Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
William Hafele · 24 Nov 2014 · Martin Fleming, Surrey
“- 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.”
judiciary.uk/prevention-of-future-death-reports/william-hafele
What was promised
Stated action 1 · response to William Hafele (24 Nov 2014) · stated 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.”
judiciary.uk/…/2014-0511-Response-by-Surrey-Borders-Partnership…
Stated action 2 · response to Kimberley Smith (9 Dec 2020) · stated timescale: none stated
“The Trust has decided to build and strengthen upon this by developing a separate, standalone written policy regarding leave for informal patients.”
judiciary.uk/…/2020-0279-Response-from-Surrey-and-Borders-Partn…
Stated action 3 · response to Kimberley Smith (9 Dec 2020) · stated timescale: none stated
“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.”
judiciary.uk/…/2020-0279-Response-from-Surrey-and-Borders-Partn…
3 further stated actions are listed on the full chain page.
What recurred
- 9 Dec 2020 · Kimberley Smith · Anna Crawford
- 7 Mar 2022 · Melanie Elms · Jessica Russell-Mitra · Identical hazard · confidence 0.90 (high)
- 15 Jun 2022 · William Savory · Anna Crawford · Closely related · confidence 0.87 (high)
The clearest link, quoted from both reports:
Earlier · 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.”
Later · Melanie Elms · 7 Mar 2022
“There was no missing person plan in place with timeframe and steps of escalation for [the deceased]'s leave.”
What happened next
No web check of the stated actions has been published for this chain.