Delayed reporting of missing detained patient
Surrey and Borders Partnership NHS Foundation Trust received 4 coroners' reports about this hazard between 24 Nov 2014 and 15 Jun 2022.
They came from 3 different coroners in 2 coroner areas. A similar concern was raised again 3 times after the first warning.
A published response was found for 2 of the 3 earlier reports, stating 6 specific actions.
The story, report by report
Spacing grows with the time between reports.
“- Training procedures in respect of the police and hospital staff on Elgar Ward in the case of reports of missing persons and lack of understanding of areas of responsibility and appropriate actions.”
Original on judiciary.uk ↗ Surrey and Borders Partnership NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“We have further emphasised the importance of the Missing Persons (MISPER) process to all our staff on these units, including making this a part of our improvement work in the reduction of the numbers of people who may be Absence Without Leave (AWOL). A member of the Clinical Assurance team is specifically assigned to wards with the view to ensure compliance with the MISPER agreement is tested.”
Stated timescale: end of February 2015
- 6 years 1 month later
“- The timeframe for reporting informal patients to the police as missing persons if they fail to return at the agreed time.”
Original on judiciary.uk ↗ Surrey and Borders Partnership NHS Foundation Trust responded, stating 5 specific actions.Response (PDF) ↗
“The Trust has decided to build and strengthen upon this by developing a separate, standalone written policy regarding leave for informal patients.”
“This issue is going to be covered in the new policy regarding leave for informal patients, as outlined above. We are also going to update our Section 17 Leave policy (for detained patients) and our Absent Without Leave policy with the same guidance.”
3 more stated actions in the Promises tab.
- 1 year 3 months laterIdentical hazardConfidence 0.90 · higha different coroner
“There was no missing person plan in place with timeframe and steps of escalation for [the deceased]'s leave.”
Original on judiciary.uk ↗ Repeated from the earlier report:missingtimeframe
No published response from Surrey and Borders Partnership NHS Foundation Trust was found for this report.
- 3 months laterClosely relatedConfidence 0.87 · higha different coroner
“The court heard evidence from some members of staff who gave evidence that they were not aware of a particular timeframe for instigating the missing persons protocol in relation to informal patients, and as such I consider there is a risk of future delays in reporting informal patients as missing persons to police, which presents a risk of future deaths.”
Original on judiciary.uk ↗ Repeated from the earlier report:staffmissingpersonspolice
The most recent report. A response may not be due or published yet.
- All reports to Surrey and Borders Partnership NHS Foundation Trust
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2020 → 2022Melanie Elms1 year 3 months after Kimberley Smith · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight the absence of a clear timeframe and procedure for reporting patients who go missing during leave.
Kimberley Smith · 9 Dec 2020
“- The timeframe for reporting informal patients to the police as missing persons if they fail to return at the agreed time.”
Original on judiciary.uk ↗ Melanie Elms · 7 Mar 2022
“There was no missing person plan in place with timeframe and steps of escalation for [the deceased]'s leave.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“This issue is going to be covered in the new policy regarding leave for informal patients, as outlined above. We are also going to update our Section 17 Leave policy (for detained patients) and our Absent Without Leave policy with the same guidance.”
2014 → 2022William Savory7 years 7 months after William Hafele · different coronerClosely relatedConfidence 0.87 · high
Closely relatedConfidence 0.87 · highBoth reports highlight failures in timely activation of missing‑person protocols due to insufficient staff training/awareness.
William Hafele · 24 Nov 2014
“- Training procedures in respect of the police and hospital staff on Elgar Ward in the case of reports of missing persons and lack of understanding of areas of responsibility and appropriate actions.”
Original on judiciary.uk ↗ William Savory · 15 Jun 2022
“The court heard evidence from some members of staff who gave evidence that they were not aware of a particular timeframe for instigating the missing persons protocol in relation to informal patients, and as such I consider there is a risk of future delays in reporting informal patients as missing persons to police, which presents a risk of future deaths.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“We have further emphasised the importance of the Missing Persons (MISPER) process to all our staff on these units, including making this a part of our improvement work in the reduction of the numbers of people who may be Absence Without Leave (AWOL). A member of the Clinical Assurance team is specifically assigned to wards with the view to ensure compliance with the MISPER agreement is tested.”
2020 → 2022William Savory1 year 6 months after Kimberley Smith · same coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight a lack of clear timing for initiating missing‑person procedures when patients do not return as expected. The earlier report focuses on absent written policy/timeframe for detained patients, while the later report points to staff unawareness of the immediate reporting requirement for informal patients.
Kimberley Smith · 9 Dec 2020
“The timeframe for reporting informal patients to the police as missing persons if they fail to return at the agreed time.”
Original on judiciary.uk ↗ William Savory · 15 Jun 2022
“staff were aware that he had not returned from 18:45 onwards. The court found that thereafter there was a delay of approximately two hours in instituting the missing persons protocol”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“This issue is going to be covered in the new policy regarding leave for informal patients, as outlined above. We are also going to update our Section 17 Leave policy (for detained patients) and our Absent Without Leave policy with the same guidance.”
Stated action · timescale: end of February 2015
“We have further emphasised the importance of the Missing Persons (MISPER) process to all our staff on these units, including making this a part of our improvement work in the reduction of the numbers of people who may be Absence Without Leave (AWOL). A member of the Clinical Assurance team is specifically assigned to wards with the view to ensure compliance with the MISPER agreement is tested.”
Stated action
“The Trust has decided to build and strengthen upon this by developing a separate, standalone written policy regarding leave for informal patients.”
Stated action
“This issue is going to be covered in the new policy regarding leave for informal patients, as outlined above. We are also going to update our Section 17 Leave policy (for detained patients) and our Absent Without Leave policy with the same guidance.”
Stated action
“Once the new and updated policies have been finalised and approved, a structured roll out of a competency framework will begin, to support our staff in understanding the new policy and the updated policies and how to put them into practice.”
Stated action
“The Trust has now completed its guidance regarding”
Stated action
“A retrospective baseline audit is also underway, looking back over a three month period between 1.8.2019 - 31.10.2019 to consider whether the Working Age Adult division identified and managed alcohol dependence appropriately. Once the improvements have been embedded, a second audit will be completed to check for improvements in our practices.”
No published response from Surrey and Borders Partnership NHS Foundation Trust was found for this report.
No published response from Surrey and Borders Partnership NHS Foundation Trust was found for this report. It is the most recent report, so a response may not be due or published yet.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Surrey and Borders Partnership NHS Foundation Trust at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2020 → 2022 | 0.66 | 0.15 | Identical · 0.90 | different |
| 2014 → 2022 | 0.69 | 0.10 | Closely related · 0.87 | different |
| 2020 → 2022 | 0.74 | 0.20 | Closely related · 0.80 | same |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.