Catherine Morgan
19 May 2026 · Coroner Patricia Harding · Kent and Medway
This report repeats 4 earlier warnings. See the linked reports.
The coroner's concerns
1. inconsistent risk assessments with NICE Guidelines
“Evidence was given at the inquest that although dynamic risk assessments were undertaken in advance of leave being authorised, risk assessments were not consistent with NICE Guidelines”
2. inadequate leave safeguarding and communication
“The systems in place for safeguarding voluntary patients in respect of leave and recording the decisions was inadequate and decisions were largely communicated by word of mouth which led to differences of understanding what had been agreed, the basis on which it had been agreed and by whom it was agreed. Documentation in respect of leave was incomplete and did not comply with policy. The nurse in charge was not informed of the decision for leave or the circumstances in which leave was granted”
3. inadequate leave monitoring leading to delayed response
“The system for monitoring leave was inadequate, reliance being placed on hourly checks. The nurse conducting the hourly check at 12.00 when [the deceased] was due to return was not aware that she was on unescorted leave and did not escalate the matter to the nurse in charge with the result that the ward only became aware that she had not returned when her mother arrived at 12.50. Consideration was not given to the appropriate amount of leeway to be given to the patient before escalating the fact of them not having returned, with patients being given 30 minutes or more”
4. missing patient photograph and checklist
“A photograph of the patient was not included in the grab pack. Unlike detained patients there was no checklist for voluntary patients as to the measures taken to locate the patient”
5. overly rigid deployment policy causing delays
“An overly rigid approach to the Right Care Right Person policy and affinity protocol resulted in a delayed deployment. Even where call handlers have real concerns that someone not returning to a mental health unit is a high risk missing person, the outcome of the toolkit not to deploy is the same if the individual's address has not been visited, even when told that they would not go there. The way in which the policy was applied removed any discretion by call handlers and despatchers to deploy whilst checks at the address were being conducted”
6. inappropriate ambulance dispatch based on address knowledge
“A call handler informed SLAM to call London Ambulance Service to do a welfare check at the home address of the patient in circumstances where the ambulance service will only attend an address if the resident is known to be there”
7. restricted professional judgement causing deployment delays
“Some changes have been made within MPS within the parameters allowed given national guidance and standards, but evidence was given to the effect that training as to the application of the policy, protocol and toolkit could result in the professional judgement of call handlers/despatchers/supervisors being restricted resulting in delays to deployment”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“The contemporaneous note in the EPJS was conceded to be an incomplete record of everything that was decided on the ward round.”
This report
“The systems in place for safeguarding voluntary patients in respect of leave and recording the decisions was inadequate and decisions were largely communicated by word of mouth”
Closely relatedConfidence 0.85 · high
Earlier report
“some parts of these policies remain ambiguous or confusing. For example, in the Call Handling, Grading and Deployment Policy, there is no specific paragraph that explains that the Force Incident Manager should be notified of a high risk missing person”
This report
“An overly rigid approach to the Right Care Right Person policy and affinity protocol resulted in a delayed deployment. Even where call handlers have real concerns that someone not returning to a mental health unit is a high risk missing person, the outcome of the toolkit not to deploy is the same if the individual's address has not been visited, even when told that they would not go there.”
Closely relatedConfidence 0.85 · high
Earlier report
“I heard that the MPS has already created a similar model under the resource and demand team. The protocol is called Affinity.”
This report
“An overly rigid approach to the Right Care Right Person policy and affinity protocol resulted in a delayed deployment.”
Closely relatedConfidence 0.85 · high
Earlier report
“The emergency response had come about because of a new 'Right Care, Right Person' policy applied by emergency services that, in fact, delivered as a first responder, the wrong person delivering the wrong care to the deceased's residence.”
This report
“An overly rigid approach to the Right Care Right Person policy and affinity protocol resulted in a delayed deployment.”