissions to prison
• urgent compassionate leave
• urgent upward transfers between hospitals (into conditions of higher security)
• significant developments in cases for mentally disordered offenders who have a high profile nationally
• hostage incidents or patient disturbances

Please note that this service applies to matters of urgency only which cannot wait until normal office hours.

12.4.5 How the service works

Callers contact the central switchboard number on 0300 303 2079. The operator will ask the caller for the following information:

• their name and contact number
• name of patient
• the relevant section of Mental Health Act for example 37/41
• the reason for call
• whether the caller needs to speak to the MHCS duty officer (yes or no)?

If the caller needs to speak to the duty officer, he or she (who is a senior member of MHCS), is then contacted and asked to call you back. The duty officer will call you, provide advice or consider your urgent request over the phone and will then provide appropriate written confirmation during the next working day.

Please note that the duty officer will not usually have access to any information or MHCS records when the call is taken. Also please note that the duty officer will not provide written warrants or other documentation during the out of hour’s service.

If the issue does not require a conversation with the out of hour’s officer, the caller should email MHCS as at section 3 above.

---

Document control

• Version: 15.1.
• Unique reference number: 395.
• Approved by: CPRAG.
• Date approved: 3 January 2023.
• Name of originator or author: MHA manager.
• Name of responsible individual: Executive director of nursing and allied health professionals.
• Date issued: 1 February 2023 (minor amendment).
• Review date: 30 December 2025.
• Target audience: All inpatient clinical staff.

Page last reviewed: December 10, 2024
Next review due: December 10, 2025

Problem with this page?

Please tell us about any problems you have found with this web page.

Report a problem